Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial.

BACKGROUND: Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems. DESIGN: The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss). SUMMARY: The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

Histologic Accuracy of Mohs Micrographic Surgery.

BACKGROUND: Mohs micrographic surgery enables the surgeon to maximize tumor removal while minimizing the amount of tissue being removed using advanced mapping techniques combined with microscopy. Interpretation of frozen section slides is vital to the success of Mohs micrographic surgery. OBJECTIVE: Evaluate and confirm the congruence of frozen section slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists. METHODS: Retrospective cohort concordance study spanning 10 years (n = 1,720 cases). RESULTS: The concordance rate for frozen slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists in this study was 99.5%. CONCLUSION: This study demonstrates agreement between the interpretation of histologic frozen section slides when evaluated by fellowship-trained Mohs surgeons and dermatopathologists.

Comparison of the metabolic demands of dance performance using three mobility devices for a dancer with spinal cord injury and an able-bodied dancer.

Mobility devices for dancers with physical mobility impairments have previously been limited to traditional manual or power wheelchairs. The hands-free torso-controlled mobility chair is a unique powered mobility device which allows greater freedom and expression of movement of the trunk and upper extremities. This study compared differences in energy expenditure during a standardized dance activity using three mobility devices: the hands-free torso-controlled mobility chair, a manual sports wheelchair with hand-arm control, and an electric power chair with hand-joystick control. An experienced dancer with C7 incomplete spinal cord injury (SCI) and an experienced able-bodied dancer were recruited for testing. Three measurement trials were obtained for each chair per subject. Oxygen uptake (VO2) and heart rate (HR) were measured continuously during the dance activity. Immediately following the dance activity, subjects rated perceived exertion. Significant differences (p ≤ 0.05) and similar linear patterns in VO2 and HR responses were observed between chairs for both dancers. When the hands-free mobility chair was used, the dance activity required a moderate level of energy expenditure compared to the manual sports chair or electric power chair for both dancers. Higher ratings of perceived exertion were observed in the manual chair compared to the other chairs for the dancer with SCI, but were similar between chairs for the able-bodied dancer. These results suggest that for a dancer with high-level SCI, the hands-free torso-controlled mobility chair may offer improved freedom and expressive movement possibilities and is an energy-efficient mobility device.

Transfemoral interface considerations: A clinical consensus practice guideline.

BACKGROUND: Although there have been a number of studies exploring the impact and efficacy of transfemoral prosthetic components such as knee and foot mechanisms, the empirical evidence surrounding transfemoral prosthetic interface considerations is limited. This constitutes a substantial void for practicing clinicians seeking to apply best practices for patients who use transfemoral prostheses. Recent years have seen increased production and availability of clinical practice guidelines germane to prosthetic rehabilitation. In those areas where empirical evidence is lacking, consensus clinical opinions may constitute the highest level of evidence. OBJECTIVE: A consensus exercise was performed to generate clinical practice recommendations in the areas of transfemoral interface considerations including socket variations and critical design features, suspension and interface considerations, alignment, heat retention and dermatologic considerations, female considerations, surgical considerations, and both regulatory and ethical considerations related to osseointegration. METHODS: This began with the generation of postulate items through systematic and narrative literature reviews. A Delphi consensus exercise was performed among clinical experts in government hospital and private clinical practice settings, culminating in a series of clinical practice recommendations associated with the prosthesis-limb interface for individuals with transfemoral amputation. RESULTS: The completed recommendations include guidance statements relative to socket variations and critical design features, female considerations, suspension and interface considerations, surgical variations and prescription considerations, rehabilitation team considerations and both regulatory and ethical considerations related to osseointegration. CONCLUSIONS: The Delphi process facilitated the development of practice guidelines for transfemoral prosthetic interface considerations based on aggregated subject matter expertise.

Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis.

PURPOSE: A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use. MATERIALS AND METHODS: A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed. RESULTS: The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) (p < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization. CONCLUSIONS: The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

Management of Upper Limb Amputation Rehabilitation: Synopsis of the 2022 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for Acquired Amputation.

