Lumbopelvic movement coordination during walking improves with transfemoral bone anchored limbs: Implications for low back pain.

BACKGROUND: Low back pain (LBP) is more prevalent in patients with transfemoral amputation using socket prostheses than able-bodied individuals, in part due to altered spinal loading caused by aberrant lumbopelvic movement patterns. Early evidence surrounding bone-anchored limb functional outcomes is promising, yet it remains unknown if this novel prosthesis influences LBP or movement patterns known to increase its risk. RESEARCH QUESTION: How are self-reported measures of LBP and lumbopelvic movement coordination patterns altered when using a unilateral transfemoral bone-anchored limb compared to a socket prosthesis? METHODS: Fourteen patients with unilateral transfemoral amputation scheduled to undergo intramedullary hardware implantation for bone-anchored limbs due to failed socket use were enrolled in this longitudinal observational cohort study (7 F/7 M, Age: 50.2±12.0 years). The modified Oswestry Disability Index (mODI) (self-reported questionnaire) and whole-body motion capture during overground walking were collected before (with socket prosthesis) and 12-months following bone-anchored limb implantation. Lumbopelvic total range of motion (ROM) and continuous relative phase (CRP) segment angles were calculated during 10 bilateral gait cycles. mODI, total ROM, CRP and CRP variabilities were compared between time points. RESULTS: mODI scores were significantly reduced 12-months after intramedullary hardware implantation for the bone-anchored limb (P = 0.013). Sagittal plane trunk and pelvis total ROM during gait were reduced after implantation (P = 0.001 and P < 0.001, respectively). CRP values were increased (more anti-phase) in the sagittal plane during single limb stance and reduced (more in-phase) in the transverse plane during pre-swing of the amputated limb gait cycle (P << 0.001 and P = 0.029, respectively). No differences in CRP values were found in the frontal plane. SIGNIFICANCE: Decreases in mODI scores and lumbopelvic ROM, paired with the changes in lumbopelvic coordination, indicate that bone-anchored limbs may reduce LBP symptoms and reduce compensatory movement patterns for people with unilateral transfemoral amputation.

Incorporating Functional Strength Integration Techniques During Total Hip Arthroplasty Rehabilitation: A Randomized Controlled Trial.

OBJECTIVE: Total hip arthroplasty (THA) is a common orthopedic procedure that alleviates pain for millions of individuals. Yet, persistent physical function deficits, perhaps associated with movement compensations, are observed after THA. These deficits negatively affect quality of life and health for many individuals. Functional strength integration (FSI) techniques combine muscle strength training with specific movement retraining to improve physical function. This study aimed to determine if FSI would improve functional performance through remediation of movement compensations for individuals after THA. METHODS: A double-blind randomized controlled trial was conducted. Ninety-five participants were randomized to either the FSI or control (CON) group for an 8-week intervention. The FSI protocol included exercise to improve muscular control and stability around the hip to minimize movement compensation during daily activity. The CON protocol included low-load resistance exercise, range-of-motion activities, and patient education. Functional performance, muscle strength, and self-reported outcomes were measured preoperatively, midway and after intervention, and 6 months after THA. Change from preoperative assessment to each time point was measured, and between-group differences were assessed. RESULTS: There were minimal differences in outcomes between groups at the first postoperative assessment. There were no statistically significant between-group differences in the later assessments, including the primary endpoint. Both groups improved functional outcomes throughout the study period. CONCLUSION: The FSI intervention did not result in greater improvements in function after THA compared to the CON intervention. Future work should further investigate additional biomechanical outcomes, timing of the FSI protocol, effective dosing, and patient characteristics predictive of success with FSI. IMPACT: Recovery after THA is complex, and individuals after THA are affected by persistent movement deficits that affect morbidity and quality of life. The present study suggests that either approach to THA rehabilitation could improve outcomes for patients, and that structured rehabilitation programs may benefit individuals after THA.

