The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Dorsal Root Ganglion Stimulation for Complex Regional Pain Syndrome (CRPS) Recurrence after Amputation for CRPS, and Failure of Conventional Spinal Cord Stimulation.

BACKGROUND: Limb amputation is sometimes being performed in long-standing complex regional pain syndrome (CRPS), although little evidence is available guiding management decisions, including how CRPS recurrence should be managed. METHODS: This report details the management of a young soldier with CRPS recurrence 2 years after midtibial amputation for CRPS. RESULTS: Conventional spinal cord stimulation did not achieve paraesthetic coverage, or pain relief in the stump, whereas L4 dorsal root ganglion stimulation achieved both coverage and initially modest pain relief, and over time, substantial pain relief. CONCLUSIONS: Current evidence does not support the use of amputation to improve either pain or function in CRPS. Before a decision is made, in exceptional cases, about referral for amputation, dorsal root ganglion stimulation should be considered as a potentially effective treatment, even where conventional spinal cord stimulator treatment has failed to achieve reliable paraesthetic cover. Furthermore, this treatment may provide pain relief in those patients with CRPS recurrence in the stump after amputation.

Temporal Spatial and Metabolic Measures of Walking in Highly Functional Individuals With Lower Limb Amputations.

OBJECTIVE: To record the temporal spatial parameters and metabolic energy expenditure during walking of individuals with amputation, walking with advanced prostheses, and after completion of comprehensive rehabilitation compared with able-bodied persons. DESIGN: Cross-sectional. SETTING: Multidisciplinary comprehensive rehabilitation center. PARTICIPANTS: Severely injured UK military personnel with amputation and subsequent completion of their rehabilitation program (n=30; unilateral transtibial: n=10, unilateral transfemoral: n=10, and bilateral transfemoral: n=10) were compared with able-bodied persons (n=10) with similar age, height, and mass (P>.537). Total number of participants (N = 40). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Temporal spatial and metabolic energy expenditure data were captured during walking on level ground at a self-selected speed. RESULTS: The individuals with amputation were all men, with a mean age of 29±4 years and a mean New Injury Severity Score of 31±16. Walking speed, stride length, step length, and cadence of individuals with a unilateral transtibial or transfemoral amputation were comparable with able-bodied persons, and only individuals with a bilateral transfemoral amputation had a significantly slower walking speed (1.12m/s, P=.025) and reduced cadence (96 steps per minute, P=.026). Oxygen cost for individuals with a unilateral transtibial amputation (0.15mL/kg/m) was the same as for able-bodied persons (0.15mL/kg/m) and significantly increased by 20% (0.18mL/kg/m, P=.023) for unilateral transfemoral amputation and by 60% (0.24mL/kg/m, P<.001) for bilateral transfemoral individuals with amputation. CONCLUSIONS: The scientific literature reports a wide range of gait and metabolic energy expenditure across individuals with amputation. The results of this study indicate that individuals with amputation have a gait pattern which is highly functional and efficient. This is comparable with a small number of studies reporting similar outcomes for individuals with a unilateral transtibial amputation, but the results from this study are better than those on individuals with transfemoral amputations reported elsewhere, despite comparison with populations wearing similar prosthetic componentry. Those studies that do report similar outcomes have included individuals who have been provided with a comprehensive rehabilitation program. This suggests that such a program may be as important as, or even more important than, prosthetic component selection in improving metabolic energy expenditure. The data are made available as a benchmark for what is achievable in the rehabilitation of some individuals with amputations, but agreeably may not be possible for all amputees to achieve.

Functional and Mental Health Status of United Kingdom Military Amputees Postrehabilitation.

