Psoas force recruitment in full-body musculoskeletal movement simulations is restored with a geometrically informed cost function weighting.

Simulations of musculoskeletal models are useful for estimating internal muscle and joint forces. However, predicted forces rely on optimization and modeling formulations. Geometric detail is important to predict muscle forces, and greater geometric complexity is required for muscles that have broad attachments or span many joints, as in the torso. However, the extent to which optimized muscle force recruitment is sensitive to these geometry choices is unclear. We developed level, uphill and downhill sloped walking simulations using a standard (uniformly weighted, "fatigue-like") cost function with lower limb and full-body musculoskeletal models to evaluate hip muscle recruitment with different geometric representations of the psoas muscle under walking conditions with varying hip moment demands. We also tested a novel cost function formulation where muscle activations were weighted according to the modeled geometric detail in the full-body model. Total psoas force was less and iliacus, rectus femoris, and other hip flexors' force was greater when psoas was modeled with greater geometric detail compared to other hip muscles for all slopes. The proposed weighting scheme restored hip muscle force recruitment without sacrificing detailed psoas geometry. In addition, we found that lumbar, but not hip, joint contact forces were influenced by psoas force recruitment. Our results demonstrate that static optimization dependent simulations using models comprised of muscles with different amounts of geometric detail bias force recruitment toward muscles with less geometric detail. Muscle activation weighting that accounts for differences in geometric complexity across muscles corrects for this recruitment bias.

Advancing a U.S. navy shipboard infrastructure for sleep monitoring with wearable technology.

Development of fatigue management solutions is critical to U.S. Navy populations. This study explored the operational feasibility and acceptability of commercial wearable devices (Oura Ring and ReadiBand) in a warship environment with 845 Sailors across five ship cohorts during at-sea operations ranging from 10 to 31 days. Participants were required to wear both devices and check-in daily with research staff. Both devices functioned as designed in the environment and reliably collected sleep-wake data. Over 10,000 person-days at-sea, overall prevalence of Oura and ReadiBand use was 69% and 71%, respectively. Individual use rates were 71 ± 38% of days underway for Oura and 59 ± 34% for ReadiBand. Analysis of individual factors showed increasing device use and less device interference with age, and more men than women found the devices comfortable. This study provides initial support that commercial wearables can contribute to infrastructures for operational fatigue management in naval environments.

Concentric and eccentric hip musculotendon work depends on backpack loads and walking slopes.

Hip muscle weakness is associated with low back and leg injuries. In addition, hiking with heavy loads is linked to high incidence of overuse injuries. Walking with heavy loads on slopes alters hip biomechanics compared to unloaded walking, but individual muscle mechanical work in these challenging conditions is unknown. Using movement simulations, we quantified hip muscle concentric and eccentric work during walking on 0° and ±10° slopes with, and without 40% bodyweight added loads, and with and without a hip belt. For gluteus maximus, psoas, iliacus, gluteus medius, and biceps femoris long head, both concentric and eccentric work were greatest during uphill walking. For rectus femoris and semimembranosus, concentric work was greatest during uphill and eccentric work was greatest during downhill walking. Loaded walking had greater concentric and eccentric work from rectus femoris, biceps femoris long head, and gluteus maximus. Psoas concentric work was greatest while carrying loads regardless of hip belt usage, but eccentric work was only greater than unloaded walking when using a hip belt. Loaded and uphill walking had high concentric work from gluteus maximus, and high eccentric work from gluteus medius and biceps femoris long head. Carrying heavy loads uphill may lead to excessive hip muscle fatigue and heightened injury risk. Effects of the greater eccentric work from hip flexors when wearing a hip belt on lumbar spine forces and pelvic stability should be investigated. Military and other occupational groups who carry heavy backpacks with hip belts should maintain eccentric strength of hip flexors and hamstrings.

Walking slope and heavy backpack loads affect torso muscle activity and kinematics.