ABSTRACT: Upper limb amputation can result in significant functional impairment necessitating a comprehensive rehabilitation approach throughout the continuum of care. In 2022, the Departments of Veteran Affairs and Defense completed an updated clinical practice guideline for the management of upper limb amputation rehabilitation. This practice guideline was developed by a workgroup of subject-matter experts from a variety of disciplines. Twelve key questions were developed by the workgroup using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) format to establish the scope of the literature review. Eighteen recommendations were developed through extensive review of the available literature and use of the Grading of Recommendations, Assessment, Development and Evaluation criteria. The strength of each recommendation was determined based on the quality of the research evidence and the additional domains of the Grading of Recommendations, Assessment, Development and Evaluation criteria. Of the 18 recommendations, 4 were found to have sufficient evidence to suggest for use of a particular rehabilitation management strategy. Thus, the 2022 Department of Veteran Affairs and Department of Defense clinical practice guideline provides updated, evidence-based information on the care and rehabilitation of persons with upper limb amputation. However, a significant lack of high-quality evidence in upper limb amputation rehabilitation limited evidence-based clinical guidance to assist healthcare providers in managing this population.

Understanding Implications of Residual Limb Length, Strength, and Range-of-Motion Impairments of Veterans With Upper Limb Amputation.

OBJECTIVE: The aim of the study was to describe and quantify the relationship between limb impairment variables to key functional outcomes. DESIGN: This was an observational study of 107 participants with unilateral above/at-elbow or below-elbow/wrist amputation. Demographics, prosthesis characteristics, residual limb length, and prevalence of passive range-of-motion restrictions, and strength impairments were described. Correlations between impairment variables were estimated. Linear regressions examined associations between impairment variables and activity performance, health-related quality of life, disability, and prosthesis satisfaction. RESULTS: Prevalence of short/very short below- and above-elbow residua was 25.7% and 12.5%, respectively. Shorter below-elbow/wrist residual limb length was correlated with elbow flexion weakness (r = 0.30) and prevalence of passive range of motion (r = 0.25). Shoulder prevalence of passive range-of-motion restrictions were correlated with shoulder (r = 0.27-0.51) and elbow weakness (r = 0.25-0.46). In regressions, activity performance was worse for those with shoulder flexion prevalence of passive range-of-motion restrictions (B = -5.0, P = 0.03) and better for those with flexion restrictions (B = 3.3, P = 0.04) compared with normal prevalence of passive range of motion. Prosthetic satisfaction was lower for those with limited elbow prevalence of passive range of motion. CONCLUSIONS: Short below-elbow residual limb length was correlated with impairment of elbow flexion strength and prevalence of passive range of motion. Prevalence of passive range-of-motion restrictions were most prevalent at the shoulder and were strongly correlated with weakness in the same planes of motion. Few significant associations were found between impairment variables and outcomes.

Benefits of the Genium microprocessor controlled prosthetic knee on ambulation, mobility, activities of daily living and quality of life: a systematic literature review.

