February 2010

In the Moment: O&P

by Jordana Bieze Foster

Amputees fight another day

Better care increases return-to-duty rates

U.S. military personnel serving in Iraq and Afghanistan are no less likely to suffer an injury requiring amputation than their counterparts who served in previous conflicts, but such an injury is far less likely to keep today’s soldiers from returning to duty.

Researchers from the U.S. Army Institute of Surgical Research and Brooke Army Medical Center in San Antonio reviewed records of 395 soldiers who underwent major limb amputation after being injured in Iraq or Afghanistan during a five-year period. They found that 16.5% of the amputee soldiers returned to active duty. Older individuals and those with higher rankings were more likely to return. The highest return rates were seen in foot amputees, at 25%, with 22% of transtibial amputees also returning.

The findings, published in the January issue of the Journal of Trauma, contrast starkly with those of an earlier study that analyzed return-to-duty rates in amputee soldiers injured during the first Gulf War in the 1980s. Researchers from Womack Army Medical Center in Fort Bragg, NC, reported that 469 soldiers sustained amputations during an eight-year period, but only 11 (2.3%) returned to active duty. Those results were published in the February 1995 issue of Military Medicine.

Pundits had theorized that amputation rates coming out of Iraq and Afghanistan would be higher than in previous conflicts, reasoning that advances in body armor and on-field medical care would improve survival of mine blasts and other traumatic events but that increased morbidity would be the trade-off for decreased mortality. However, research suggests that does not seem to be the case.

In a January 2008 study published in the Journal of Orthopaedic Trauma, a different team of investigators from the  Institute of Surgical Research identified 5684 major limb injuries to soldiers serving in Iraq or Afghanistan during a 56-month period. Of those, 423 (7.4%) required major limb amputation at or proximal to the wrist or ankle joint. By comparison, a 1967 study in the Journal of Trauma reported that 8.3% of major limb injuries resulted in amputation early in the Vietnam war—suggesting that the amputation rate has not changed substantially.

Given that the incidence of amputation has not increased, the fact that so many more amputee soldiers are returning to duty now appears to be a testament to the quality of care they are receiving in the aftermath of their injuries. Advances in prosthetic technology have been supplemented by advances in trauma care—from the combat zone to military hospitals in Europe to the Walter Reed Army Medical Center in Washington, DC, where the majority of amputees undergo rehabilitation. The rehab process at Walter Reed—designed for a young, active population—progresses from activities of daily living to more complex tasks such as plyometrics, and then to sports-inspired rehabilitation exercises.

A 2008 study published in the Journal of Rehabilitation Research & Development surveyed 158 military personnel about their satisfaction with the care they received following a major limb amputation between 2003 and 2005. Of those, 68% had undergone lower-limb amputations.

Survey respondents reported being very satisfied with inpatient therapy (mean of 9 points out of 10), medical care (8.6), and pain management (8.4) at Walter Reed. The “peer visitor” program, in which new amputees are visited by volunteer military amputees who have received special training on psychological and emotional issues related to war-related trauma, also earned high marks (8.7) from the respondents.

Age, race, rank, and level of amputation had little impact on satisfaction levels. Interestingly, amputees injured in Iraq were more likely to be satisfied with their care than those injured in Afghanistan or elsewhere. The authors theorized that because of the volume of injuries handled in Iraq, medical protocols there have become more streamlined.

Balance, more than foot positioning, may affect amputee stair ambulation

Balance during stair ambulation may be a greater concern for transtibial amputees than foot placement or stair clearance, Swedish research suggests.

Investigators from Jonkoping University in Jonkoping, Sweden, performed three-dimensional motion analysis of 10 transtibial amputees and 10 healthy non-amputees during stair ascent and descent.

Neither foot positioning nor foot clearance differed significantly between the two groups. However, there were a number of significant temporospatial differences. During both ascent and descent, amputees walked with a slower velocity, reduced cadence, increased time in stance phase and double support, and increased step width compared to the control subjects.

The findings, published in the December issue of Prosthetics & Orthotics International, suggest that these temporospatial alterations could be a sign of impaired balance or balance confidence.

Meanwhile, an Israeli study found that internal peak and root mean square stresses on the residual limbs of 18 transtibial amputees were significantly higher while descending a slope than while walking on a level floor. Those results were e-published on January 12 by Medical Engineering & Physics.

Time to stabilization fails to detect effect of ankle brace on stability

A measure commonly used to assess dynamic balance in patients with chronic ankle instability may not be sensitive enough to quantify the stabilizing effect of an ankle brace, according to research from the University of Toledo.

In 15 patients with unilateral chronic ankle instability, investigators calculated time to stabilization during a single-leg landing from a jump with and without a lace-up ankle brace. Ground reaction force was measured upon landing, and that value was used to calculate resultant vector time to stabilization. However, the researchers found no significant differences in TTS between limbs or between brace conditions.

The authors suggested that researchers work to identify more sensitive testing methods to more effectively assess the effect of bracing in patients with chronic ankle instability, which is supported by epidemiological data.

The findings, published in the Feburary issue of Physical Therapy in Sport, seem to be consistent with those of a May-June 2008 Journal of Athletic Training review, which concluded that instrumented postural control testing was not consistently able to identify postural control deficits in the CAI population.

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