The independent effects of sloped walking or carrying a heavy backpack on posture and torso muscle activations have been reported. While the combined effects of sloped walking and backpack loads are known to be physically demanding, how back and abdominal muscles adapt to walking on slopes with heavy load is unclear. This study quantified three-dimensional pelvis and torso kinematics and muscle activity from longissimus, iliocostalis, rectus abdominis, and external oblique during walking on 0° and ± 10° degree slopes with and without backpack loads using two different backpack configurations (hip-belt assisted and shoulder-borne). Iliocostalis activity was greater during downhill and uphill compared to level walking, but longissimus was only greater during uphill. Rectus abdominis activity was greater during downhill and uphill compared to level, while external oblique activity decreased as slopes progressed from down to up. Longissimus, but not iliocostalis, activity was reduced during both backpack configurations compared to walking with no pack. Hip-belt assisted load carriage required less rectus abdominis activity compared to using shoulder-borne only backpacks; however, external oblique was not influenced by backpack condition. Our results revealed different responses between iliocostalis and longissimus, and between rectus abdominis and external obliques, suggesting different motor control strategies between anatomical planes.

Effects of foot intensive rehabilitation (FIRE) on clinical outcomes for patients with chronic ankle instability: a randomized controlled trial protocol.

BACKGROUND: Lateral ankle sprains account for a large proportion of musculoskeletal injuries among civilians and military service members, with up to 40% of patients developing chronic ankle instability (CAI). Although foot function is compromised in patients with CAI, these impairments are not routinely addressed by current standard of care (SOC) rehabilitation protocols, potentially limiting their effectiveness. The purpose of this randomized controlled trial is to determine if a Foot Intensive REhabilitation (FIRE) protocol is more effective compared to SOC rehabilitation for patients with CAI. METHODS: This study will use a three-site, single-blind, randomized controlled trial design with data collected over four data collection points (baseline and post-intervention with 6-, 12-, and 24-month follow-ups) to assess variables related to recurrent injury, sensorimotor function, and self-reported function. A total of 150 CAI patients (50 per site) will be randomly assigned to one of two rehabilitation groups (FIRE or SOC). Rehabilitation will consist of a 6-week intervention composed of supervised and home exercises. Patients assigned to SOC will complete exercises focused on ankle strengthening, balance training, and range of motion, while patients assigned to FIRE will complete a modified SOC program along with additional exercises focused on intrinsic foot muscle activation, dynamic foot stability, and plantar cutaneous stimulation. DISCUSSION: The overall goal of this trial is to compare the effectiveness of a FIRE program versus a SOC program on near- and long-term functional outcomes in patients with CAI. We hypothesize the FIRE program will reduce the occurrence of future ankle sprains and ankle giving way episodes while creating clinically relevant improvements in sensorimotor function and self-reported disability beyond the SOC program alone. This study will also provide longitudinal outcome findings for both FIRE and SOC for up to two years. Enhancing the current SOC for CAI will improve the ability of rehabilitation to reduce subsequent ankle injuries, diminish CAI-related impairments, and improve patient-oriented measures of health, which are critical for the immediate and long-term health of civilians and service members with this condition. Trial Registration Clinicaltrials.gov Registry: NCT #NCT04493645 (7/29/20).

Assessing Injury Susceptibility at Marine Corps Recruit Depot, San Diego, California.