OBJECTIVES: To evaluate the functional and mental health status of severely injured traumatic amputees from the United Kingdom military at the completion of their rehabilitation pathway and to compare these data with the published normative data. DESIGN: Retrospective independent group comparison of descriptive rehabilitation data recorded postrehabilitation. SETTING: A military complex trauma rehabilitation center. PARTICIPANTS: Amputees (N=65; mean age, 29±6 y) were evaluated at the completion of their rehabilitation pathway; of these, 54 were operationally (combat) injured (23 unilateral, 23 bilateral, 8 triple) and 11 nonoperationally injured (all unilateral). INTERVENTIONS: Continuous ∼4-week inpatient, physician-led, interdisciplinary rehabilitation followed by ∼4-weeks of patient-led, home-based rehabilitation. MAIN OUTCOME MEASURES: The New Injury Severity Score at the point of injury was used as the baseline reference. The 6-minute walk test, Amputee Mobility Predictor with Prosthesis, Special Interest Group in Amputee Medicine, Defence Medical Rehabilitation Centre mobility and activity of daily living scores as well as depression (Patient Health Questionnaire-9), anxiety (General Anxiety Disorder Scale-7), mental health support, and pain scores were recorded at discharge and compared with the published normative data. RESULTS: The mean New Injury Severity Score was 40±15. After 34±14 months of rehabilitation, amputees achieved a mean 6-minute walk distance of 489±117 m compared with age-matched normative distances of 459 to 738 m. The 2 unilateral groups walked (544 m) significantly further (P>.05) than did the bilateral amputee (445±104 m) and triple amputee (387±99 m) groups. All groups demonstrated mean functional mobility scores consistent with scores of either active adults or community ambulators with limb loss. In total, 85% could walk/run independently and 95% could walk and perform activities of daily living independently with an aid/adaptation. No significant difference in mental health outcome was reported between the groups (P>.05). At discharge, 98% of patients were able to control their pain. CONCLUSIONS: Severely injured military amputees who completed intensive interdisciplinary rehabilitation achieved levels of physical function comparable with those in age-matched healthy adults. Mental health outcomes were indicative of preparedness for full integration back into society.

What Is the Magnitude and Long-term Economic Cost of Care of the British Military Afghanistan Amputee Cohort?

BACKGROUND: Personal protection equipment, improved early medical care, and rapid extraction of the casualty have resulted in more injured service members who served in Afghanistan surviving after severe military trauma. Many of those who survive the initial trauma are faced with complex wounds such as multiple amputations. Although costs of care can be high, they have not been well quantified before. This is required to budget for the needs of the injured beyond their service in the armed forces. QUESTION/PURPOSES: The purposes of this study were (1) to quantify and describe the extent and nature of traumatic amputations of British service personnel from Afghanistan; and (2) to calculate an estimate of the projected long-term cost of this cohort. METHODS: A four-stage methodology was used: (1) systematic literature search of previous studies of amputee care cost; (2) retrospective analysis of the UK Joint Theatre Trauma and prosthetic database; (3) Markov economic algorithm for healthcare cost and sensitivity analysis of results; and (4) statistical cost comparison between our cohort and the identified literature. RESULTS: From 2003 to 2014, 265 casualties sustained 416 amputations. The average number of limbs lost per casualty was 1.6. The most common type of amputation was a transfemoral amputation (153 patients); the next most common amputation type was unilateral transtibial (143 patients). Using a Markov model of healthcare economics, it is estimated that the total 40-year cost of the UK Afghanistan lower limb amputee cohort is £288 million (USD 444 million); this figure estimates cost of trauma care, rehabilitation, and prosthetic costs. A sensitivity analysis on our model demonstrated a potential ± 6.19% variation in costs. CONCLUSIONS: The conflict in Afghanistan resulted in high numbers of complex injuries. Our findings suggest that a long-term facility to budget for veterans' health care is necessary. CLINICAL RELEVANCE: Estimates here should be taken as the start of a challenge to develop sustained rehabilitation and recovery funding and provision.

Influence of traumatic lower-limb amputation on physical activity, body composition, and cardiometabolic risks: A descriptive preliminary study.

