Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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underwent intensive rehabilitation managed by multidisci- plinary teams with years of experience in surgical management of war-related traumatic amputation and soft tissue injuries, pain management, and prosthesis prescription, fabrication, fitting,
and troubleshooting. Furthermore, military treatment facilities provides a dedicated environment where SMs can focus on returning to premorbid level of function, with minimal distraction from family needs and financial pressure. These inherent differences limit the generalizability of the finding in this study into non-military population. Other limitations include the time period between initial and follow-up evalua- tions being variable from patient to patient. Lastly, though we detected generally favorable changes in the tested instru- ments, only improvements in 6MWT and ABC reached sta- tistical signi ficance, and we found no significant changes in the stair ambulation. In summary, we showed that through intensive rehabilita- tion, the recovery of SMs with BTFA is generally favorable, with statically signi ficant improvement in walking distance over the
first year of independent ambulation, while the improvement of their stairs ambulation function remained static. These findings can be used to help set outcome expec- tation as well as rehabilitation guidelines. ACKNOWLEDGMENTS The authors acknowledge Ms Jenna Trout for collection and processing of data in this study and Dr. Benjamin Darter of Virginia Commonwealth University for his contribution to the development of the research study. Fac- tors In
fluencing Rehabilitation Effectiveness in the Restoration of Physical Function in the Military Amputee was funded by the Military Amputee Program through a CRADA between MRMC (USAMRAA) and the Henry M. Jackson Foundation for the Advancement of Military Medicine. REFERENCES 1. Krueger CA, Wenke JC, Ficke JR: Ten years at war: comprehensive analysis of amputation trends. J Trauma Acute Care Surg 2012; 73: S438
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29. Buell NC, Willingham LL, Allyn KJ, Hafner BJ, Smith DG: Evaluation of gait style to ascend and descend stairs for lower limb amputees. In: Proceedings of the 11th World Congress of the International Society of Prosthetics and Orthotics. Edited by Boone D. Hong Kong, 2004. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 60 Outcomes of Service Members With Bilateral TF/KD Amputations MILITARY MEDICINE, 181, 11/12:61, 2016 Core Temperature in Service Members With and Without Traumatic Amputations During a Prolonged Endurance Event LTC Anne M. Andrews, SP USA (Ret.)*†; CPT Christina Deehl, SP USA‡; LTC Reva L. Rogers, SP USA (Ret.)‡; Alison L. Pruziner, PT, DPT, ATC*† ABSTRACT Introduction: Service members with traumatic amputations may be at an increased risk of elevated core body temperature, since their ability to dissipate heat may decrease with the reduction in body surface area (BSA) after injury. Elevated core temperature can impair physical performance during combat operations potentially putting the service members and their teams at risk. The purpose of this study was to compare core temperature between individ- uals with and without amputations during a prolonged endurance event. Materials and Methods: Twenty healthy male military service members (10 with amputations, 10 without) participated in the Bataan Memorial Death March 26.2-mile event on March 27, 2011. Data collected include BSA, body mass index, body composition, body weight before and after the event, core temperature during the event, and postevent hydration status. Body composition was measured by dual-energy X-ray absorptiometry. Body weight was measured by digital scale. Core temperature was measured by ingestible sensor. Hydration was measured by urine speci fic gravity. The Walter Reed Army Medical Center Institutional Review Board approved this study and participants provided written informed consent. Results: Three participants ’ data were not included in the analyses. No significant differences in core temperature were found between participants in both groups, and no correlation was found between core temperature and either BSA or hydra- tion status. There was no signi ficant difference in maximal core temperature between the groups ( p = 0.27) Nearly all participants (8 control, 6 amputation) reached 38.3°C, the threshold for increased risk of heat exhaustion. No subjects reached 40.0°C, the threshold for increased risk of heat stroke. Time spent above the 38.3°C threshold was not signi fi- cantly different between groups, but varied widely by participant in relation to the duration of the event. Participants without amputations finished the event faster than participants with amputations (7.9 ± 1.4 vs. 9.6 ± 0.96, p < 0.01), possibly indicating that participants with amputations self-selected a slower pace to attenuate increased core tempera- ture. Conclusion: Until conclusive evidence is accumulated, it is prudent for military leaders, trainers, and military ser- vice members to closely monitor this population during physical activity to prevent heat injuries. INTRODUCTION Heat illness and injury continue to be a concern for the mili- tary with 2,027 documented incidences of heat stroke/injury in active duty service members in 2014. 1 Elevated core temperature has harmful effects on the brain, liver, muscles, and kidneys, and can signi ficantly impair a military service member
