Heterotopic ossification in civilians with lower limb amputations.

OBJECTIVES: To report the incidence of symptomatic heterotopic ossification (HO) in a defined civilian amputee population, describe its characteristics, and compare these findings to published data in military amputees. DESIGN: Retrospective chart analysis from July 1998 to July 2009. SETTING: Ambulatory amputee clinic within a large university medical center. PARTICIPANTS: Adults with lower limb amputation (N=158). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Patients with symptomatic HO confirmed by radiographs. RESULTS: A total of 261 patients were evaluated; 158 met inclusion criteria, with 59% having traumatic etiology, 18% vascular etiology, 22% infection, and 1% tumor. Symptomatic HO was diagnosed in 36 (22.8%) patients, and 94% patients had mild HO on radiographic scoring. Rate of HO in amputations related to trauma was not increased compared with those of other etiologies. Surgical resection of the ectopic bone was required in 4 (11%) patients. CONCLUSIONS: HO is seen commonly after civilian lower limb amputation regardless of etiology. The prevalence was less than that observed in previous reports from military populations. This is the first report estimating the prevalence of HO in adult civilian amputees.

Innovations in Amputation Rehabilitation and Prosthetic Design.

This article reviews emerging surgical techniques and prosthetic innovations related to amputation rehabilitation. Osseointegration is discussed from conception to modern implant designs. Motor and sensory reinnervation techniques are reviewed and compared. Prosthetic socket casting, interface, and design innovations are discussed, including direct molded sockets, water casting, adjustable sockets, and magnetic suspension. Advanced components with hydraulic and microprocessor control, power and crossover prosthetic feet are described.

Examining patient reported outcome measures for phantom limb pain: measurement use in a sample of Veterans with amputation.

PURPOSE: Phantom limb pain (PLP) is treated with medications and non-drug treatments. Best clinical practices for measuring treatment outcomes have not been defined. The objective of this study was to evaluate the internal consistency of patient-reported outcomes measures (PROMs) in a sample of Veterans with lower limb amputation. MATERIALS AND METHODS: The Veteran phone survey included administering PROMs [1) PLP numeric rating scale (NRS), 2) general pain NRS, 3) Pain, Enjoyment, and General Activity (PEG) scale, 4) Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Short Form 6b Replacement, 5) PROMIS Short Form Depression 4a and 6) PROMIS Short Form Anxiety 4a]. RESULTS: Fifty Veterans (48 male, 2 female; average age: 66 years) completed PROMs. In our sample, 40 Veterans (80%) experienced PLP with an average PLP NRS of 5 (±3.4). Internal consistency of each measure was good to excellent based on Cronbach's alpha co-efficient of >0.80. Correlations were moderate between PLP NRS and all other measures (≤0.32). Although many Veterans expressed bothersome PLP, the scores reflecting pain interference and impact on function were lower than pain intensity. Consistent use of outcome measures is needed to determine the effect of interventions for amputation-related pain.

The majority of Veterans reported phantom limb pain and residual limb pain, though the frequency and duration of the pain conditions varied.Clinicians should use caution when using only the numeric rating scale to assess pain, as it may not give enough information to fully evaluate the pain experience.It is recommended that clinicians evaluate phantom limb pain separate from general pain to best serve patients' needs.

Development and pilot administration of the amputation-related pain and sensation assessment tool.

PURPOSE: To develop and administer an assessment tool for facilitating patient-clinician discussions regarding amputation-related pain and sensation. MATERIALS AND METHODS: An assessment tool was developed to measure the impact of different types of amputation-related pain and sensation on a patient's life. The tool first provides patients with written descriptions and images of three common types of amputation-related pain or sensations: residual limb pain, phantom limb sensation, and phantom limb pain. The tool then asks them to rate the frequency, intensity, and interference of each experience. Participants were also asked to provide qualitative descriptions of these experiences. RESULTS: Fifty Veterans with lower limb amputation participated in the study. In the past month, 74% reported experiencing residual limb pain, 76% reported phantom limb sensation, and 84% reported phantom limb pain, with 52% reporting all three. Participants' descriptions of some experiences were distinct, while others (e.g., "tingling") were common between experiences. Phantom limb pain had the most varied descriptions. CONCLUSIONS: The amputation-related pain and sensation assessment tool can be used to identify and measure the effects of different experiences on patients' lives, thereby improving the specificity of diagnosis and informing clinical treatment recommendations. Further development of this tool should include evaluating its psychometric properties.

The amputation-related pain and sensation assessment tool was developed for use in patient­clinician discussions to identify and measure residual limb pain, phantom limb sensation, and phantom limb pain.In our sample, participants used common words to describe all three experiences.The use of illustrations in combination with descriptions may aid in differentiating these distinct experiences.Next steps for this assessment tool include further development of illustrations to represent patient diversity as well as evaluation of psychometric properties.

Impact of the COVID-19 pandemic on the rate of lower limb amputation in Veterans.

