Effects of footwear on the gait kinematics of women with unilateral transtibial amputation: an observational case series.

PURPOSE: Prosthesis geometry and behaviour limit the footwear options available to women. Using a commercially available prosthetic foot that permits user-alignment to accommodate shoes with different heel heights, we investigated the effect of footwear on gait kinematics, with and without adjustment for differences in heel-forefoot differential. MATERIALS AND METHODS: Three women with transtibial amputation walked at a self-selected pace, first in an athletic shoe (prosthetist-aligned; baseline condition), then (i) in a flatter shoe without realigning the prosthesis, and (ii) in flat and heeled shoes following user re-alignment. Kinematics in each condition were compared to baseline. RESULTS: Baseline gait patterns were highly variable across participants. Gait was slower in comparison to baseline in all conditions, but movement compensations varied across participants. An increased lower limb extension tendency was evident with the misaligned prosthesis. With user re-alignment to accommodate the shoe there were fewer deviations from baseline, however kinematic differences remained in both the flat and heeled shoes. CONCLUSIONS: The user-alignment feature of the prosthetic foot reduced the effect of a change in footwear on kinematics, and permitted walking in heeled shoes when it might otherwise not be possible. Persistence of some deviations suggests differences in walking task demand remained despite adjustment.Implications for rehabilitationPermitting prosthesis users to don footwear of choice may improve body image, well-being and quality of life following amputation.Prosthetic feet that permit user ankle adjustment can reduce gait deviations associated with a change in footwear heel height, although kinematic adaptations are individual.

Ankle sprain bracing solutions and future design consideration for civilian and military use.

INTRODUCTION: Ankle sprains are common injuries within the civilian and military populations, with lingering symptoms that include pain, swelling, giving-way, and a high likelihood for recurrence. Numerous bracing systems are available to stabilize the ankle joint following sprains, with new design iterations frequently entering the market. Currently available braces generally include sleeve, lace-up, and stirrup designs. Sleeves provide mild compression and warmth but limited stability for the ankle, while lace-ups and stirrups appear to be more effective at preventing and treating lateral ankle sprains. AREAS COVERED: This review summarizes the use of various brace options in practice. Their major clinical benefits, and limitations are highlighted, followed by an overview of emerging concepts in brace design. Current advancements in biomechanical simulation, multifunctional material fabrication, and wearable, field-deployed devices for human injury surveillance are discussed, providing possibilities for conceiving new design concepts for next-generation smart ankle braces. EXPERT OPINION: Performance of the commercially available braces are limited by their current design concepts. Suggestions on future brace design include: (1) incorporating high-performance materials suitable for extreme environments, (2) leveraging modeling and simulation techniques to predict mechanical support requirements, and (3) implementing adaptive, customizable componentry material to meet the needs of each unique patient.

Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory.

Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.

Focusing research efforts on the unique needs of women prosthesis users.

INTRODUCTION: Women with lower limb loss represent a relevant and growing patient cohort with unique rehabilitation needs. These needs are emphasized in a growing body of literature and the most recent Veteran Affairs/Department of Defense clinical practice guidelines. PROSTHETICS CHALLENGES: Women with limb loss experience greater dissatisfaction with prosthetic fit, appearance, and types of footwear they can use. There is a lack of prosthetics solutions to accommodate the desire of women to wear different footwear varieties, including high heels. The choice to wear a variety of footwear is important to attire and hence community participation. Despite these recognized challenges, women are still underserved in prosthetics research, which limits available information to guide the rehabilitation process. RESEARCH INITIATIVES: This narrative review describes considerations of lower limb prosthesis prescription and use by women, and examples of current research to address these topics. Research efforts are beginning to explore factors that contribute to prosthetics prescription for women, and design creative prosthetics solutions to expand the range of available footwear options. Research is still needed to characterize the types of footwear women with limb loss prefer to use, and the effects of prosthesis designs, footwear, and lower limb loss on women mobility outcomes and community participation. CONCLUSIONS: Through targeted research initiatives, scientists and clinicians can be responsive to the specific needs of women to provide evidence-based guidelines for prosthetics prescription and improve the patient-centered care after limb loss.