ABSTRACT: Poh, PYS, Sessoms, PH, Haluch, KS, and Trone, DW. Assessing injury susceptibility at Marine Corps Recruit Depot, San Diego, California. J Strength Cond Res 37(7): 1530-1536, 2023-Marine Corps Recruit Depot (MCRD) recruits undergo demanding training. Musculoskeletal injury (MSKI) accounts for attrition and graduation delays. Functional tests, such as Functional Movement Screen (FMS), Y-Balance Test-Lower Quarter (YBT-LQ), and ankle dorsiflexion range of motion (AD-ROM), may identify individuals at greater MSKI risk. This study tested the hypothesis that functional assessments may inform injury prediction. Male recruits ( N = 407; mean ± SD : age, 20 ± 2 years) performed baseline functional tests. Marine Corps Recruit Depot staff tracked MSKI and graduation outcomes. The chi-square test of independence (individual FMS exercises) and Mann-Whitney U (FMS composite score) test examined the relationship between FMS and MSKI incidence. One-way analysis of variance compared YBT-LQ and AD-ROM with MSKI incidence. Twelve recruits (3%) incurred a lower extremity MSKI and were dropped. Of those 12, 9 had a delayed graduation, and 3 separated from enlistment. The level of significance was set at p < 0.10 to identify between-group differences (yes-MSKI vs. no-MSKI). Functional movement screen composite score ( p = 0.064), hurdle step ( p = 0.059), and trunk stability ( p = 0.001) were lower in yes-MSKI. Y-Balance Test-Lower Quarter anterior direction difference between legs ( p = 0.011) and AD-ROM right side ( p = 0.055) was greater in yes-MSKI. Odds ratios (OR) were calculated using cut-off scores, with strong odds of sustaining MSKI with FMS trunk stability score <2 (OR: 7.56, 95% confidence interval [CI]: [2.32, 24.61]) and YBT-LQ anterior difference >6.25 cm (OR: 6.38, 95% CI: [1.98, 20.55]). Recruits who incurred MSKI had scores that indicated lesser mobility and stability of the lower extremity, providing preliminary evidence that when assessed together, FMS, YBT-LQ, and AD-ROM, may have predictive value for identifying those at MSKI risk.

Muscle Engagement Monitoring Using Self-Adhesive Elastic Nanocomposite Fabrics.

Insight into, and measurements of, muscle contraction during movement may help improve the assessment of muscle function, quantification of athletic performance, and understanding of muscle behavior, prior to and during rehabilitation following neuromusculoskeletal injury. A self-adhesive, elastic fabric, nanocomposite, skin-strain sensor was developed and validated for human movement monitoring. We hypothesized that skin-strain measurements from these wearables would reveal different degrees of muscle engagement during functional movements. To test this hypothesis, the strain sensing properties of the elastic fabric sensors, especially their linearity, stability, repeatability, and sensitivity, were first verified using load frame tests. Human subject tests conducted in parallel with optical motion capture confirmed that they can reliably measure tensile and compressive skin-strains across the calf and tibialis anterior. Then, a pilot study was conducted to assess the correlation of skin-strain measurements with surface electromyography (sEMG) signals. Subjects did biceps curls with different weights, and the responses of the elastic fabric sensors worn over the biceps brachii and flexor carpi radialis (i.e., forearm) were well-correlated with sEMG muscle engagement measures. These nanocomposite fabric sensors were validated for monitoring muscle engagement during functional activities and did not suffer from the motion artifacts typically observed when using sEMGs in free-living community settings.

Uneven Treadmill Training for Rehabilitation of Lateral Ankle Sprains and Chronic Ankle Instability: Protocol for a Pragmatic Randomized Controlled Trial.