BACKGROUND: The COVID-19 pandemic led to changes in health care, including postponement of nonurgent appointments. These changes, combined with overall decreased activity levels, may have placed individuals with vascular disease at increased risk for skin ulceration and amputation. OBJECTIVE: To determine the rates of lower limb amputation in Veterans due to complications of diabetes and/or vascular disease in the year following onset of the COVID-19 pandemic (March 2020-March 2021) compared to the previous 3 years (March 2017-March 2020). DESIGN: Retrospective chart review. SETTING: Minneapolis Veterans Affairs Health Care System. PARTICIPANTS: Veterans with a vascular consult appointment note between March 1, 2017, and February 28, 2021. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Primary outcome was lower limb amputation rate in the year following onset of the COVID-19 pandemic compared to the previous 3 years. Secondary outcome was the rate of lower limb wounds in the same time frame. We hypothesized that rates of lower limb amputation and wounds increased during the pandemic. RESULTS: Vascular consult appointments (n = 4183) were reviewed between March 1, 2017, and February 28, 2021. Significantly higher rates of amputation (7.52% vs. 5.19%; p = .006) and wound presence (16.77% vs. 11.66%; p < .001) were found 1 year postpandemic compared to the previous 3 years. Amputation and wound rates did not significantly increase between pairs of consecutive years prior to the pandemic but significantly increased between the year preceding the pandemic and the first year of the pandemic (amputation p = .047; wound p = .004). CONCLUSIONS: Increased rates of amputation and wounds in Veterans following the onset of the COVID-19 pandemic are likely due to disruption of care, lifestyle changes, and other pandemic-related factors. Awareness of COVID-19-related negative health effects is imperative for health care providers to ensure appropriate allocation of resources and alternate models for care delivery for amputation and preventative care as part of disaster response.

Feasibility testing of a novel prosthetic socket sensor system.

PURPOSE: Poorly fitting prosthetic sockets contribute to decreased quality of life, health, and well-being for persons with amputations. Therefore, improved socket fit is a high clinical priority. METHODS: In this study, we describe the design and testing of a novel sensor system that can be incorporated into a prosthetic socket to measure distal end weight bearing in the socket and can alert a prosthesis user if poor socket fit is suspected. We present the results of testing this device with three Veterans who were new prosthesis users and three Veterans who were experienced prosthesis users. RESULTS AND CONCLUSIONS: We collected sensor data during walking trials while participants wore varying numbers of sock plies and qualitative feedback on the design of the socket fit sensor system. For analysis, peak sensor measurements during walking cycles were identified and combined with socket fit data (i.e., a clinician-determined level of "good," "too tight," or "too loose" and the number of sock ply worn each trial). We found consistent relationships between peak sensor measurements and socket fit in our sample. Also, all users expressed an interest in the device, highlighting its potential benefits during early prosthesis training.Implications for RehabilitationEnsuring socket fit is challenging for many prosthesis users.A novel wearable sensor system can be used to identify socket fit issues for some prosthesis users.This type of system could be most helpful for new prosthesis users and those with sensory and cognitive challenges.

Veteran Perspectives on Phantom Limb Pain and Non-Drug Interventions.

Background: Phantom limb pain (PLP) commonly occurs post-amputation and can negatively affect the daily functioning of persons with amputation. Best practices for medication and non-drug management remain unclear. Objective: To better understand the PLP experience and patients' familiarity with treatments, phone interviews were conducted at the Minneapolis Veterans Affairs Regional Amputation Center in Veterans with amputations. Methods: Fifty Veteran participants (average age 66, 96% male) with lower limb amputation were recruited for phone-based data collection of patient-reported outcomes (ie, demographics using the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) and pain experience using the Phantom Phenomena Questionnaire) to characterize the population and a semi-structured interview. Notes taken during interviews were analyzed using the Krueger and Casey constant comparison analysis method. Results: Participants had an average of 15 years since amputation, and 80% reported PLP as identified with the Phantom Phenomena Questionnaire. Investigators identified several core themes from the qualitative interviews including 1) high variability in the experience of PLP, 2) acceptance and resilience, and 3) PLP treatment perceptions. The majority of participants reported trying common non-drug treatments with none endorsed consistently as highly effective. Conclusion: More research is needed to inform identification and implementation of clinical best practices for non-drug interventions for PLP and understand the factors that influence engagement in non-drug interventions. The participants in this study were largely male, so these results may not be generalizable to females.

Clinician perspectives on postamputation pain assessment and rehabilitation interventions.