’s physical performance. 2 When service members develop heat illness and injury during combat, their team ’s capabilities degrade placing all team members at risk. Deter- mining who is more likely to suffer heat illness, and devel- oping strategies to mitigate the risk, may increase the safety of the entire combat team. 3 From September 2001 to 2014, 1,573 military service members suffered traumatic major limb amputations as a result of combat operations. 4 The proportion of U.S. service members remaining on active duty after undergoing amputa- tions has increased from 2.3% in the 1980s to about 16.5% in 2010. 5 Many of these active duty service members return to combat operations conducted in harsh environmental con- ditions. Anecdotal information suggests that service members with amputations report feeling hotter than before their ampu- tation, and experience more profuse sweating during activity. Individuals with amputations may be at higher risk for experiencing elevated core temperature during exercise than their uninjured counterparts, potentially due to increased heat production and/or decreased dissipation ability. Exercise inten- sity signi ficantly impacts the amount of heat produced during exercise 6 and persons with amputations have higher levels of energy expenditure when performing the same task, such as walking, as persons without amputation. 7 Body surface area (BSA) plays a signi ficant role in the body’s ability to regulate core temperature and dissipate heat. 2,8
Individuals with amputations have decreased BSA and frequently their *Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, MD 20889. †Extremity Trauma and Amputation Center of Excellence, 2748 Worth Road, Suite 29 Fort Sam Houston, TX 78234. ‡U.S. Military/Baylor University Graduate Program in Nutrition, U.S. Army Medical Department Center and School, Joint Base San Antonio, TX 78234. Research was conducted at Walter Reed Army Medical Center, 6900 Georgia Avenue, Washington DC 20307; Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889; U.S. Army Medical Department Center and School, 3630 Stanley Road, Joint Base San Antonio, TX 78234; and Bataan Memorial Death March, White Sands Missile Range, NM 88002. Military Amputee Research Program (MARP) and the Telemedicine and Advanced Technology Research Center (TATRC) Prime Award No W81XWH-06-2-0073. The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21701-5014 is the awarding and administering acquisition of fice. It was administered by the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc. The DoD-VA Extremity Trauma and Amputation Center of Excellence (Public Law 110-417, National Defense Authorization Act 2009, Section 723) supported this project. doi: 10.7205/MILMED-D-15-00515 MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 61
residual limbs are covered with a prosthesis, both of which may decrease the ability to dissipate heat. Hindrance to any thermoregulatory mechanisms may increase the risk of heat injuries. 2 To date, there is only one published pilot study compar- ing the core temperatures of service members with and with- out amputations leaving open to discussion whether service members with amputations are more susceptible to heat inju- ries than their counterparts without amputations. 9 The pri-
mary objective of this study was to determine if individuals with amputations were more predisposed to heat illnesses than individuals without amputations by comparing core tempera- ture during a prolonged endurance event. We hypothesized that individuals with amputations would have higher core temperatures than individuals without amputations. Second- ary objectives included determining how BSA and hydra- tion status affected core temperature in individuals with and without amputations during a prolonged exercise event. We hypothesized that decreased BSA would be directly cor- related with higher core temperature while hydration status would be inversely correlated. METHODS The current study is a case –control investigation to test whether individuals with amputation are at increased risk of heat injury while performing duties typical to military service, this study was conducted during the Bataan Memo- rial Death March (BMDM), a 26.2-mile road march in New Mexico, on March 27, 2011. The event mimics extended marching frequently performed by many operational mili- tary forces. Twenty participants from a convenience sample of service members planning to participate in the event volunteered for this study: 10 with amputations and 10 with- out amputations served as a control group. The participants with limb loss included 7 participants with a unilateral trans- tibial (below the knee) limb loss, 1 participant with a unilat- eral transfemoral (above the knee) limb loss, 1 participant with unilateral transradial limb loss, and 1 participant with unilateral transhumeral limb loss. The range in time since amputation was 