BACKGROUND: Following traumatic lower-limb amputation (LLA), humans are predisposed to numerous unfavorable changes in health, including the development of secondary chronic health conditions such as metabolic disorders and cardiovascular disease. OBJECTIVE: To determine within and between group differences in cardiometabolic component risks, body composition, and physical activity (PA) in individuals with traumatic unilateral and bilateral LLA, compared to noninjured controls. DESIGN: Prospective observational cohort study. SETTING: A military complex trauma rehabilitation center. PARTICIPANTS: Sixteen males with traumatic LLA (8 unilateral, mean age 30 ± 5 years and 8 bilateral, mean age 29 ± 3 years). Thirteen active age-matched males with no LLA (28 ± 5 years) acted as controls and performed habitual activities of daily living. INTERVENTION: Participants with LLA attended two 4-week periods of inpatient rehabilitation, separated by two 6-week periods of home-based recovery. MAIN OUTCOME MEASURES: Venous blood samples were taken prior to and following a 75 g oral glucose load, for determination of biomarkers, including insulin and glucose, at baseline and 20 weeks. Body composition (dual X-ray absorptiometry) was measured at baseline, 10 weeks, and 20 weeks. Daily PA was recorded using a triaxial accelerometer for 7 days during inpatient rehabilitation and while at home. Energy expenditure was estimated using population-specific equations. RESULTS: Individuals with bilateral LLA demonstrated more unfavorable mean body composition values, lower PA, and increased cardiometabolic health risk compared to controls. Cardiometabolic syndrome was identified in 63% of individuals with bilateral LLA. No statistically significant differences in cardiometabolic component risk factors, body composition, and estimated daily PA were reported between unilateral LLA and control groups (p > .05). While at home, mean PA counts.day-1 reduced by 17% (p = .018) and 42% (p = .001) in the unilateral and bilateral LLA groups, respectively. CONCLUSIONS: Despite extensive inpatient rehabilitation, cardiometabolic component risks are elevated in individuals with bilateral LLA but are comparable between unilateral LLA and active noninjured control groups. Innovative strategies that improve/support the long-term PA and cardiometabolic health of severely injured individuals with bilateral LLA are warranted.

Mortality in Wegener's granulomatosis: a bimodal pattern.

OBJECTIVE: To characterize the long-term mortality in patients with WG compared with matched population-based controls. METHODS: We used data from the General Practice Research Database, which contains the computerized records of 6.25 million patients and is representative of the population of the UK. We identified all subjects with a new diagnosis of WG in the period 1989-2004, and for each case, compared mortality with 10 controls matched for age, gender and practice. RESULTS: We identified 255 patients with a new diagnosis of WG (mean age 58.1 years, range 9-90 years, 47% females) and 2546 controls (mean age 58.1 years, range 9-89 years, 47% females). Mean follow-up was 6.4 years. The mortality for patients with WG was significantly increased during the first year after diagnosis [HR 9.0 (95% CI 5.8, 13.9)], especially for those ≤ 65 years of age [HR 19.9 (95% CI 8.8, 44.9)]. The excess mortality was less marked after the first year: 1-5 years [HR 1.68 (95% CI 1.08, 2.60)], 5-10 years [HR 2.41 (95% CI 1.43, 4.07)], but started to increase by 10-15 years [HR 4.4 (95% CI 2.0, 9.8)]. The Kaplan-Meier survival curve showed an increase in mortality after 8 years. CONCLUSIONS: Despite current therapy, patients with WG have a 9-fold increased risk of death in the first year of disease, attributed to infection, active vasculitis and renal failure. Between 1 and 8 years the risk is at its lowest, although higher than the control population. There is an increased mortality from 8 years onwards that remains unexplained.

The modern "deck-slap" injury--calcaneal blast fractures from vehicle explosions.

BACKGROUND: Anti-vehicle mines and improvised explosive devices remain the most prevalent threat to coalition troops operating in Iraq and Afghanistan. Detonation of these devices causes rapid deflection of the vehicle floor resulting in severe injuries to calcaneus. Anecdotally referred to as a "deck-slap" injury, there have been no studies evaluating the pattern of injury or the effect of these potentially devastating injuries since World War II. Therefore, the aim of this study is to determine the pattern of injury, medical management, and functional outcome of UK Service Personnel sustaining calcaneal injuries from under-vehicle explosions. METHOD: From January 2006 to December 2008, using a prospectively collected trauma registry (Joint Theater Trauma Registry), the records of all UK Service Personnel sustaining a fractured calcaneus from a vehicle explosion were identified for in-depth review. For each patient, demographic data, New Injury Severity Score, and associated injuries were recorded. In addition, the pattern of calcaneal fracture, the method of stabilization, local complications, and the need for amputation were noted. Functional recovery was related to the ability of the casualty to return to military duties. RESULTS: Forty calcaneal fractures (30 patients) were identified in this study. Mean follow-up was 33.2 months. The median New Injury Severity Score was 17, with the lower extremity the most severely injured body region in 90% of cases. Nine (30%) had an associated spinal injury. The overall amputation rate was 45% (18/40); 11 limbs (28%) were amputated primarily, with a further 3 amputated on return to the United Kingdom. Four (10%) casualties required a delayed amputation for chronic pain (mean, 19.5 months). Of the 29 calcaneal fractures salvaged at the field hospital, wound infection developed in 11 (38%). At final follow-up, only 2 (6%) were able to return to full military duty with 23 (76%) only fit for sedentary work or unfit for any military duty. CONCLUSION: Calcaneal injuries following under-vehicle explosions are commonly associated with significant multiple injuries including severe lower limb injury. The frequency of associated spinal injuries mandates radiologic evaluation of the spine in all such patients. The severity of the hindfoot injury is reflected by the high infection rate and amputation rate. Only a small proportion of casualties were able to return to preinjury military duties.