PURPOSE: The benefits of advanced hydraulic microprocessor controlled knee (MPK) joints have been well established and repeatedly confirmed. The Genium knee was introduced in 2011 containing an enhanced control concept including additional sensors and improved algorithms enabling a range of new functions for transfemoral amputees (TFAs). A systematic review was conducted to evaluate the effect of the Genium knee on ambulation, mobility, activities of daily living (ADLs) and quality of life compared to standard MPKs. MATERIALS AND METHODS: The review was conducted according to PRISMA Guidelines and Recommendations of the State-of-Science Evidence Report Guidelines of the American Academy of Orthotists & Prosthetists. RESULTS: Twelve articles were included in the review and reported primarily on active subjects (MFCL-3/4) transitioning from C-Leg to Genium knee systems. The overall validity of the evidence was medium to high with the exception of one article having low validity. Synthesis of biomechanical analyses concludes that gait during level walking, stairs and ramps is more physiological and symmetric following accommodation and use of the Genium in community ambulating TFAs. Further, sound side loading and compensatory motions are reduced. Transitioning from C-Leg to the Genium knee additionally resulted in significant improvements in mobility, quality of life and the performance in activities of daily living (ADLs). CONCLUSION: A high level of evidence was identified when assessing the ability of Genium to improve gait quality and safety and performance in ADLs. While individual studies report significant improvements in terms of quality of life and mobility, additional studies are needed to increase the evidence level.Implications for rehabilitationMicroprocessor controlled prosthetic knees (MPKs) are well-established devices to serve patients with transfemoral amputation. Studies conducted mostly with the C-Leg MPK show that such knees significantly increase patient safety, ambulation, mobility, performance in activities of daily living and quality of life.Genium MPK includes advanced features which enable a range of new functions and functional benefits to patients. Transitioning from conventional MPKs (i.e., C-Leg) to Genium MPK resulted in more physiological gait, more equally distributed loading between the prosthetic and sound limbs, as well as reduced compensatory movements on the sounds side. These outcomes could potentially reduce the long-term risks of secondary physical complications in prosthetic users (i.e., osteoarthritis, osteoporosis). Genium significantly improved mobility, performance in activities of daily living, and quality of life in the patients using a conventional MPK (C-Leg).Different functioning principles of the MPKs presently available are responsible for different performance levels the knees offer to users. The amount of clinical evidence is also knee-dependent, with the C-Leg knee being most extensively tested in clinical studies. This systematic review concludes that Genium offers further advantages to transfemoral patients as compared to conventional MPKs (C-Leg).

Amputation Care Quality and Satisfaction With Prosthetic Limb Services: A Longitudinal Study of Veterans With Upper Limb Amputation.

PURPOSE: This study sought to measure and identify factors associated with satisfaction with care among veterans. The metrics were colelcted for those receiving prosthetic limb care at the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) care settings and at community-based care providers. METHODS: A longitudinal cohort of veterans with major upper limb amputation receiving any VA care from 2010 to 2015 were interviewed by phone twice, 1 year apart. Care satisfaction was measured by the Orthotics and Prosthetics User's Survey (OPUS) client satisfaction survey (CSS), and prosthesis satisfaction was measured by the OPUS client satisfaction with device (CSD), and the Trinity Amputation and Prosthetic Experience Scale satisfaction scales. The Quality of Care index, developed for this study, assessed care quality. Bivariate analyses and multivariable linear regressions identified factors associated with CSS. Wilcoxon Mann-Whitney rank tests and Fisher exact tests compared CSS and Quality of Care items at follow-up for those with care within and outside of the VA and DoD. RESULTS: The study included 808 baseline participants and 585 follow-up participants. Device satisfaction and receipt of amputation care in the prior year were associated with greater satisfaction with care quality. Persons with bilateral amputation were significantly less satisfied with wait times. Veterans who received amputation care in the VA or DoD had better, but not statistically different, mean (SD) CSS scores: 31.6 (22.6) vs 39.4 (16.9), when compared with those who received care outside the VA or DoD. Those with care inside the VA or DoD were also more likely to have a functional assessment in the prior year (33.7% vs 7.1%, P = .06), be contacted by providers (42.7% vs 18.8%, P = .07), and receive amputation care information (41.6% vs 0%, P =.002). No statistically significant differences in CSS, Quality of Care scores, or pain measures were observed between baseline and follow-up. In regression models, those with higher CSD scores and with prior year amputation care had higher satisfaction when compared to those who had not received care. CONCLUSIONS: Satisfaction with prosthetic limb care is associated with device satisfaction and receipt of care within the prior year. Veterans receiving amputation care within the VA or DoD received better care quality scores than those receiving prosthetic care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the 12 months of this study. Findings from this study can serve as benchmarks for future work on care satisfaction and quality of amputation rehabilitative care.

Effect of transfemoral prosthetic socket interface design on gait, balance, mobility, and preference: A randomized clinical trial.