6.97 to 39.87 months (mean 15.10 months). All participants were recruited from teams at Walter Reed Army Medical Center, Washington, DC, and Joint Base San Antonio, Texas who were trained and had already registered for the event. Participants were contacted by the study team during training sessions for the event or by word of mouth upon referral from the medical staff. The Walter Reed Army Medical Center Institutional Review Board approved the pro- tocol and all participants provided written, informed consent. Research team members met with participants at their respec- tive sites before the pre-event data collection session in order to explain the study and study-related risks. All participants were active duty or retired service mem- bers. Participants with amputations were required to have had at least 6 months of prosthesis usage before the event and a physician cleared all participants who were still under- going medical treatment. Participants were excluded from the study if they had previous heat injuries, nontraumatic amputations, neurological, cardiovascular, pulmonary, ortho- pedic, or other conditions or medications that would contra- indicate completion of a 26.2-mile march or swallowing an ingestible sensor. Data collected before the event included height, weight, body composition, body mass index (BMI), and BSA. Pre- event weight was collected just before the start. During the event, core temperature was monitored using ingestible core temperature sensors. Following completion of the event, event duration was recorded and postevent weight and urine specimen were collected. All participants wore comfortable attire and shoes or boots during the event. Body composition and background information were collected within 4 weeks of the event. Background infor- mation included age, gender, and the date and level of any amputation. Body weight was measured on a calibrated digital scale to the nearest 0.1 kg. Participants reported their height from their last preinjury physical fitness test. This is an of ficial military measurement conducted according to pre- cise standards. 10 BMI was calculated using standard calculations (kg/m 2 ). Adjusted weight was used for participants with amputations. Adjusted body weight was calculated as current body weight/ (1 − P), where P is the proportion of total body weight rep- resented by the missing limb or limbs. 11 BSA was calculated using the Mosteller (1987) for- mula, the preferred method in clinical medicine for deter- mining BSA: 12 Without amputations : BSA m 2 À Á ¼ H cm ½ Â W kg ½ =3; 600 ð Þ 0 :5 With amputations : BSA m 2 À Á ¼ BSA À BSA ½ Â % BSA part ½ ð Þ Percent (%) BSA part re flects the level of amputation of the missing limb or limbs. 13 Calculated BSA for participants with amputations used adjusted weight and excluded the area covered by the prosthesis liner. Body composition was measured by dual-energy X-ray absorptiometry (DXA Windows XP version QDR software, Hologic, Discovery-Wi, Bedford, Massachusetts). Data col- lected include lean mass, fat mass, and body fat percentage. Participants were scanned in minimal clothing with prosthe- ses, jewelry, and metal objects removed. Participants were weighed on site using a calibrated digi- tal scale before and after the event to account for fluid loss. Participants consumed food and beverages ad libitum during the race. Urine samples were taken immediately after par- ticipants completed the BMDM to assess hydration status. Urine-speci fic gravity (USG) was assessed using a calibrated hand –held refractometer (model HR-200 ATC, AFAB Enter- prises, Eustis, Florida). Calibrated temperature sensors (CoreTemp, HQ Inc, Palmetto, Florida) were distributed to the participants the night before the event and ingested by participants the MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 62 Core Temperature in Service Members With and Without Traumatic Amputations following morning approximately 2 hours before starting the event. In previous studies, ingesting the sensor 4 to 6 hours prior was optimal; however, due to the projected event dura- tion, a shorter lead-time was chosen to minimize early excre- tion of the sensor during the event. 14,15
Once ingested, the sensor telemetrically transmitted core temperature data every 10 seconds to an external receiver worn on the participant ’s waist. The data were downloaded from the receiver to a study laptop after the event. Minimum and maximum air temperature were recorded for the day of the race. 16 Statistical Analysis Data are presented as mean ± SD. Core temperature data were processed to provide 5-minute averages for the dura- tion of the event. The primary outcome variables of interest were maximal core temperature, time to reach maximal core temperature, time to 38.3°C, time above 38.3°C, time to 40°C, and time above 40°C. These core temperature levels were chosen based on risk of heat exhaustion and heat stroke, respectively. 17 Group temperature means and demo- graphic data were compared using an independent t test. Levene
’s test for equality of variance was used to ensure assumptions of normality were met for the two groups. Yüklə 2,47 Mb. Dostları ilə paylaş:
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