Can high-functioning amputees with state-of-the-art prosthetics walk normally? A kinematic and dynamic study of 40 individuals.

BACKGROUND: Previous work has highlighted the highly functional post-rehabilitation level of military individuals who sustained traumatic amputation. Understanding how these individuals walk with their prosthesis could be key to setting a precedent for what is realistically possible in the rehabilitation of individuals with amputations. OBJECTIVE: The aim of this paper is to answer how "normal" should the gait of an individual with an amputation(s) be and can we aspire to mimic able-bodied gait with the most advanced prosthetics in highly functioning individuals? METHODS: This was a cross-sectional study comparing the gait of severely injured and highly functional UK trans-tibial (n=10), trans-femoral (n=10) and bilateral trans-femoral (n=10) military amputees after completion of their rehabilitation programme to that of able-bodied controls (n=10). Joint kinematics and kinetics of the pelvis, hip, knee and ankle were measured with 3-D gait analysis during 5min of walking on level ground at a self-selected speed. Peak angle, moment or range of motion of intact and prosthetic limbs were compared to control values. RESULTS: Joint kinematics of unilateral trans-tibial amputees was similar to that of controls. Individuals with a trans-femoral amputation walked with a more anterior tilted pelvis (P=0.006), with reduced range of pelvic obliquity (P=0.0023) and ankle plantarflexion (P<0.001) than controls. Across all amputee groups, hip joint moments and power were greater and knee and ankle joint moments were less than for controls. CONCLUSIONS: This is the first study to provide a comprehensive description of gait patterns of unilateral trans-tibial, trans-femoral and bilateral trans-femoral amputees as compared with healthy able-bodied individuals. The groups differed in joint kinematics and kinetics, but these can be expected in part because of limitations in prosthesis and socket designs. The results from this study could be considered benchmark data for healthcare professionals to compare gait patterns of other individuals with amputation who experienced similar injuries and rehabilitation services.

Direct Skeletal Fixation in bilateral above knee amputees following blast: 2 year follow up results from the initial cohort of UK service personnel.

AIMS: The aim of the study is to evaluate the clinical outcome and complications from the initial cohort of blast injured bilateral lower limb, above knee amputees who underwent Direct Skeletal Fixation (DSF). PATIENTS AND METHODS: We undertook a retrospective analysis of a prospective data base identifying patients who had undergone implantation with the Australian Osseointegration Group of Australia-Osseointegration Prosthetic Limb (OGAP-OPL) prosthesis, with minimum 24 months follow up. Patient demographics, injury profile, and polymicrobial colonisation status were recorded. Physical functional performance measures recorded were the 6 minute Walk Test (6-MWT) and patient reported outcome measures were the Short Form Health Survey-36 (SF-36). Post operatively, complications including infection, re-operation, and fracture were recorded. RESULTS: 7 patients (14 femora) were identified (mean age 29.8yrs), all injured by dismounted blast. Mean follow up was 46 months. All were polytrauma patients and all had previous polymicrobial colonisation. Following surgery, all patients mobilised with significant improvement in 6-minute walk time, with a mean improvement of 154 m (248 m vs 402 m, p = 0.018). The physical component score for the SF-36 demonstrated a statistically significant improvement from 34.65 to 54.5 (p = 0.018) and the mental component score demonstrated a similar improvement (41.55-58.19 p = 0.018). At follow up, no patient required explantation of the implant. Each had been prescribed a minimum of 1 course of antibiotics with no evidence of deep infection. CONCLUSION: DSF is an option for amputees who, due to the nature of their injuries, may not be able to tolerate traditional suspension socket prostheses and have exhausted all other treatment options. At a minimum of 2 year follow up, the absence of significant infective complications suggests DSF may be utilised in the blast injured despite chronic polymicrobial colonisation. Longer term surveillance of these patients is required to assess the long-term suitability of this technique in this cohort of patients.

Predicting ambulatory energy expenditure in lower limb amputees using multi-sensor methods.

