A controlled clinical trial of a clinically-tuned powered ankle prosthesis in people with transtibial amputation.

OBJECTIVE: To determine whether there are changes in level walking performance for people using a powered ankle prosthesis that was tuned by an independent, manufacturer-certified prosthetist in accordance with device recommendations. DESIGN: Intervention study with cross-over design. SETTING: Laboratory. PARTICIPANTS: Convenience sample of 10 individuals with unilateral, transtibial amputation, and 10 age- and gender-matched control participants. INTERVENTIONS: Powered ankle prosthesis (BiOM T2 Ankle System). Main outcome metrics: Metabolic costs of walking, preferred walking speed. RESULTS: There were no significant differences in oxygen consumption (2.9% difference; P = 0.606, d = 0.26), cost of transport (~1% difference; P = 0.652, d = 0.23), or preferred walking speed (~1% difference; P = 0.147, d = 0.76) when using the powered ankle compared to unpowered prostheses. Secondary analyses of user characteristics revealed that participants who were classified as having the highest function (K4 on Medicare's 5-point scale from K0 to K4) were significantly more likely to exhibit energy cost savings than those classified as having lower function (K3; P = 0.014, d = 2.36). CONCLUSIONS: Participants did not demonstrate significant improvements in energetics or preferred speed when wearing a clinically tuned powered ankle prosthesis compared to their non-powered prostheses. Prescribers of powered devices should understand that not all users will show an immediate reduction in energy expenditure.

Regenerative Peripheral Nerve Interfaces for the Treatment of Postamputation Neuroma Pain: A Pilot Study.

BACKGROUND: Originally designed for prosthetic control, regenerative peripheral nerve interfaces (RPNIs) prevent neuroma formation by providing free muscle grafts as physiological targets for peripheral nerve ingrowth. We report the first series of patients undergoing RPNI implantation for treatment of symptomatic postamputation neuromas. METHODS: A retrospective case series of all amputees undergoing RPNI implantation for treatment of symptomatic neuromas between November 2013 and June 2015 is presented. Data were obtained via chart review and phone interviews using questions derived from the Patient Reported Outcomes Measurement Information System instruments. Statistical analyses were performed using dependent sample t tests with a significance threshold of P < 0.01. RESULTS: Forty-six RPNIs were implanted into 16 amputees for neuroma relief (3 upper extremities and 14 lower extremities). Mean age was 53.5 years (6 females and 10 males). All patients participated in postoperative phone interviews at 7.5 ± 3.4 (range: 3-15) months. Patients reported a 71% reduction in neuroma pain and a 53% reduction in phantom pain. Most patients felt satisfied or highly satisfied with RPNI surgery (75%), reporting decreased (56%) or stable (44%) levels of analgesic use. Most patients would strongly recommend RPNI surgery to a friend (88%) and would do it again if given the option (94%). Complications included delayed wound healing (n = 4) and neuroma pain at a different site (n = 2). CONCLUSIONS: RPNI implantation carries a reasonable complication profile while offering a simple, effective treatment for symptomatic neuromas. Most patients report a significant reduction in neuroma and phantom pain with a high level of satisfaction. The physiological basis for preventing neuroma recurrence is an intriguing benefit to this approach.

Venous thromboembolic events in the rehabilitation setting.

Venous thromboembolism (VTE) is a disease entity that encompasses both deep venous thrombosis and pulmonary embolism. During the past decade there have been significant advances in the understanding of prophylaxis and treatment of VTE. There is an extensive research base from which conclusions can be drawn, but the heterogeneity within the rehabilitation patient population makes the development of rigid VTE protocols challenging and overwhelming for the busy clinician. Given the prevalence of this condition and its associated morbidity and mortality, we review the evidence for the prevention, identification, and optimal treatment of VTE in the rehabilitation population. Our goal is to highlight studies that have the most clinical applicability for the care of VTE patients from a physiatrist's perspective. At times, information about acute care protocols is included in our discussion because these situations are encountered during the consultation process that identifies patients for rehabilitation needs.

Preliminary trial of symmetry-based resistance in individuals with post-stroke hemiparesis.