BACKGROUND: Lateral ankle sprains (LASs) are common injuries among military service members. Approximately 40% of individuals with an LAS progress to develop chronic ankle instability (CAI), a condition that results in substantial mechanical and neurophysiological impairment and activity limitation. Since proprioceptive and balance training improve functional outcomes and prevent secondary injury following LAS, they are recommended in clinical practice. Uneven treadmills are an innovative modality that challenge the sensorimotor system while performing an ecologically valid task simulating environments frequently encountered by service members with LAS and CAI. OBJECTIVE: The aim of this study is to evaluate whether the inclusion of uneven treadmill training in standard rehabilitation can improve clinical, functional, biomechanical, and patient-reported outcomes compared with the standard of care alone in service members with LAS and CAI. The prophylactic effects of treatment on secondary injury and identification of any contributing or mediating factors that influence outcomes following treatment will also be evaluated. We hypothesize that service members receiving uneven treadmill training will demonstrate greater improvements in clinical and instrumented measures of impairment, patient-reported function, and lower risk of injury recurrence than the control group immediately post and 18 months following treatment. METHODS: A multisite, parallel randomized clinical trial will be performed among service members aged 18-49 years being treated for LAS and CAI in military treatment facilities in the United States. Participants randomly assigned and allocated to receive the experimental intervention will be provided up to 12 sessions of training on an uneven terrain treadmill over a 6-week treatment course to supplement standard rehabilitation care. Treatment intensity of the rehabilitation exercises and treadmill training will be progressed on the basis of patient-perceived intensity and treatment responses. Outcome measures will include patient-reported outcomes, functional assessments, performance measures, and biomechanical measures. Investigators collecting outcome measures will be blinded to treatment allocation. Reinjury rates and patient-reported outcomes of function will be tracked over 18 months following treatment. RESULTS: The project was funded in September 2020. Patient recruitment began in November 2021, with 3 participants enrolled as of February 2022. Dissemination of the main study findings is anticipated in 2024. CONCLUSIONS: This study will assess the impact of an innovative uneven-terrain treadmill on treatment outcomes in the rehabilitation of service members with LAS and CAI. The results of this study will be used to inform rehabilitation practices and to potentially improve functional outcomes and secondary prevention in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04999904; https://clinicaltrials.gov/ct2/show/NCT04999904?term=NCT04999904. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/38442.

Head and Body Dyskinesia During Gait in Tactical Athletes With Vestibular Deficit Following Concussion.

Background: Vestibular deficit is common following concussion and may affect gait. The purpose of this study was to investigate differences in head and pelvic center of mass (COM) movement during gait in military tactical athletes with and without concussion-related central vestibular impairment. Material and Methods: 24 patients with post-concussion vestibular impairment (20 males, 4 females; age: 31.7 ± 7.9 years; BMI: 27.3 ± 3.3) and 24 matched controls (20 males, 4 females; age: 31.8 ± 6.4 years; BMI: 27.2 ± 2.6) were included in the analyses. Three-dimensional head and pelvic displacement and velocities were collected at a 1.0 m/s standardized treadmill walking speed and assessed using Statistical Parametric Mapping t-tests. Maximum differences (d max ) between groups were reported for all significant kinematic findings. Results: The Vestibular group demonstrated significantly diminished anteroposterior head excursions (d max = 2.3 cm, p = 0.02) and slower anteroposterior (d max = 0.37 m/s, p = 0.01), mediolateral (d max = 0.47 m/s, p = 0.02) and vertical (d max = 0.26 m/s, p < 0.001) velocities during terminal stance into pre-swing phases compared to the Control group. Vertical pelvic excursion was significantly increased in midstance (d max = 2.4 cm, p = 0.03) and mediolaterally during pre- to initial-swing phases (d max = 7.5 cm, p < 0.001) in the Vestibular group. In addition, pelvic velocities of the Vestibular group were higher mediolaterally during midstance (d max = 0.19 m/s, p = 0.02) and vertically during post-initial contact (d max = 0.14 m/s, p < 0.001) and pre-swing (d max = 0.16 m/s, p < 0.001) compared to the Control group. Significance: The Vestibular group demonstrated a more constrained head movement strategy during gait compared with Controls, a finding that is likely attributed to a neurological impairment of visual-vestibular-somatosensory integration.

A backpack load sharing model to evaluate lumbar and hip joint contact forces during shoulder borne and hip belt assisted load carriage.