OBJECTIVE: The purpose of this study was to explore self-reported Veterans Affairs (VA) amputation clinician perspectives and clinical practices regarding the measurement and treatment for amputation-related pain. STUDY DESIGN: Cross-sectional survey with 73 VA rehabilitation clinicians within the VA Health Care System. RESULTS: The most frequent clinical backgrounds of respondents included physical therapists (36%), prosthetists (32%), and physical medicine and rehabilitation specialist (21%). Forty-one clinicians (56%) reported using pain outcome measures with a preference for average pain intensity numeric rating scale (generic) (97%), average phantom limb pain intensity numeric rating scale (80%), or Patient-Reported Outcomes Measurement Information System pain interference (12%) measures. Clinicians' most frequently recommended interventions were compression garments, desensitization, and physical therapy. Clinicians identified mindset, cognition, and motivation as factors that facilitate a patient's response to treatments. Conversely, clinicians identified poor adherence, lack of belief in interventions, and preference for traditional pain interventions (e.g., medications) as common barriers to improvement. We asked about the frequently used treatment of graded motor imagery. Although graded motor imagery was originally developed with 3 phases (limb laterality, explicit motor imagery, mirror therapy), clinicians reported primarily using explicit motor imagery and mirror therapy. RESULTS: Most clinicians who use standardized pain measures prefer intensity ratings. Clinicians select pain interventions based on the patient's presentation. This work contributes to the understanding of factors influencing clinicians' treatment selection for nondrug interventions. Future work that includes qualitative components could further discern implementation barriers to amputation pain rehabilitation interventions for greater consistency in practice.

The relationship between lumbar lordosis angle and low back pain in individuals with transfemoral amputation.

BACKGROUND:: Low back pain is a common secondary disabling condition in the transfemoral amputee population. Transfemoral amputees are at risk of excessive lumbar lordosis; it has been suggested that increased lumbar lordosis may be associated with low back pain. However, the relationship between lumbar lordosis angle and low back pain has not yet been studied in this population. OBJECTIVE:: To determine whether the extent of lumbar lordosis is associated with low back pain in transfemoral amputees. STUDY DESIGN:: Case-control observational study. METHODS:: Participants included eight transfemoral amputees without low back pain and nine transfemoral amputees with low back pain. Etiology of amputation was primarily trauma. All participants underwent lateral view radiographs of the lumbar spine, from which lumbar lordosis angle and sacral inclination angle were measured. RESULTS:: Lumbar lordosis angle mean ± standard deviation was 46.1° ± 12.4° in participants with low back pain and 51.0° ± 12.6° in those without. Sacral inclination angle mean ± standard deviation was 38.3° ± 8.7° in participants with low back pain and 39.1° ± 7.5° in those without. There was no significant difference in lumbar lordosis angle or sacral inclination angle between participants with and without low back pain. CONCLUSION:: This study suggests that increased lumbar lordosis angle and sacral inclination angle are not significantly associated with low back pain in transfemoral amputees of a primarily traumatic etiology. CLINICAL RELEVANCE: Low back pain (LBP) is a common, disabling condition in transfemoral amputees. In the clinical setting, increased lumbar lordosis is implicated in LBP. This study does not support an association between increased lumbar lordosis and LBP; further study is needed to understand the increased prevalence of LBP in this population.

Comparing Electrical Stimulation With and Without Ultrasound Guidance for Phenol Neurolysis to the Musculocutaneous Nerve.

BACKGROUND: Ultrasound guidance is increasingly being used for neurolytic procedures that have traditionally been done with electrical stimulation (e-stim) guidance alone. Ultrasound visualization with e-stim-guided neurolysis can potentially allow adjustments in injection protocols that will reduce the volume of neurolytic agent needed to achieve clinical improvement. OBJECTIVE: This study compared e-stim only to e-stim with ultrasound guidance in phenol neurolysis of the musculocutaneous nerve (MCN) for elbow flexor spasticity. We also evaluated the ultrasound appearance of the MCN in this population. DESIGN: Retrospective review. SETTING: University hospital outpatient clinic. PARTICIPANTS: Adults (N = 167) receiving phenol neurolysis to the MCN for treatment of elbow flexor spasticity between 1997 and 2014 and adult control subjects. METHODS: For each phenol injection of the MCN, the method of guidance, volume of phenol injected, technical success, improved range of motion at the elbow postinjection, adverse effects, reason for termination of injections, and details of concomitant botulinum toxin injection were recorded. The ultrasound appearance of the MCN, including nerve cross-sectional area and shape, were recorded and compared between groups. MAIN OUTCOME MEASURES: The volume of phenol injected and MCN cross-sectional area and shape as demonstrated by ultrasound. RESULTS: The addition of ultrasound to e-stim-guided phenol neurolysis was associated with lower doses of phenol when compared to e-stim guidance alone (2.31 mL versus 3.69 mL, P < .001). With subsequent injections, the dose of phenol increased with e-stim guidance (P < .001), but not with e-stim and ultrasound guidance (P = .95). Both methods of guidance had high technical success, improved ROM at elbow postinjection, and low rates of adverse events. In comparing the ultrasound appearance of the MCN in patients with spasticity to that of normal controls, there was no difference in the cross-sectional area of the nerve, but there was more variability in shape. CONCLUSIONS: Combined e-stim and ultrasound guidance during phenol neurolysis to the MCN allows a smaller volume of phenol to be used for equal effect, both at initial and repeat injection. The MCN shape was more variable in individuals with spasticity; this should be recognized so as to successfully locate the nerve to perform neurolysis. LEVEL OF EVIDENCE: IV.