Development and alpha testing of a patient shared decision aid for prosthesis design for new lower limb prosthesis users.

BACKGROUND: After lower limb amputation, several prosthesis design options exist. However, prosthesis design decisions do not always reflect a prosthesis user's needs, values, and preferences. OBJECTIVE: To develop a patient decision aid (PDA) prototype for prosthetists and new prosthesis users facing prosthesis design decisions after lower limb amputation, and to assess its usability, accuracy, and comprehensibility. STUDY DESIGN: Exploratory mixed methods. METHODS: PDA development was informed by a qualitative needs assessment and guided by the International Patient Decision Aid Standards. The PDA was evaluated by steering groups of experienced prosthesis users and prosthetic professionals (prosthetists and researchers) to test usability, accuracy, and comprehensibility through focus groups, individual interviews, and rating on a Likert scale ranging from 1 to 10. RESULTS: The resulting PDA included 6 sections: (1) Amputation and Early Recovery, (2) Communication, (3) Values, (4) Prosthesis Design, (5) Preferences, and (6) Prosthetic Journey. Usability, accuracy, and comprehensibility were rated as 9.2, 9.6, and 9.6, respectively, by prosthetic professionals, and 9.4, 9.6, and 9.6, respectively, by prosthesis users. DISCUSSION: The PDA incorporated guidance by relevant stakeholders and was rated favorably, emphasizing a need for shared decision-making support in prosthesis design. One challenge was determining the amount of information in the PDA, highlighting the diversity in end users' informational needs. Future iterations of the PDA should undergo beta testing in clinical settings. CONCLUSIONS: A standardized, iterative method was used to develop a PDA for new lower limb prosthesis users and prosthetists when considering prosthesis design decisions. The PDA was considered useable, accurate, and comprehensible.

How Comprehensive and Efficient Are Patient-Reported Outcome Measures for Individuals with Lower Extremity Amputation Undergoing Implantation of Osseointegrated Bone Anchored Limbs?

¼ Patient-reported outcome measures (PROMs) are essential for measuring quality and functional outcomes after implantation of osseointegrated bone anchored limbs for patients with lower extremity amputation.¼ Using a novel assessment criterion with 8 domains, this study assessed all commonly used PROMs for their efficiency and comprehensiveness.¼ Comprehensiveness was scored according to the presence or absence of PROM questions related to these 8 domains (maximum score = 60): mobility (15 items), prosthesis (14 items), pain (10 items), psychosocial status (10 items), independence/self-care (4 items), quality of life/satisfaction (4 items), osseoperception (1 item), general information (1 item), and vitality (1 item).¼ The efficiency scores were calculated by dividing the comprehensiveness score by the total number of questions answered by the patients with higher scores being deemed more efficient.¼ The most comprehensive PROMs were Orthotics and Prosthetics User's Survey-Lower Extremity Functional Status (OPUS-LEFS) (score = 36), Prosthesis Evaluation Questionnaire (PEQ) (score = 31), and Questionnaire for Persons with a Transfemoral Amputation (score = 27).¼ The most efficient PROMs were the OPUS-LEFS (score = 1.8) and European Quality of Life (score = 1.4).

Dynamic gait stability and stability symmetry for people with transfemoral amputation: A case-series of 19 individuals with bone-anchored limbs.