Musculoskeletal injuries of the lumbar spine occur frequently among military service members and are associated with heavy backpack loads. Musculoskeletal modeling and simulation facilitate biomechanical evaluation to compare different backpack designs. We developed a backpack attachment model that can be tuned to represent various load distributions between the torso and pelvis. We generated walking simulations to estimate muscle and joint contact forces of unloaded walking and while carrying 38 kg using shoulder-borne backpacks and hip belt-assisted backpacks for six U.S. Marines. Three-dimensional peak and average lumbar (L4-L5) and hip joint contact forces over the stance phase were compared between each load condition. Axial L4-L5 and axial and anterior hip joint contact forces were greater during both backpack conditions compared to the unloaded condition. Joint contact forces were similar between backpack conditions. Future studies incorporating additional participants, walking conditions, and backpack load distributions are suggested for further model development and backpack design evaluation.

Trauma Exposure and Functional Movement Characteristics of Male Tactical Athletes.

CONTEXT: Tactical athletes commonly experience high levels of physical stress, which may increase their risk of musculoskeletal injury. It is critical to understand psychological predictors of functional movement (FM), which may help prevent musculoskeletal injury in this population. OBJECTIVE: To determine the associations of combat and trauma exposure with FM characteristics of male tactical athletes. Secondary objectives were to explore confounding influences of age and physical injury history as well as the mediating role of bodily pain. DESIGN: Cross-sectional study. SETTING: Research laboratory. PATIENTS OR OTHER PARTICIPANTS: Eighty-two healthy, male, active-duty US Navy Explosive Ordnance Disposal personnel (age = 34.0 ± 6.7 years). MAIN OUTCOME MEASURE(S): Participants completed measures of combat exposure, trauma exposure, physical injury history, and bodily pain. We assessed FM characteristics (ie, Functional Movement Screen [FMS], Y-Balance Test), from which we derived a composite functional status (CFS) measure. Hypotheses were tested using correlational and multiple regression (causal-steps) models. RESULTS: In unadjusted models, trauma exposure was inversely associated with the FMS (P = .005) and CFS (P = .009) scores. In adjusted models, these relationships were robust to the confounding influences of age and physical injury history. Trauma exposure and bodily pain were substantive, independent predictors of FMS and CFS in causal-steps models (all P values < .05), implying additive rather than mediated effects (R2adj = 0.18-0.20). Combat exposure did not predict FM characteristics. CONCLUSIONS: To our knowledge, this is the first evidence of the influence of trauma exposure on the FM characteristics of male tactical athletes, independent of age, physical injury, and bodily pain. This program of research may help to advance the prevention and treatment of musculoskeletal injuries in the tactical environment.

Effect of a load distribution system on mobility and performance during simulated and field hiking while under load.

This study was conducted to test a modular scalable vest-load distribution system (MSV-LDS) against the plate carrier system (PC) currently used by the United States Marine Corps. Ten Marines engaged in 1.6 km load carriage trials in seven experimental conditions in a laboratory study. Kinematic, kinetic, and spatiotemporal gait parameters, muscle activity (electromyography), heart rate, caloric expenditure, shooting reaction times, and subjective responses were recorded. There was lower mean trapezius recruitment for the PC compared with the MSV-LDS for all conditions, and muscle activity was similar to baseline for the MSV-LDS. Twenty-seven Marines carrying the highest load were evaluated in the field, which measured an increase in energy expenditure with MSV-LDS; however, back discomfort was reduced. The field evaluation showed significantly reduced estimated ground reaction force on flat-ground segments with the MSV-LDS, and the data suggest both systems were comparable with respect to mobility and energy cost. Practitioner summary: This study found that a novel load distribution system appears to redistribute load for improved comfort as well as reduce estimated ground reaction force when engaged in hiking activities. Further, hiking with a load distribution system enables more neutral walking posture. Implications of load differences in loads carried are examined. Abbreviations: AGRF: anterior-posterior ground reaction forces; CAREN: Computer Assisted Rehabilitation Environment; GRF: ground reaction forces; HR: heart rate; ML-GRF: mediolateral ground reaction forces; MOLLE: Modular Lightweight Load-carrying Equipment; MSV-LDS: modular scalable vest-load distribution system; NHRC: Naval Health Research Center; PC: plate carrier; PPE: personal protective equipment; RPE: rating of perceived exertion; SAPI: small arms protective insert; sEMG: surface electromyography; USMC: United States Marine Corps; VGRF: Ground reaction forces in the vertical.

