Marilynn Wyatt

Method for evoking a trip-like response using a treadmill-based perturbation during locomotion

Because trip-related falls account for a significant proportion of falls by patients with amputations and older adults, the ability to repeatedly and reliably simulate a trip or evoke a trip-like response in a laboratory setting has potential utility as a tool to assess trip-related fall risk and as a training tool to reduce fall risk. This paper describes a treadmill-based method for delivering postural perturbations during locomotion to evoke a trip-like response and serve as a surrogate for an overground trip. Subjects walked at a normalized velocity in a Computer Assisted Rehabilitation Environment (CAREN). During single-limb stance, the treadmill belt speed was rapidly changed, thereby requiring the subject to perform a compensatory stepping response to avoid falling. Peak trunk flexion angle and peak trunk flexion velocity during the initial compensatory step following the perturbation were smaller for responses associated with recoveries compared to those associated with falls. These key fall prediction variables were consistent with the outcomes observed for laboratory-induced trips of older adults. This perturbation technique also demonstrated that this method of repeated but randomly delivered perturbations can evoke consistent, within-subject responses.

Functional Improvement After Ablative Fractional Laser Treatment of a Scar Contracture

D C Since first reported in 2004 [1], fractional laser therapy has been used for a range of skin indications, including photoaging, dyschromia, melasma, actinic keratoses, and acne scarring [2]. This technique involves the generation of noncontiguous columnar microscopic thermal wounds that penetrate the skin at depths up to approximately 2 mm with a single pulse. The adjacent untreated skin provides a reservoir of viable tissue, which permits rapid re-epithelialization and dermal remodeling while minimizing potential complications such as infection or worsening scarring [2] (Fig 1). Most laser scar therapy to date has focused on osmesis. Only a few reports in the literature describe functional improvements in traumatic cars and scar contractures after fractional laser treatment, often as incidental findings [3-6].

Pilot testing of a haptic feedback rehabilitation system on a lower-limb amputee

Lower-limb amputation, whether by trauma or complication of another condition, affects more than 800,000 people in the United States alone. These patient groups typically suffer from decreased mobility and an increased incidence of injury due to fall, even with the application of prosthetic limbs. A haptic feedback system prototype was previously developed to provide augmentative sensory information to patients suffering from total or attenuated lower-limb sensory loss. By providing tactile cues to the user based on plantar pressure distributions, it is hoped that this system can improve rehabilitation and functional outcomes following lower-limb injury. This paper presents an updated system that was fitted to the residual limb of a below-knee amputee, as well as a pilot study using the device. The pilot study demonstrated that the amputee could accurately perceive various tactile stimuli with high accuracy (≫ 87.5%), therefore indicating that the approach is feasible.

Integrated Musculoskeletal Rehabilitation Care at a Comprehensive Combat and Complex Casualty Care Program

OBJECTIVE The purpose of this study is to describe the musculoskeletal rehabilitation model used to care for combat and severely wounded or ill US military service members at an integrated Comprehensive Combat and Complex Casualty Care center located at Naval Medical Center San Diego. METHODS Through a collaborative and iterative process, providers from the various services included at the Comprehensive Combat and Complex Casualty Care program developed a description of the integration of services provided at this location. RESULTS After construction of the facility in 2007, the program has provided services for approximately 2 years. Eighteen different health care providers from 10 different specialties provide integrated musculoskeletal services, which include primary care, physical therapy, occupational therapy, vestibular therapy, gait analysis, prosthetics, recreational therapy, and chiropractic care. At the time of this writing (early 2009), the program had provided musculoskeletal rehabilitation care to approximately 500 patients, 58 with amputations, from the operational theater, Veterans Affairs, other military treatment facilities, and local trauma centers. CONCLUSION The complex nature of combat wounded and polytrauma patients requires an integrated and interdisciplinary team that is innovative, adaptable, and focused on the needs of the patient. This article presents a description of the model and the experiences of our musculoskeletal rehabilitation team; it is our hope that this article will assist other centers and add to the small but emerging literature on this topic.