The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for Service Members With Complex Trauma.

The Center for Rehabilitation Sciences Research (CRSR) was established to advance the rehabilitative care for service members with combat-related injuries, particularly those with orthopedic, cognitive, and neurological complications. The center supports comprehensive research projects to optimize treatment strategies and promote the successful return to duty and community reintegration of injured service members. The center also provides a unique platform for fostering innovative research and incorporating clinical/technical advances in the rehabilitative care for service members. CRSR is composed of four research focus areas: (1) identifying barriers to successful rehabilitation and reintegration, (2) improving pain management strategies to promote full participation in rehabilitation programs, (3) applying novel technologies to advance rehabilitation methods and enhance outcome assessments, and (4) transferring new technology to improve functional capacity, independence, and quality of life. Each of these research focus areas works synergistically to influence the quality of life for injured service members. The purpose of this overview is to highlight the clinical research efforts of CRSR, namely how this organization engages a broad group of interdisciplinary investigators from medicine, biology, engineering, anthropology, and physiology to help solve clinically relevant problems for our service members, veterans, and their families.

The influence of ankle-foot orthosis stiffness on walking performance in individuals with lower-limb impairments.

BACKGROUND: Passive-dynamic ankle-foot orthoses utilize stiffness to improve gait performance through elastic energy storage and return. However, the influence of ankle-foot orthosis stiffness on gait performance has not been systematically investigated, largely due to the difficulty of manufacturing devices with precisely controlled stiffness levels. Additive manufacturing techniques such as selective laser sintering have been used to successfully manufacture ankle-foot orthoses with controlled stiffness levels. The purpose of this study was to use passive-dynamic ankle-foot orthoses manufactured with selective laser sintering to identify the influence of orthosis stiffness on walking performance in patients with lower-limb neuromuscular and musculoskeletal impairments. METHODS: Thirteen subjects with unilateral impairments were enrolled in this study. For each subject, one passive-dynamic ankle-foot orthosis with stiffness equivalent to the subject's clinically prescribed carbon fiber orthosis, one 20% more compliant and one 20% more stiff, were manufactured using selective laser sintering. Three-dimensional kinematic and kinetic data and electromyographic data were collected from each subject while they walked overground with each orthosis at their self-selected velocity and a controlled velocity. FINDINGS: As the orthosis stiffness decreased, ankle range of motion and medial gastrocnemius activity increased while the knee became more extended throughout stance. Minimal changes in other kinematic, kinetic and electromyographic quantities were observed. INTERPRETATION: Subjects effectively compensated for changes in ankle-foot orthosis stiffness with altered gastrocnemius activity, and the stiffness levels analyzed in this study had a minimal effect on overall walking performance.

Does unilateral transtibial amputation lead to greater metabolic demand during walking?

Previous literature reports greater metabolic demand of walking following transtibial amputation. However, most research focuses on relatively older, less active, and often dysvascular amputees. Servicemembers with traumatic amputation are typically young, fit, and highly active before and often following surgical amputation of their lower limb. This study compared the metabolic demand of walking in young, active individuals with traumatic unilateral transtibial amputation (TTA) and nondisabled controls. Heart rate (HR), rate of oxygen consumption, and rating of perceived exertion (RPE) were calculated as subjects walked at a self-selected velocity and at five standardized velocities based on leg length. The TTA group completed a Prosthetics Evaluation Questionnaire. Oxygen consumption (p = 0.89), net oxygen consumption (p = 0.32), and RPE (p = 0.14) did not differ between groups. Compared with controls, HR was greater in the TTA group and increased to a greater extent with velocity (p < 0.001). Overall, the TTA group rated their walking abilities as high (mean: 93% out of 100%). This is the first study to report equivalent metabolic demand between persons with amputation and controls walking at the same velocity. These results may reflect the physical fitness of the young servicemembers with traumatic amputations and may serve to guide outcome expectations in the future.