For some individuals with severe socket-related problems, prosthesis osseointegration directly connects a prosthesis to the residual limb creating a bone-anchored limb (BAL). We compared dynamic gait stability and between-limb stability symmetry, as measured by the Margin of Stability (MoS) and the Normalized Symmetry Index (NSI), for people with unilateral transfemoral amputation before and one-year after BAL implantation. The MoS provides a mechanical construct to assess dynamic gait stability and infer center of mass and limb control by relating the center of mass and velocity to the base of support. Before and one-year after BAL implantation, 19 participants walked overground at self-selected speeds. We quantified dynamic gait stability anteriorly and laterally at foot strike and at the minimum lateral MoS value. After implantation, we observed decreased lateral MoS at foot strike for the amputated (MoS mean(SD) %height; pre: 6.6(2.3), post: 5.9(1.3), d = 0.45) and intact limb (pre: 6.2(1.2), post: 5.8(1.0), d = 0.38) and increased between-limb MoS symmetry at foot strike (NSI mean(SD) %; anterior-pre: 10.3(7.3), post: 8.4(3.6), d = 0.23; lateral-pre: 18.8(12.4), post: 12.4(4.9), d = 0.47) and at minimum lateral stability (pre: 28.1(18.1), post: 19.2(6.8), d = 0.50). Center of mass control using a BAL resulted in dynamic gait stability more similar between limbs and may have reduced the adoption of functional asymmetries. We suggest that improved between-limb MoS symmetry after BAL implantation is likely due to subtle changes in individual limb MoS values at self-selected walking speeds resulting in an overall positive impact on fall risk through improved center of mass and prosthetic limb control.

Blood Flow Restriction and Veterans With Multiple Sclerosis and Advanced Disability: Protocol for a Randomized Controlled Trial.

OBJECTIVE: The purpose of this study will be to determine the efficacy of low intensity lower extremity resistance training with and without blood flow restriction (BFR) on quadriceps muscle strength and thickness in veterans with advanced multiple sclerosis (MS). METHODS: This will be an assessor-blinded, 2-group (1 to 1 allocation) randomized controlled trial targeting an enrollment of 58 participants with advanced MS as defined by Patient-Determined Disease Steps scale levels 4 to 7. Both groups will complete 10 weeks of twice weekly low-load resistance training (20%-30% of 1-repetition max) targeting knee and hip extension, knee flexion, and ankle plantarflexion. The intervention group will perform all training using BFR, with limb occlusion pressures between 60% and 80% of maximal limb occlusion pressure. Primary outcomes will be quadriceps muscle strength and thickness. Secondary outcomes will include knee flexion and ankle plantarflexion strength, functional mobility, physical activity, and patient-reported measures. All outcomes will be assessed at baseline before the intervention, immediately after the intervention, and at a 2-month follow-up assessment. The change between groups postintervention and after the 2-month follow-up will be reported for all outcomes. All analyses will assume a 2-sided test of hypothesis (α = .05). IMPACT: There is very little evidence for the efficacy of exercise interventions in people with MS who have advanced mobility disability. Resistance training with BFR may be an important approach for people with advanced MS who may not tolerate more conventional, moderate-to-high intensity resistance training. The results of this study will inform clinicians regarding exercise decisions for people with advanced MS and future investigations on the role of BFR in people with MS.

Cumulative loading increases and loading asymmetries persist during walking for people with a transfemoral bone-anchored limb.

BACKGROUND: A bone-anchored limb (BAL) is an alternative to a traditional socket-type prosthesis for people with transfemoral amputation. Early laboratory-based evidence suggests improvement in joint and limb loading mechanics during walking with a BAL compared to socket prosthesis use. However, changes in cumulative joint and limb loading measures, which may be predictive of degenerative joint disease progression, remain unknown. RESEARCH QUESTION: Do cumulative total limb and hip joint loading during walking change using a BAL for people with unilateral transfemoral amputation, compared to prior socket prosthesis use? METHODS: A case-series cohort of eight participants with prior unilateral transfemoral amputation who underwent BAL hardware implantation surgery were retrospectively analyzed (4 M/4 F; BMI: 27.7 ± 3.1 kg/m2; age: 50.4 ± 10.2 years). Daily step count and whole-body motion capture data were collected before (using socket prosthesis) and one-year after BAL hardware implantation. Cumulative total limb and hip joint loading and between-limb loading symmetry metrics were calculated during overground walking at both time points and compared using Cohen's d effect sizes. RESULTS: One year after BAL hardware implantation, participants demonstrated bilateral increases in cumulative total limb loading (amputated: d = -0.65; intact: d = -0.72) and frontal-plane hip moment (amputated: d = -1.29; intact: d = -1.68). Total limb loading and hip joint loading in all planes remained asymmetric over time, with relative overloading of the intact limb in all variables of interest at the one-year point. SIGNIFICANCE: Despite increases in cumulative total limb and hip joint loading, between-limb loading asymmetries persist. Habitual loading asymmetry has been implicated in contributing to negative long-term joint health and onset or progression of degenerative joint diseases. Improved understanding of methods to address habitual loading asymmetries is needed to optimize rehabilitation and long-term joint health as people with transfemoral amputation increase physical activity when using a BAL.