PURPOSE: To assess the validity of a derived algorithm, combining tri-axial accelerometry and heart rate (HR) data, compared to a research-grade multi-sensor physical activity device, for the estimation of ambulatory physical activity energy expenditure (PAEE) in individuals with traumatic lower-limb amputation. METHODS: Twenty-eight participants [unilateral (n = 9), bilateral (n = 10) with lower-limb amputations, and non-injured controls (n = 9)] completed eight activities; rest, ambulating at 5 progressive treadmill velocities (0.48, 0.67, 0.89, 1.12, 1.34m.s-1) and 2 gradients (3 and 5%) at 0.89m.s-1. During each task, expired gases were collected for the determination of [Formula: see text] and subsequent calculation of PAEE. An Actigraph GT3X+ accelerometer was worn on the hip of the shortest residual limb and, a HR monitor and an Actiheart (AHR) device were worn on the chest. Multiple linear regressions were employed to derive population-specific PAEE estimated algorithms using Actigraph GT3X+ outputs and HR signals (GT3X+HR). Mean bias±95% Limits of Agreement (LoA) and error statistics were calculated between criterion PAEE (indirect calorimetry) and PAEE predicted using GT3X+HR and AHR. RESULTS: Both measurement approaches used to predict PAEE were significantly related (P<0.01) with criterion PAEE. GT3X+HR revealed the strongest association, smallest LoA and least error. Predicted PAEE (GT3X+HR; unilateral; r = 0.92, bilateral; r = 0.93, and control; r = 0.91, and AHR; unilateral; r = 0.86, bilateral; r = 0.81, and control; r = 0.67). Mean±SD percent error across all activities were 18±14%, 15±12% and 15±14% for the GT3X+HR and 45±20%, 39±23% and 34±28% in the AHR model, for unilateral, bilateral and control groups, respectively. CONCLUSIONS: Statistically derived algorithms (GT3X+HR) provide a more valid estimate of PAEE in individuals with traumatic lower-limb amputation, compared to a proprietary group calibration algorithm (AHR). Outputs from AHR displayed considerable random error when tested in a laboratory setting in individuals with lower-limb amputation.

How do orthopaedic surgeons and rehabilitation professionals interpret and assess 'toe touch' weight bearing and 'partial' weight bearing status in the rehabilitation setting?

AIM: To compare the interpretation of toe touch weight bearing (TTWB) and partial weight bearing (PWB) among orthopaedic surgeons, rehabilitation professionals and patients. METHODOLOGY: 78 consultant and middle-grade orthopaedic surgeons in the UK completed a questionnaire. 64 rehabilitation professionals (including physiotherapists) at Defence Medical Rehabilitation Centre Headley Court were also recruited. Both groups provided their interpretation of TTWB and PWB as a percentage of total body weight (%TBW). Each rehabilitation professional, then applied what they interpreted to be TTWB and PWB using a Lasar Posture weighing device. The predicted values were compared with the actual values demonstrated. RESULTS: There was no significant difference between orthopaedic surgeons and rehabilitation professionals in their interpretation of TTWB and PWB, however there was a wide range of responses. There was a significant difference between the predicted %TBW and the actual values demonstrated by the 'educated patient' (mean difference 4.8 (TTWB) and 22.9 (PWB)). CONCLUSION: Healthcare professionals vary greatly in their interpretation of the terms TTWB and PWB. Therefore, for a consistency in rehabilitation delivery the terms should not be used in isolation without a further descriptor. Static measures of weight application are lower than people think they are applying. We encourage the use of loading practice with a scale to reassure and educate patients.

Impact of anatomical placement of an accelerometer on prediction of physical activity energy expenditure in lower-limb amputees.