Improvements in dizziness and imbalance results from using a multi disciplinary and multi sensory approach to Vestibular Physical Therapy - a case study.

This paper discusses a case study of a 41-year-old active duty male service member who sustained head trauma from a motorcycle accident and underwent multidisciplinary vestibular physical therapy rehabilitation. He was initially treated with traditional physical therapy applications of treadmill walking and standing balance with some symptom improvements, but was not able to maintain a running speed that would allow him to return to full active duty status. Further treatment utilizing a Computer Assisted Rehabilitation Environment was performed in order to increase level of difficulty and further enhance function. This treatment is able to elicit vestibular deficits seen in the community as it requires subjects to walk and balance while performing tasks within a virtual scenario incorporating platform motion, visual surround and flow, and cognitive processing. After 6 weeks of therapy, twice weekly, improvements in clinical vestibular measures were observed as well as walking speed and patient confidence. The patient was able to return to full duty after treatment. This case study provides supportive evidence that multidimensional tasking in a virtual environment provides a safe but demanding form of vestibular therapy for patients needing more challenging tasks than those provided with traditional therapy techniques. Those persons requiring higher levels of performance before returning to full duty (e.g., pilots, special operators, etc.) may find this type of therapy beneficial.

Head stabilization measurements as a potential evaluation tool for comparison of persons with TBI and vestibular dysfunction with healthy controls.

A large percentage of persons with traumatic brain injury incur some type of vestibular dysfunction requiring vestibular physical therapy. These injuries may affect the natural ability to stabilize the head while walking. A simple method of utilizing motion capture equipment to measure head movement while walking was used to assess improvements in head stabilization of persons undergoing computerized vestibular physical therapy and virtual reality training for treatment of their vestibular problems. Movement data from the head and sacrum during gait were obtained over several visits and then analyzed to determine improved oscillatory head movement relative to the sacrum. The data suggest that, over time with treatment, head stabilization improves and moves toward a pattern similar to that of a healthy control population. This simple analysis of measuring head stability could be transferred to smaller, portable systems that are easily utilized to measure head stability during gait for use in gait assessment and physical therapy training.

Improvements in gait speed and weight shift of persons with traumatic brain injury and vestibular dysfunction using a virtual reality computer-assisted rehabilitation environment.

Many people sustaining a traumatic brain injury experience vestibular pathology requiring physical therapy for treatment. This study measured improvements in gait speed and weight shift for subjects receiving vestibular physical therapy using a Computer-Assisted Rehabilitation Environment (CAREN). A 6-session CAREN, 6-session traditional vestibular therapy group was compared with a 12-session CAREN only (0 traditional sessions) therapy group. These two groups were compared to each other and with data from healthy controls performing similar tasks on the CAREN. Those participating in 12 CAREN sessions had greater improvements in gait speed (p=0.014) and weight shift scores (p<0.001) and demonstrated similar values achieved by a healthy control population.

Task-specific fall prevention training is effective for warfighters with transtibial amputations.

