Daily steps and stepping cadence increase one-year following prosthesis osseointegration in people with lower-limb amputation.

PURPOSE: People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes. This study evaluated the effect of lower-limb prosthesis osseointegration on physical activity, including daily steps and stepping cadence. METHODS: Free-living walking activity was assessed from 14 patients scheduled to undergo prosthesis osseointegration at two time points (within 2 weeks prior to osseointegration surgery and 12-months following). Daily step count, stepping time, number of walking bouts, average step cadence per bout, maximum step cadence per bout, and time spent in bands of step cadence were compared before and after osseointegration. RESULTS: Twelve months after prosthesis osseointegration, participants increased daily steps, daily stepping time, average step cadence, and maximum cadence per walking bout compared to pre-osseointegration. CONCLUSIONS: Participants engaged in more daily steps, higher stepping cadence, and longer bouts at higher cadence one year following osseointegration compared to when using a socket prosthesis. As a novel intervention that is becoming more common, it is important to understand walking activity outcomes as these are critical for long-term health.

People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes.Daily step count, walking bouts, and step cadence during free-living walking activity are promising measures to capture physical functional performance in patients with lower-limb amputation.This study shows that patients with osseointegrated prostheses increase their stepping activity, including daily steps, number of bouts, and stepping cadence compared to when using a socket prosthesis, which has positive implications on overall patient health.As a novel intervention that is becoming more common, it is important for clinicians, patients, and researchers to understand expectations for walking activity outcomes as a critical factor in long-term patient health after prosthesis osseointegration.

The Amputated Limb Gluteus Medius is Biomechanically Disadvantaged in Patients with Unilateral Transfemoral Amputation.

Patients with transfemoral amputation (TFA) are at an increased risk of secondary musculoskeleteal comorbidities, primarily due to asymmetric joint loading. Amputated limb muscle weakness is also prevalent in the TFA population, yet all factors that contribute to muscle strength and thus joint loading are not well understood. Our objective was to bilaterally compare gluteus medius (GMED) muscle factors (volume, fatty infiltration, moment arm) that all contribute to joint loading in patients with TFA. Quantitative magnetic resonance (MR) images of the hip were collected from eight participants with unilateral TFA (2M/6F; age: 47.3 ± 14.7 y/o; BMI: 25.4 ± 5.3 kg/m2; time since amputation: 20.6 ± 15.0 years) and used to calculate normalized GMED muscle volume and fatty infiltration. Six participants participated in an instrumented gait analysis session that collected whole-body kinematics during overground walking. Subject-specific musculoskeletal models were used to calculate bilateral GMED (anterior, middle, posterior) moment arms and frontal plane hip joint angles across three gait cycles. Differences in volume, fatty infiltration, hip adduction-abduction angle, and peak moment arms were compared between limbs using paired Cohen's d effect sizes. Volume was smaller by 36.3 ± 18.8% (d = 1.7) and fatty infiltration was greater by 6.4 ± 7.8% (d = 0.8) in the amputated limb GMED compared to the intact limb. The amputated limb GMED abduction moment arms were smaller compared to the intact limb for both overground walking (anterior: d = 0.9; middle: d = 0.1.2) and during normal range of motion (anterior: d = 0.8; middle: d = 0.8) while bilateral hip adduction-abduction angles were similar during overground walking (d = 0.5). These results indicate that in patients with TFA, the amputated limb GMED is biomechanically disadvantaged compared to the intact limb, which may contribute to the etiology of secondary comorbidities. This population might benefit from movement retraining to lengthen the amputated limb GMED abduction moment arm during gait.

Unilateral transfemoral osseointegrated prostheses improve joint loading during walking.

People with unilateral transfemoral amputation using socket prostheses are at increased risk for developing osteoarthritis in both the residual hip and intact lower-limb joints. Osseointegrated prostheses are a surgical alternative to socket prostheses that directly attach to the residual femur via a bone-anchored implant, however their multi-joint loading effect is largely unknown. Our objective was to establish how osseointegrated prostheses influence joint loading during walking. Motion capture data (kinematics, ground reaction forces) were collected from 12 participants at baseline, with socket prostheses, and 12-months after prosthesis osseointegration during overground walking at self-selected speeds. Subject-specific musculoskeletal models were developed at each timepoint relative to osseointegration. Internal joint moments were calculated using inverse dynamics, muscle and joint reaction forces (JRFs) were estimated with static optimization. Changes in internal joint moments, JRFs, and joint loading-symmetry were compared using statistical parametric mapping (p≤ 0.05) before and after osseointegration. Amputated limb hip flexion moments and anterior JRFs decreased during terminal stance (p = 0.002, <0.001; respectively), while amputated limb hip abduction moments increased during mid-stance (p < 0.001), amputated hip rotation moment changed from internal to external throughout early stance (p < 0.001). Intact limb hip extension and knee flexion moments (p = 0.028, 0.032; respectively), superior and resultant knee JRFs (p = 0.046, 0.049; respectively) decreased during the loading response following prosthesis osseointegration. These results may indicate that the direct loading transmission of these novel prostheses create a more typical mechanical environment in bilateral joints, which is comparable with loading observed in able-bodied individuals and could decrease the risk of development or progression of osteoarthritis.

Cognitive-Behavioral-Based Physical Therapy for Improving Recovery After Traumatic Orthopaedic Lower Extremity Injury (CBPT-Trauma).