We tested a novel control strategy for robotic rehabilitation devices used by individuals with post-stroke hemiparesis. Symmetry-based resistance increases resistance when limb forces become more asymmetric during bilateral exercise. The underlying rationales for the control mode are that it will guide patients to increase paretic limb activation while teaching them to accurately gauge paretic limb force production relative to the non-paretic limb. During a one day training session, seven subjects post-stroke performed lower limb extensions in symmetry-based resistance mode on a robotic exercise machine. Subjects improved lower limb symmetry from 28.6%+/-3.9% to 36.2%+/-4.3% while under symmetry-based resistance training (ANOVA, P = 0.03), but did not maintain the improved lower limb symmetry during a constant resistance post-test. Two subjects that showed the large improvements in symmetry during the one day session performed additional days of training. Those results suggest that some patients demonstrate long lasting benefits with symmetry-based resistance training.

Sense of effort determines lower limb force production during dynamic movement in individuals with poststroke hemiparesis.

OBJECTIVE: This study's purpose was to determine if individuals who have had a stroke primarily use sense of effort to gauge force production during static and dynamic lower limb contractions. If relying on sense of effort while attempting to generate equal limb forces, participants should produce equal percentages of their maximum voluntary strength rather than equal absolute forces in their limbs. METHODS: Ten stroke participants performed isometric and isotonic lower limb extensions on an exercise machine. RESULTS: When participants attempted to produce equal bilateral isometric forces, there was a significant difference in absolute force between limbs (ANOVA, P < .0001) but no significant difference when force was normalized to each limb's maximum voluntary contraction (MVC) force (P = .5129). During bilateral isotonic contractions, participants produced less absolute force in their paretic limb (P = .0005) and less relative force in their paretic limb (normalized to MVC force) when participants were given no instructions on how to perform the extension (P = .0002). When participants were instructed to produce equal forces, there was no significant difference between relative forces in the 2 limbs (P = .2111). CONCLUSIONS: For both isometric and isotonic conditions hemiparetic participants relied primarily on sense of effort, rather than proprioceptive feedback, for gauging lower limb force production. This outcome indicates that sense of effort is the major factor determining force production during movements. Lower limb rehabilitation therapies should not only train strength in the paretic limb but should also train patients to recalibrate force-scaling abilities to improve function.

Comprehensive care for the child with upper extremity limb deficiency.

Children with limb deficiencies/amputations are best managed by a multidisciplinary team comprised of physicians specializing in their care, prosthetists, and therapists. For a successful functional outcome, the rehabilitation team will need to consider the goals of the child and parents as they select appropriate components that will aid and not overwhelm the child. The prosthesis will need to accommodate growth and development and withstand the rigors of use during play. The child will benefit from a team approach to introduce, train, and problem-solve the process of prosthetic restoration. We examine strategies for decision making for children with upper extremity limb deletions that will allow appropriate component selection to ensure the prosthesis will be accepted and improve function for the child.

The stroke rehabilitation paradigm.

The matrix of stroke rehabilitation is evolving as we look outside the box of traditional therapy type, timing, and intensity of rehabilitation techniques. For inpatient wards, the goal of medical stability and prompt resolution of complications to maximize participation in therapy remains paramount. In the current medical model, we focus on teaching compensatory strategies and rarely on restorative approaches because of time and financial limitations. Researchers aim to identify new technologic and molecular approaches to improve functional outcomes and more accurately predict disability. This article examines different concepts surrounding the comprehensive rehabilitation paradigm of stroke survivors.

Orthotic and prosthetic prescriptions for today and tomorrow.

The prosthetic and orthotic field is in constant flux, with newer technology and materials being incorporated into everyday practice. Research into the field is increasing as interest in restoring or simulating lost human function becomes more of a reality with advances in computer and microprocessor technology. This article explores the world of braces and artificial limbs, and reviews the inherent challenges encountered during rehabilitation of patients who have these specific orthotic/prosthetic needs. The authors provide quick-reference tables and highlight critical information needed to manage patients. It examines newer technology being developed and gauges how close the field really is to the era of Steve Austin, television's Six-Million Dollar Man.

Rehabilitation methods for the burn injured individual.

Physiatrists play a critical role in managing the medical and functional consequences of serious burn injuries. Goals of rehabilitation include wound healing, scar prevention, hypertrophic scarring suppression, full range of motion, strengthening, and independent mobility and activities of daily living. This article is an overview of burn rehabilitation principles and patient management. The ultimate rehabilitation goal is independence in all spheres of an individual's life. Achievement of independence depends on the commitment of the injured individual and the entire health care team.