BACKGROUND: There are alternative transfemoral (TF) socket interface designs that have not been compared with the standard of care, ischial ramus containment (IRC). The interface directly affects performance. OBJECTIVES: To compare 3 TF interface designs, IRC, dynamic socket (DS), and subischial (Sub-I), regarding gait, balance, mobility, and preference. The authors hypothesized that these more active users may experience gait, mobility, and preference benefits from the less intrusive DS and Sub-I interface designs. STUDY DESIGN: Single-blind, repeated-measures, 3-period randomized controlled crossover clinical trial. METHODS: People with unilateral TF amputation with 1 year or longer prosthesis use experience, independent community ambulatory status, 18 to 60 years of age, of any race or ethnicity, with a body mass of 45 to 125 kg, and with a self-reported ability to walk for 20 minutes continuously were included in the study. Each participant was fit in all 3 interface designs. RESULTS: Thirteen participants completed the clinical trial. Velocity, cadence, mobility, and balance were not statistically different between the 3 socket conditions. The DS demonstrated significantly greater symmetry in swing, stance, single support percentage, and toe angle compared with IRC and Sub-I. Sixty days after study completion, 7 participants changed interfaces, trending away from IRC. CONCLUSIONS: Large differences were not observed. Small differences in spatiotemporal gait measures combined with patient preference may make a meaningful difference to individual patients and should be considered.

The effect of the transfemoral prosthetic socket interface designs on skeletal motion and socket comfort: A randomized clinical trial.

BACKGROUND: The most crucial aspect of a prosthesis is the socket, as it will directly determine gait stability and quality. The current standard of care ischial ramus containment socket is reported to increase coronal stability through gait; however, socket discomfort is the primary complaint among prosthetic users. OBJECTIVES: The purpose of this study is to compare ischial ramus containment to alternatives in the transfemoral amputee population. All subjects were fit with three different sockets: traditional ischial ramus containment, a dynamic socket, and a sub-ischial. In this study, authors hypothesized socket skeletal motion would be equivalent across interventions. STUDY DESIGN: Single-blind, repeated-measures, three-period randomized crossover clinical trial. METHODS: Outcome measures were socket comfort score and skeletal motion, viewed coronally with X-ray measuring the position of the skeleton in relationship to the socket in full weight-bearing and full un-loading. RESULTS: The mean age was 38.2 and mean Amputee Mobility Predictor score was 40. Mean vertical movement, horizontal movement, single limb prosthetic stance, mean femoral adduction in swing and stance, and median socket comfort score were not statistically different. CONCLUSION: The socket design did not significantly effect skeletal motion and socket comfort. All socket designs are suitable depending on the patient-centric preferences and prosthetist skill set. CLINICAL RELEVANCE: The comfort of the standard of care transfemoral amputation socket has been widely reported as problematic. A comparison of alternative designs in a controlled clinical trial environment will assist the clinician in understanding the impact of design regarding skeletal motion and comfort. Users could benefit from alternatives applied in clinical practice.

Clinical Practice Guidelines for the Rehabilitation of Lower Limb Amputation: An Update from the Department of Veterans Affairs and Department of Defense.

Between 2015 and 2017, the US Department of Veterans Affairs and the US Department of Defense developed a clinical practice guideline for rehabilitation of lower limb amputation to address key clinical questions. A multidisciplinary workgroup of US Department of Veterans Affairs and US Department of Defense amputation care subject matter experts was formed, and an extensive literature search was performed which identified 3685 citations published from January 2007 to July 2016. Articles were excluded based on established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded using the National Academies of Science GRADE criteria. Recommendations were formulated after extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semirigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this clinical practice guideline used the best available evidence from the past 10 yrs to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation.

Low back pain in persons with lower extremity amputation: a systematic review of the literature.

BACKGROUND CONTEXT: Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life. PURPOSE: The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research. STUDY DESIGN/SETTING: Systematic review of the literature. METHODS: A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs. RESULTS: Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES. CONCLUSIONS: Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

FUNCTIONAL DIFFERENCES OF BILATERAL TRANSFEMORAL AMPUTEES USING FULL-LENGTH AND STUBBY-LENGTH PROSTHESES.