SUMMARY: Physical and psychological impairment resulting from traumatic injuries is often significant and affects employment and functional independence. Extremity trauma has been shown to negatively affect long-term self-reported physical function, the ability to work, and participation in recreational activities and contributes to increased rates of anxiety and/or depression. High pain levels early in the recovery process and psychosocial factors play a prominent role in recovery after traumatic lower extremity injury. Cognitive-behavioral therapy pain programs have been shown to mitigate these effects. However, patient access issues related to financial and transportation constraints and the competing demands of treatment focused on the physical sequelae of traumatic injury limit patient participation in this treatment modality. This article describes a telephone-delivered cognitive-behavioral-based physical therapy (CBPT-Trauma) program and design of a multicenter trial to determine its effectiveness after lower extremity trauma. Three hundred twenty-five patients from 7 Level 1 trauma centers were randomized to CBPT-Trauma or an education program after hospital discharge. The primary hypothesis is that compared with patients who receive an education program, patients who receive the CBPT-Trauma program will have improved physical function, pain, and physical and mental health at 12 months after hospital discharge.

Dealing With Catastrophic Outcomes and Amputations in the Mangled Limb.

Successful management of the mangled extremity is difficult; however, recent advancements are changing the outcomes of these difficult cases. Multiple centers are working on new bionic limbs with real-time feedback and better performance parameters. Research progress, particularly in the military sector, has aided in our understanding of heterotopic ossification after devastating limb injuries. This progress has also allowed a better treatment program for the residual limb in surgery and postsurgery. It is an exciting time in the management and rehabilitation of amputated limbs, as both biologic and technological advancements are enabling better patient satisfaction. This article looks at some of these discoveries and how they are changing the treatment of the residual limb.

Tactile, thermal, and electrical thresholds in patients with and without phantom limb pain after traumatic lower limb amputation.

PURPOSE: To examine whether there is central sensitization in patients with phantom limb pain (PLP) after traumatic limb amputation. METHODS: Seventeen patients after unilateral lower limb amputation secondary to trauma were enrolled. Ten patients had chronic PLP, while the other seven patients had no PLP. Tactile-sensation threshold, cold- and warm-sensation thresholds, cold- and heat-pain thresholds, electrical-sensation threshold (EST), and electrical-pain threshold on the distal residual limb and the symmetrical site on the sound limb were measured in all tested patients. Their thresholds were compared within the PLP and non-PLP group, and between the groups. RESULTS: The novel findings included: 1) electrical-pain threshold was only decreased in the sound limb in the PLP group and there was no difference between two limbs in the non-PLP group, suggesting central sensitization in patients with PLP; and 2) EST was increased on the affected limb as compared to the sound limb within the PLP group, but there were no significant differences in EST between the PLP and non-PLP group. There were in general no significant differences in other tested thresholds within the groups and between groups. CONCLUSION: Our results demonstrate central sensitization in the patients with PLP after traumatic limb amputation.

Modification of electrical pain threshold by voluntary breathing-controlled electrical stimulation (BreEStim) in healthy subjects.

BACKGROUND: Pain has a distinct sensory and affective (i.e., unpleasantness) component. BreEStim, during which electrical stimulation is delivered during voluntary breathing, has been shown to selectively reduce the affective component of post-amputation phantom pain. The objective was to examine whether BreEStim increases pain threshold such that subjects could have improved tolerance of sensation of painful stimuli. METHODS: Eleven pain-free healthy subjects (7 males, 4 females) participated in the study. All subjects received BreEStim (100 stimuli) and conventional electrical stimulation (EStim, 100 stimuli) to two acupuncture points (Neiguan and Weiguan) of the dominant hand in a random order. The two different treatments were provided at least three days apart. Painful, but tolerable electrical stimuli were delivered randomly during EStim, but were triggered by effortful inhalation during BreEStim. Measurements of tactile sensation threshold, electrical sensation and electrical pain thresholds, thermal (cold sensation, warm sensation, cold pain and heat pain) thresholds were recorded from the thenar eminence of both hands. These measurements were taken pre-intervention and 10-min post-intervention. RESULTS: There was no difference in the pre-intervention baseline measurement of all thresholds between BreEStim and EStim. The electrical pain threshold significantly increased after BreEStim (27.5±6.7% for the dominant hand and 28.5±10.8% for the non-dominant hand, respectively). The electrical pain threshold significantly decreased after EStim (9.1±2.8% for the dominant hand and 10.2±4.6% for the non-dominant hand, respectively) (F[1, 10] = 30.992, p = .00024). There was no statistically significant change in other thresholds after BreEStim and EStim. The intensity of electrical stimuli was progressively increased, but no difference was found between BreEStim and EStim. CONCLUSION: Voluntary breathing controlled electrical stimulation selectively increases electrical pain threshold, while conventional electrical stimulation selectively decreases electrical pain threshold. This may translate into improved pain control.

Breathing-controlled electrical stimulation could modify the affective component of neuropathic pain after amputation: a case report.

In this case, a 31-year-old male suffered phantom neuropathic pain for more than 3 years after an above-the-knee amputation. His shooting phantom pain disappeared after the first session of breathing-controlled electrical stimulation, and reappeared or was triggered 28 days after an experimental error during which he received sustained electrical stimulation. In other words, painful shooting stimuli may not have been "cured" but forgotten and retriggered by a fearful event due to the experimental error. Therefore, this accidental finding provides a unique opportunity to understand sensory and affective components of neuropathic pain, and a novel intervention could modify the affective component of it.