PURPOSE: To assess the influence of the anatomical placement of a tri-axial accelerometer on the prediction of physical activity energy expenditure (PAEE) in traumatic lower-limb amputees during walking and to develop valid population-specific prediction algorithms. METHODS: Thirty participants, consisting of unilateral (n = 10), and bilateral (n = 10) amputees, and non-injured controls (n = 10) volunteered to complete eight activities; resting in a supine position, walking on a flat (0.48, 0.67, 0.89, 1.12, 1.34 m.s-1) and an inclined (3 and 5% gradient at 0.89 m.s-1) treadmill. During each task, expired gases were collected and an Actigraph GT3X+ accelerometer was worn on the right hip, left hip and lumbar spine. Linear regression analyses were conducted between outputs from each accelerometer site and criterion PAEE (indirect calorimetry). Mean bias ± 95% limits of agreement were calculated. Additional covariates were incorporated to assess whether they improved the prediction accuracy of regression models. Subsequent mean absolute error statistics were calculated for the derived models at all sites using a leave-one out cross-validation analysis. RESULTS: Predicted PAEE at each anatomical location was significantly (P< 0.01) correlated with criterion PAEE (P<0.01). Wearing the GT3X+ on the shortest residual limb demonstrates the strongest correlation (unilateral; r = 0.86, bilateral; r = 0.94), smallest ±95% limits of agreement (unilateral; ±2.15, bilateral ±1.99 kcal·min-1) and least absolute percentage error (unilateral; 22±17%, bilateral 17±14%) to criterion PAEE. CONCLUSIONS: We have developed accurate PAEE population specific prediction models in lower-limb amputees using an ActiGraph GT3X+ accelerometer. Of the 3 anatomical locations considered, wearing the accelerometer on the side of the shortest residual limb provides the most accurate prediction of PAEE with the least error in unilateral and bilateral traumatic lower-limb amputees.

Influence of Immediate and Delayed Lower-Limb Amputation Compared with Lower-Limb Salvage on Functional and Mental Health Outcomes Post-Rehabilitation in the U.K. Military.

BACKGROUND: Medical practitioners face difficult decisions over whether to amputate or to salvage a lower limb that has undergone trauma. To our knowledge, there has been little evidence reporting the impact of different surgical decisions on functional and mental health outcomes following intensive rehabilitation that might inform decision-making. METHODS: This study is a retrospective, independent-group comparison of rehabilitation outcomes from a U.K. military complex trauma rehabilitation center. There were 100 procedures examined: 36 unilateral amputations (11 immediate-below-the-knee amputations, 15 delayed below-the-knee amputations, and 10 immediate above-the-knee amputations), 43 bilateral amputations, and 21 single-limb salvages (including 13 below-the-knee limb salvages); the patients had a mean age (and standard deviation) of 29 ± 6 years and a mean New Injury Severity Score of 34 ± 15 points. The outcome measures at completion of rehabilitation included a 6-minute walk test (6MWT), Defence Medical Rehabilitation Centre mobility and activities of daily living scores, screening for depression (Patient Health Questionnaire [PHQ-9]) and general anxiety disorder (General Anxiety Disorder 7-item scale [GAD-7]), mental health support, and pain scores. RESULTS: On completion of their rehabilitation, the unilateral amputation group walked significantly farther in 6 minutes (564 ± 92 m) than the limb-salvage group (483 ± 108 m; p < 0.05) and the bilateral amputation group (409 ± 106 m; p < 0.001). The delayed below-the-knee amputation group (595 ± 89 m) walked significantly farther than the group with limb salvage below the knee (472 ± 110 m; p < 0.05), and there was no significant difference between the group with delayed below-the-knee amputation and the group with immediate below-the-knee amputation (598 ± 63 m; p > 0.05). The limb-salvage group was less capable of running independently compared with all amputee groups. No significant differences (p > 0.05) were reported in mean mental health outcomes between the below-the-knee injury groups, and depression and anxiety scores were comparable with population norms. At discharge, 97% of all patients were able to control their pain. CONCLUSIONS: After completing a U.K. military interdisciplinary rehabilitation program, the unilateral amputation group demonstrated a significant functional advantage over the limb-salvage and bilateral amputation groups. We found that patients electing for delayed amputation below the knee after attempted limb salvage achieved superior functional gains in mobility compared with patients who underwent limb salvage below the knee and experienced no functional disadvantage compared with patients who underwent immediate amputation. The mental health outcomes were comparable with general population norms, optimizing the prospect of full integration back into society. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cross-sectional study of alteration of phantom limb pain with visceral stimulation in military personnel with amputation.