Reliability of 3D gait data across multiple laboratories

The aim of this study was to analyze the repeatability of gait analysis studies performed across multiple trials, sessions, and laboratories. Ten healthy participants (6 male/4 female, mean age of 30, mean BMI of 24kg/m(2)) were assessed in 3 sessions conducted at each of the three Centers of Excellence for Amputee Care within the Department of Defense. For each test session, kinematic and kinetic parameters were collected during five walking trials for each limb. One independent examiner at each site placed markers on the subjects. Biomechanical data were collected at two walking speeds: self-selected and Froude speed. Variability of the gait data was attributed to inter-trial, inter-session, and inter-lab errors for each subject. These error sources were averaged across all ten subjects to obtain a pooled error estimate. The kinematic errors were fairly consistent at the two walking speeds tested. Median inter-lab kinematic errors were <5.0° (median 2.3°) for all joint angle measurements. However, the kinetic error differed significantly between walking speeds. The median inter-lab kinetic error for the self-selected speed was 0.112Nm/kg (ICR 0.091-0.184) with a maximum of 0.226Nm/kg. The errors were greatly reduced when the subjects walked at their Froude speed. The median inter-lab error was 0.048Nm/kg (ICR 0.025-0.078, maximum 0.086). These data demonstrate that it is possible to get reliable data across multiple gait laboratories, particularly when gait speed is standardized across testing sessions. A key similarity between sites was the use of identical anatomical segment definitions for the respective gait models.

A Narrative Review of the Prevalence and Risk Factors Associated With Development of Knee Osteoarthritis After Traumatic Unilateral Lower Limb Amputation.

INTRODUCTION Young military Service Members with traumatic unilateral lower limb amputations may be at a high risk for developing knee osteoarthritis (OA). There is growing evidence for potential influence and predictive value of nonsystemic risk factors on development and progression of primary knee OA in older adults. Proposed factors include chronic knee pain, obesity, abnormal knee joint mechanics, muscle weakness, previous knee trauma, and altered physical activity level. However, there is limited information available regarding whether such nonsystemic risk factors could also be responsible for the increased risk of knee OA after traumatic, unilateral lower limb amputation in young military Service Members. The purpose of this narrative review is to compile and present evidence regarding prevalence of nonsystemic and potentially modifiable knee OA risk factors in Service Members with traumatic, unilateral lower limb amputation, and to identify potential strategies for intervention. MATERIALS AND METHODS A comprehensive literature search was performed in July 2015 using structured search terms related to nonsystemic risk factors for knee OA. RESULTS Current collective evidence does suggest an elevated prevalence of the nonsystemic knee OA risk factors in young military Service Members with unilateral lower limb amputation. In conclusion, the present state of the literature supports that young military Service Members with traumatic unilateral lower limb amputations may be at increased risk for developing knee OA compared to nonamputees. Military Service Members injured at a young age have a long life expectancy, and thus require comprehensive rehabilitation programs to prevent or delay progression of knee OA. Given the lack of strong evidence, further clinical research is needed to determine whether early identification and modification of nonsystemic risk factors for knee OA could optimize long-term function and quality of life in young Service Members after traumatic, unilateral, limb amputations.

Mechanical testing for three-dimensional motion analysis reliability

The purpose of this study was to use simple mechanical tests to evaluate the reliability of three-dimensional motion analysis systems and biomechanical models. Three different tests were conducted at four motion analysis laboratories where clinical care and research studies are routinely performed. The laboratories had different motion capture systems, different types and number of cameras, different types and numbers of force plates and different biomechanical models. These mechanical tests evaluated the accuracy of the motion capture system, the integration of the force plate and the motion capture system, and the strength of the biomechanical model used to calculate rotational kinematics. Results of motion capture system accuracy tests showed that, for all labs, the error between the measured and calculated distances between markers was less than 2mm and 1° for marker separations which ranged from 24mm to 500mm. Results from the force plate integration tests demonstrated errors in center of pressure calculation of less than 4mm across all labs, despite varied force plate and motion system configurations. Finally, errors across labs for single joint rotations and for combined rotations at the hip and knee were less than 2° at the hip and less than 10° at the knee. These results demonstrate that system accuracy and reliability can be obtained allowing the collection of comparable data across different motion analysis laboratories with varying configurations and equipment. This testing is particularly important when multi-center studies are planned in order to assure data consistency across labs.