Many unilateral amputations are followed by a contralateral amputation within three years, sometimes presenting as bilateral transfemoral amputations. Bilateral transfemoral amputees that successfully use prostheses are an understudied patient population. This study establishes reference values for this population in users of short non-articulating (stubby) or full-length articulating prostheses. Anthropometric and demographic information was collected from participants. Additionally, participants completed a self-reported Prosthesis Evaluation Questionnaire-Mobility Subscale 12/5 (PEQ-MS) and performed multiple physical mobility tests, including walking tests and the multi-directional Four Square Step Test (FSST). Full-length users rated their abilities to complete the PEQ-MS tasks as less difficult than stubby users in eight of the 12 items. Gait analysis revealed a greater amount of time is spent in stance phase with a greater portion in double limb support for both user groups, and a greater percentage in stance phase for the subject-reported dominant limb. Stubby users' gait velocity had a significant reduction from that of their full-length peers; however, cadence was similar between groups. Both user groups completed the FSST at comparable times. These outcomes may be of benefit for identifying tasks bilateral transfemoral prosthetic users may find to be most difficult as well as for identifying normal ambulation patterns within this population. Future studies with a greater number of subjects would enable these results to be further generalized.

Clinically Relevant Outcome Measures Following Limb Osseointegration; Systematic Review of the Literature.

OBJECTIVES: The current standard of care for an amputee is a socket-based prostheses. An osseointegrated implant (OI) is an alternative for prosthetic attachment. Osseointegration addresses reported problems related to wearing a socket interface, such as skin issues, discomfort, diminished function, quality of life, prosthetic use, and abandonment. The purpose of this report is to systematically review current literature regarding OI to identify and categorize the reported clinically relevant outcome measures, rate the quality of available evidence, and synthesize the findings. DATA SOURCES: A multidisciplinary team used PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) methods. Search methodology was based on identifying clinically relevant articles. Three databases were searched: PubMed, CINAHL, and Web of Science. STUDY SELECTION: Clinical studies with aggregated data reporting at least 1 clinically relevant outcome measure were included. DATA EXTRACTION: The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criterion was used for critical appraisal and recommendations. CONCLUSIONS: This review identified 21 clinically relevant observational studies. Outcome measures were categorized into the following 9 categories: vibratory stimulation, complications, biomechanics, economics, patient-reported outcome measures, electromyography, x-ray, physical functional performance, and energy consumption. This systematic review consisted of Level III and IV observational studies. Homogeneous outcome measures with strong psychometric properties across prospective studies do not exist to date. Higher-level, prospective, randomized, long-term, clinically relevant trials are needed to prove efficacy of OI compared with socket prosthetic attachment. Osseointegration was at least equivalent to sockets in most studies. In some cases, it was superior. Osseointegration represents a promising alternative to socket prosthetic attachments for extremity amputees. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Shuttle lock release modification of a trans-tibial prosthesis with an obese client.

This article describes the procedure taken to modify trans-tibial shuttle lock release mechanisms to decrease standard reach requirements in a case of limited mobility secondary to morbid obesity. The participant was a middle-aged, morbidly obese client with bilateral trans-tibial amputations. The distomedial shuttle lock release buttons were modified to activate with a cable/Dacron pull strap located proximal/lateral. The outcome of the modification was determined by whether or not the client would be able to independently doff the prostheses, if the patient was satisfied with the prostheses and by the condition of the components at the three-month follow-up. The client was independently successful at doffing both prostheses following the modification procedure. The patient expressed satisfaction with operation of the release mechanism but cosmetic covering was an issue. Components were optimally functioning at the three month follow-up. It was concluded that this procedure is a viable option for relocating distomedial release lock buttons more proximally when reach is limited. The procedure is not indicated in every case as gadget tolerance, cosmesis and manufacturer warranty issues must be considered.

Energy costs and performance of transfemoral amputees and non-amputees during walking and running: A pilot study.