While phantom limb pain is a well-recognized phenomenon, clinical experience has suggested that the augmentation of phantom limb pain with visceral stimulation is an issue for many military personnel with amputation (visceral stimulation being the sensation of the bowel or bladder either filling or evacuating). However, the prevalence of this phenomenon is not known. The aim of this study was to investigate the prevalence of the alteration in phantom limb pain and the effect that visceral stimulation has on phantom limb pain intensity. A cross-sectional study of 75 military personnel who have lost one or both lower limbs completed a questionnaire to assess the prevalence of the alteration of phantom limb pain with visceral stimulation. Included in the questionnaire was a pain visual analog scale (VAS) graded from 0 to 10. Patients recorded the presence and intensity of phantom limb pain. They also recorded whether and how this pain altered with a need to micturate or micturition, and/or a need to defecate or defecation, again using a pain VAS. Time since amputation, level of amputation, and medications were also recorded. Patients reported a phantom limb pain prevalence of 85% with a mean VAS of 3.6. In all, 56% of patients reported a change in the severity of phantom limb pain with visceral stimuli. The mean increase in VAS for visceral stimulation was 2.5 +/- 1.6 for bladder stimulation and 2.9 +/- 2.0 for bowel stimulation. Of the patients questioned, 65% reported an improvement in symptoms over time. VAS scores were highest in the subgroup less than 6 mo postamputation. An increase in phantom limb pain with visceral stimulation is a common problem for military personnel with amputation.

FASS is a better predictor of poor outcome in lower limb blast injury than AIS: implications for blast research.

OBJECTIVES: Due to the absence of clinical blast data, automotive injury data using the abbreviated injury score (AIS) has been extrapolated to define current North Atlantic Treaty Organisation (NATO) injury thresholds for anti-vehicle mine tests. We hypothesized that AIS, being a marker of fatality rather than disability, would be a worse predictor of poor clinical outcome compared with the lower limb-specific foot and ankle severity score (FASS). METHODS: Using a prospectively collected trauma database, we identified UK Service Personnel sustaining lower leg injuries from under-vehicle explosions from January 2006 to December 2008. A full review of all medical documentation was performed to determine patient demographics and the severity of lower leg injury, as assessed by AIS and FASS. Clinical endpoints were defined as (1) need for amputation or (2) poor clinical outcome (defined as amputation or ongoing clinical problems). Statistical models were developed to explore the relationship between the scoring systems and clinical endpoints. RESULTS: Sixty-three UK casualties (89 limbs) were identified with a lower limb injury after under-vehicle explosion. The mean age of the casualty was 26.0 years. At 33.6 months follow-up, 29.1% (26 of 89) required an amputation and 74.6% (67 of 89) having a poor clinical outcome. Only 9 (14%) casualties were deemed medically fit to return to full military duty. Receiver operating characteristic analysis revealed that both AIS = 2 and FASS = 4 could predict the risk of amputation, with FASS = 4 demonstrating greater specificity (43% vs. 20%) and greater positive predictive value (72% vs. 34%). In predicting poor clinical outcome, FASS was significantly superior to AIS. Probit analysis revealed that a relationship could not be developed between AIS and the probability of a poor clinical outcome. CONCLUSIONS: Our study clearly demonstrates that AIS is not a predictor of long-term clinical outcome and that FASS would be a better quantitative measure of lower limb injury severity.

Outcomes of IED foot and ankle blast injuries.

BACKGROUND: Improvements in protection and medical treatments have resulted in increasing numbers of modern-warfare casualties surviving with complex lower-extremity injuries. To our knowledge, there has been no prior analysis of foot and ankle blast injuries as a result of improvised explosive devices (IEDs). The aims of this study were to report the pattern of injury and determine which factors are associated with a poor clinical outcome. METHODS: U.K. service personnel who had sustained lower leg injuries following an under-vehicle explosion from January 2006 to December 2008 were identified with the use of a prospective trauma registry. Patient demographics, injury severity, the nature of the lower leg injury, and the type of clinical management were recorded. Clinical end points were determined by (1) the need for amputation and (2) ongoing clinical symptoms. RESULTS: Sixty-three U.K. service personnel (eighty-nine injured limbs) with lower leg injuries from an explosion were identified. Fifty-one percent of the casualties sustained multisegmental injuries to the foot and ankle. Twenty-six legs (29%) required amputation, with six of them amputated because of chronic pain eighteen months following injury. Regression analysis revealed that hindfoot injuries, open fractures, and vascular injuries were independent predictors of amputation. At the time of final follow-up, sixty-six (74%) of the injured limbs had persisting symptoms related to the injury, and only nine (14%) of the service members were fit to return to their preinjury duties. CONCLUSIONS: This study demonstrates that foot and ankle injuries from IEDs are associated with a high amputation rate and frequently with a poor clinical outcome. Although not life-threatening, they remain a source of long-term morbidity in an active population.