The Extremity Trauma and Amputation Center of Excellence: Overview of the Research and Surveillance Division

Congress authorized creation of the Extremity Trauma and Amputation Center of Excellence (EACE) as part of the 2009 National Defense Authorization Act. The legislation mandated the Department of Defense (DoD) and Department of Veterans Affairs (VA) to implement a comprehensive plan and strategy for the mitigation, treatment, and rehabilitation of traumatic extremity injuries and amputation. The EACE also was tasked with conducting clinically relevant research, fostering collaborations, and building partnerships across multidisciplinary international, federal, and academic networks to optimize the quality of life of service members and veterans who have sustained extremity trauma or amputations. To fulfill the mandate to conduct research, the EACE developed a Research and Surveillance Division that complements and collaborates with outstanding DoD, VA, and academic research programs across the globe. The EACE researchers have efforts in four key research focus areas relevant to extremity trauma and amputation: (1) Novel Rehabilitation Interventions, (2) Advanced Prosthetic and Orthotic Technologies, (3) Epidemiology and Surveillance, and (4) Medical and Surgical Innovations. This overview describes the EACE efforts to innovate, discover, and translate knowledge gleaned from collaborative research partnerships into clinical practice and policy.

Functional Gait Analysis Before and After Delayed Military Trauma-related Amputation: A Report of Three Cases

The current conflicts in Iraq and Afghanistan have produced a large number of service members with severe combat-related injuries. Eighty-two percent of service members with combat-related injuries have sustained extremity trauma, which accounts for 54% of wounds overall1. Of all the lower-extremity amputations performed at military treatment facilities, approximately 13% (125 of 975) were the result of delayed or “elective” procedures2. Recent studies have shown that the outcomes of extensive salvage procedures for severely injured limbs are not necessarily definitive in a nonmilitary population3 and that early amputation can be preferable to limb salvage in many such instances3-12. Some military and nonmilitary population studies have considered a delayed amputation as occurring within as little as twenty-four hours postinjury, while other studies have cited a range over years4,13,14. Up to 15% of combat-related amputations have occurred later than twelve weeks postinjury, and the military medical community has adopted this as a reasonable timeframe during which initial operative efforts at limb salvage can be attempted2,14. Given the incidence of trauma-related amputation in the active duty military population, as well as the likely underreported frequency of similar scenarios in civilian trauma settings3,8,15-17, the goal of this report is to provide an analysis of gait in combat-injured patients before and after delayed amputation. Our institutional review board approved the retrospective review of the data presented in this manuscript. The three patients included in this case series were informed that data would be submitted for publication, and they all gave consent. Case 1. A forty-one-year-old male U.S. Navy navigator was involved in a midair collision and was ejected from his aircraft. Upon landing, he sustained a Gustilo …

The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for Service Members With Complex Trauma

The Center for Rehabilitation Sciences Research (CRSR) was established to advance the rehabilitative care for service members with combat-related injuries, particularly those with orthopedic, cognitive, and neurological complications. The center supports comprehensive research projects to optimize treatment strategies and promote the successful return to duty and community reintegration of injured service members. The center also provides a unique platform for fostering innovative research and incorporating clinical/technical advances in the rehabilitative care for service members. CRSR is composed of four research focus areas: (1) identifying barriers to successful rehabilitation and reintegration, (2) improving pain management strategies to promote full participation in rehabilitation programs, (3) applying novel technologies to advance rehabilitation methods and enhance outcome assessments, and (4) transferring new technology to improve functional capacity, independence, and quality of life. Each of these research focus areas works synergistically to influence the quality of life for injured service members. The purpose of this overview is to highlight the clinical research efforts of CRSR, namely how this organization engages a broad group of interdisciplinary investigators from medicine, biology, engineering, anthropology, and physiology to help solve clinically relevant problems for our service members, veterans, and their families.