BACKGROUND: Key factors limiting patients with lower extremity amputations to achieve maximal functional capabilities are falls and fear of falling. A task-specific fall prevention training program has successfully reduced prospectively recorded trip-related falls that occur in the community by the elderly. However, this program has not been tested in amputees. QUESTIONS/PURPOSES: In a cohort of unilateral transtibial amputees, we aimed to assess effectiveness of a falls prevention training program by (1) quantifying improvements in trunk control; (2) measuring responses to a standardized perturbation; and (3) demonstrating retention at 3 and 6 months after training. Second, we collected patient-reported outcomes for balance confidence and falls control. METHODS: Fourteen male military service members (26 ± 3 years) with unilateral transtibial amputations and who had been walking without an assistive device for a median of 10 months (range, 2-106 months) were recruited to participate in this prospective cohort study. The training program used a microprocessor-controlled treadmill designed to deliver task-specific postural perturbations that simulated a trip. The training consisted of six 30-minute sessions delivered over a 2-week period, during which task difficulty, including perturbation magnitude, increased as the patient's ability progressed. Training effectiveness was assessed using a perturbation test in an immersive virtual environment. The key outcome variables were peak trunk flexion and velocity, because trunk kinematics at the recovery step have been shown to be a determinant of fall likelihood. The patient-reported outcomes were also collected using questionnaires. The effectiveness of the rehabilitation program was also assessed by collecting data before perturbation training and comparing the key outcome parameters with those measured immediately after perturbation training (0 months) as well as both 3 and 6 months posttraining. RESULTS: Mean trunk flexion angle and velocity significantly improved after participating in the training program. The prosthetic limb trunk flexion angle improved from pretraining (42°; 95% confidence interval [CI], 38°-47°) to after training (31°; 95% CI, 25°-37°; p < 0.001). Likewise, the trunk flexion velocity improved from pretraining (187°/sec; 95% CI, 166°-209°) to after training (143°/sec; 95% CI, 119°-167°; p < 0.004). The results display a significant side-to-side difference for peak trunk flexion angle (p = 0.01) with perturbations of the prosthetic limb resulting in higher peak angles. Prosthetic limb trips also exhibited significantly greater peak trunk flexion velocity compared with trips of the prosthetic limb (p = 0.005). These changes were maintained up to 6 months after the training. The peak trunk flexion angle of the subjects when the prosthetic limb was perturbed had a mean of 31° (95% CI, 25°-37°) at 0 month, 32° (95% CI, 28°-37°) at 3 months, and 30° (95% CI, 25°-34°) at 6 months. Likewise, the peak trunk flexion velocity for the prosthetic limb was a mean of 143°/sec (95% CI, 118°-167°) at 0 months, 143°/sec (95% CI, 126°-159°) at 3 months, and 132° (95% CI, 115°-149°) at 6 months. The peak trunk flexion angle when the nonprosthetic limb was perturbed had a mean of 22° (95% CI, 18°-24°) at 0 months, a mean of 26° (95% CI, 20°-32°) at 3 months, and a mean of 23° (95% CI, 19°-28°) at 6 months. The peak trunk flexion velocity for the nonprosthetic limb had a mean of 85°/sec (95% CI, 71°-98°) at 0 months, a mean of 96° (95% CI, 68°-124°) at 3 months, and 87°/sec (95% CI, 68°-105°) at 6 months. There were no significant changes in the peak trunk flexion angle (p = 0.16) or peak trunk flexion velocity (p = 0.35) over time after the training ended. The skill retention was present when either the prosthetic or nonprosthetic limb was perturbed. There were side-to-side differences in the trunk flexion angle (p = 0.038) and trunk flexion velocity (p = 0.004). Perturbations of the prosthetic side resulted in larger trunk flexion and higher trunk flexion velocities. Subjects prospectively reported decreased stumbles, semicontrolled falls, and uncontrolled falls. CONCLUSIONS: These results indicate that task-specific fall prevention training is an effective rehabilitation method to reduce falls in persons with lower extremity transtibial amputations.

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.

Vestibular physical therapy intervention: utilizing a computer assisted rehabilitation environment in lieu of traditional physical therapy.

Advanced technology such as virtual reality or immersive environments increases the complexities and challenges therapists can impose on their patients. In this study, four patients with mild traumatic brain injury utilized a Computer Assisted Rehabilitation Environment (CAREN) in place of traditional vestibular physical therapy. Patients visited the CAREN twice weekly for 6 weeks. Therapy sessions included a variety of applications that tasked the cognitive and physical capabilities of individual patients. After the 6 weeks, all patients showed improvement on balance, gait and visual measures. Virtual reality based therapy is an engaging and effective tool to treat patients with deficiencies related to a prior brain injury.