BACKGROUND: Limited information is available concerning the effects of prosthetic foot components on energy costs and ambulatory performance for transfemoral amputees. OBJECTIVES: Compare energy costs (VO2; gait economy) and ambulatory performance (self-selected walking speeds, self-selected running speeds, peak running speeds) differences during walking and running for transfemoral amputees and matched, non-amputee runners. STUDY DESIGN: Repeated measures. METHODS: Transfemoral amputees were accommodated and tested with three prosthetic feet: conventional foot, solid-ankle cushioned heel (SACH); energy storing and return foot, Renegade; and running-specific energy storing and return foot, Nitro. RESULTS: During walking, VO2 was similar between transfemoral amputees but was increased compared to controls. Self-selected walking speeds were slower for SACH compared to Renegade and Nitro. For transfemoral amputees, gait economy was decreased and self-selected walking speeds were slower compared to controls. During fixed running speeds, transfemoral amputees ran using Nitro, and VO2 was greater compared to controls. Transfemoral amputees ran at self-selected running speeds using Renegade and Nitro. Self-selected running speeds were slower for Renegade compared to Nitro. For transfemoral amputees, gait economy was decreased and self-selected running speeds were slower compared to controls. VO2 peak was similar between transfemoral amputees and controls, but controls achieved greater peak running speeds and % grade. CONCLUSION: Energy costs were greater and ambulatory performance was lower for transfemoral amputees compared to matched, non-amputee controls for all prosthetic foot conditions. Clinical relevance Both types of energy storing and return feet may improve walking performance for transfemoral amputees by providing faster self-selected walking speeds. For transfemoral amputees interested in performing vigorous running (exercise and running competition), clinicians should recommend a running-specific energy storing and return foot.

Predictors of success on the American Board for Certification's prosthetics certification examination.

BACKGROUND: Many factors can potentially impact pass or fail performance of a certification examination. While studies regarding predictors of success have been conducted in other professions, no such studies have been conducted in prosthetics and orthotics. OBJECTIVES: Determine whether there are significant differences in prosthetics certification examination success or failure based on gender, Carnegie ranking of the institution from where the candidate received the degree, and whether the candidate is extending credential from orthotics to include prosthetics. STUDY DESIGN: Retrospective study. METHODS: Data of candidates who completed prosthetics residency in 2011 and 2012 were evaluated for relationships with the dependent variables. RESULTS: Only credential extension showed a statistically significant relationship with written multiple choice ( p = 0.000), written simulation ( p = 0.006), and clinical patient management examinations ( p = 0.005) as well as with success or failure in obtaining prosthetics certification ( p < 0.001). CONCLUSIONS: Currently available data for analysis regarding predictors of success are limited. Collection of additional variables (i.e. pre-requisite grade point average) in the future will permit analysis of more robust information. Presently available data reveal that candidates seeking to extend credential are more successful in obtaining certified prosthetist status compared with those testing for the first time. Clinical relevance Understanding factors contributing to attaining licensure is important as the prosthetic/orthotic practitioner population ages. This is the first study to investigate this dimension of prosthetics and orthotics training, which upholds professional standards and protects patients. It helps the profession develop best educational and clinical practices in managing patients who utilize prosthetic technologies.

Biopsychosocial risk factors associated with chronic low back pain after lower limb amputation.

Low back pain is a common secondary health condition after lower limb amputation with important implications related to functional capabilities and overall quality of life. Despite the high prevalence of low back pain after lower limb amputation, the underlying etiologies of the disorder remain unknown. This hypothesis-driven communication provides evidence in support of using the multifactorial, biopsychosocial model of low back pain experience in the general population for identification of potential risk factors and rehabilitation targets for low back pain after lower limb amputation. Key findings that link biological, psychological, and social factors and the experience of low back pain in the general patient population with LBP are discussed while highlighting gaps in our current state of knowledge related to the association of these factor and presence of low back pain after lower limb amputation. Importantly, the aim of this communication was not to propose a new model, but rather to organize data originating from prior work into a coherent hypothesis-driven conceptual framework to better understand the need for multifaceted and multidisciplinary intervention approaches for effective treatment of low back pain after lower limb amputation.