The biomechanical influence of transtibial Bone-Anchored limbs during walking.

Individuals with unilateral transtibial amputation (TTA) using socket prostheses demonstrate asymmetric joint biomechanics during walking, which increases the risk of secondary comorbidities (e.g., low back pain (LBP), osteoarthritis (OA)). Bone-anchored limbs are an alternative to socket prostheses, yet it remains unknown how they influence multi-joint loading. Our objective was to determine the influence of bone-anchored limb use on multi-joint biomechanics during walking. Motion capture data (kinematics, ground reaction forces) were collected during overground walking from ten participants with unilateral TTA prior to (using socket prostheses) and 12-months after bone-anchored limb implantation. Within this year, each participant completed a rehabilitation protocol that guided progression of loading based on patient pain response and optimized biomechanics. Musculoskeletal models were developed at each testing timepoint (baseline or 12-months after implantation) and used to calculate joint kinematics, internal joint moments, and joint reaction forces (JRFs). Analyses were performed during three stance periods on each limb. The between-limb normalized symmetry index (NSI) was calculated for joint moments and JRF impulses. Discrete (range of motion (ROM), impulse NSI) dependent variables were compared before and after implantation using paired t-tests with Bonferroni-Holm corrections while continuous (ensemble averages of kinematics, moments, JRFs) were compared using statistical parametric mapping (p < 0.05). When using a bone-anchored limb, frontal plane pelvic (residual: pre = 9.6 ± 3.3°, post = 6.3 ± 2.5°, p = 0.004; intact: pre = 10.2 ± 3.9°, post = 7.9 ± 2.6°, p = 0.006) and lumbar (residual: pre = 15.9 ± 7.0°, post = 10.6 ± 2.5°, p = 0.024, intact: pre = 17.1 ± 7.0°, post = 11.4 ± 2.8°, p = 0.014) ROM was reduced compared to socket prosthesis use. The intact limb hip extension moment impulse increased (pre = -11.0 ± 3.6 Nm*s/kg, post = -16.5 ± 4.4 Nm*s/kg, p = 0.005) and sagittal plane hip moment impulse symmetry improved (flexion: pre = 23.1 ± 16.0 %, post = -3.9 ± 19.5 %, p = 0.004, extension: pre = 29.2 ± 20.3 %, post = 8.7 ± 22.9 %, p = 0.049). Residual limb knee extension moment impulse decreased compared to baseline (pre = 15.7 ± 10.8 Nm*s/kg, post = 7.8 ± 3.9 Nm*s/kg, p = 0.030). These results indicate that bone-anchored limb implantation alters multi-joint biomechanics, which may impact LBP or OA risk factors in the TTA population longitudinally.

Optimizing Total Knee Arthroplasty Rehabilitation with Telehealth Physical Activity Behavior Change Intervention: A Randomized Clinical Trial.

OBJECTIVE: Conventional total knee arthroplasty (TKA) rehabilitation has little impact on sedentary lifestyles that have negative long-term health consequences. The purpose of this trial was to determine the effect of telehealth-based physical activity behavior change intervention on physical activity and functional outcomes following TKA. METHODS: This study was a 2-arm, parallel randomized controlled superiority trial at a regional Veterans Affairs medical center. The participants were 92 US military Veterans (mean age = 65.7 [SD =7.8] y) undergoing unilateral TKA. The Physical Activity Behavior Change (PABC) intervention included telehealth-based self-management training (ten 30-minute sessions) delivered over 12 weeks. The control intervention included telehealth-based health education sessions that matched PABC frequency and duration. Both groups participated in standardized conventional outpatient rehabilitation. Physical activity, measured as average daily step count, was the primary outcome. Secondary outcomes were Life-Space Assessment questionnaire, 30-Second Chair-Stand test, Timed Up-and-Go Test, Six-Minute Walk test, Western Ontario and McMaster Universities Osteoarthritis Index, and Veterans RAND 12-Item Health Survey. The Self Efficacy for Exercise scale and daily time spent in different postures (sitting/lying, standing, stepping) were exploratory variables. Outcomes were measured at baseline (before surgery), mid-intervention (8 weeks after surgery), after the intervention (14 weeks after surgery; primary endpoint), and follow-up (38 weeks after surgery). RESULTS: The PABC group had an estimated 931 (95% CI = 42-1819) more daily steps than the control group from baseline to 14 weeks, though a between-group effect was not sustained at 38 weeks. There were no group differences in secondary outcomes. Participants included only military veterans using Veteran's Health Administration services. The intervention targeted self-management and did not include peer support. CONCLUSIONS: The PABC intervention improved physical activity for Veterans recovering from unilateral TKA at 14 weeks after surgery, though the effect was not sustained at 38 weeks. Physical function improved with rehabilitation but was not different between groups, indicating that physical function was not a primary driver of physical activity behavior. IMPACT: Conventional TKA rehabilitation has a negligible effect on free-living physical activity, which is relevant to long-term health outcomes. This trial identified telehealth physical activity self-management as effective in addressing activity behaviors, separate from conventional rehabilitation strategies.

Chronotropic Incompetence During Exercise Testing as a Marker of Autonomic Dysfunction in Individuals with Early Parkinson's Disease.

BACKGROUND: An attenuated heart rate response to exercise, termed chronotropic incompetence, has been reported in Parkinson's disease (PD). Chronotropic incompetence may be a marker of autonomic dysfunction and a cause of exercise intolerance in early stages of PD. OBJECTIVE: To investigate the relationship between chronotropic incompetence, orthostatic blood pressure change (supine - standing), and exercise performance (maximal oxygen consumption, VO2peak) in individuals with early PD within 5 years of diagnosis not on dopaminergic medications. METHODS: We performed secondary analyses of heart rate and blood pressure data from the Study in Parkinson's Disease of Exercise (SPARX). RESULTS: 128 individuals were enrolled into SPARX (63.7±9.3 years; 57.0% male, 0.4 years since diagnosis [median]). 103 individuals were not taking chronotropic medications, of which 90 had a normal maximal heart rate response to exercise testing (155.3±14.0 bpm; PDnon-chrono) and 13 showed evidence of chronotropic incompetence (121.3±11.3 bpm; PDchrono, p < 0.05). PDchrono had decreased VO2peak compared to PDnon-chrono (19.7±4.5 mL/kg/min and 24.3±5.8 mL/kg/min, respectively, p = 0.027). There was a positive correlation between peak heart rate during exercise and the change in systolic blood pressure from supine to standing (r = 0.365, p < 0.001). CONCLUSIONS: A subgroup of individuals with early PD not on dopaminergic medication had chronotropic incompetence and decreased VO2peak, which may be related to autonomic dysfunction. Evaluation of both heart rate responses to incremental exercise and orthostatic vital signs may serve as biomarkers of early autonomic impairment and guide treatment. Further studies should investigate whether cardiovascular autonomic dysfunction affects the ability to exercise and whether exercise training improves autonomic dysfunction.