Predictors of long-term pain and function in individuals who received a custom dynamic orthosis and device-centric care pathway

INTRODUCTION

Carbon fiber custom dynamic orthoses (CDOs) have been shown to effectively reduce pain and improve function in military service members with lower-limb impairment, but data are limited for civilians.

OBJECTIVES

To evaluate the long-term outcomes of individuals who completed a CDO-centric care pathway in a civilian clinic by comparing baseline pain, mobility, and function with outcomes at long-term follow-up. To identify baseline characteristics and postintervention outcomes predictive of outcomes at long-term follow-up.

METHODS

Records of 131 adult patients who received a CDO and CDO-centric training were reviewed. Patient-reported measures of pain and physical function and timed assessment of walking and agility collected during routine clinical care were extracted. These patients were contacted on average 4 (±1) years postintervention to complete a survey including measures of pain and physical function.

RESULTS

The 63 participants who responded reported improved or greatly improved function, maximum pain, and typical pain on average, irrespective of age or sex ( P < 0.001). Change in function from baseline to long-term follow-up was predicted by short-term change in function (35.1% of the variance; P < 0.001). Change in pain from baseline to long-term follow-up was predicted by baseline typical pain and change in four square step test time (63% of variance; P < 0.001).

CONCLUSIONS

Most survey respondents reported positive outcomes. Long-term pain reduction and improved function were predicted by baseline status and by short-term changes associated with receiving a CDO and completing an intensive training program.

Advanced Functional Bracing in Lower Extremity Trauma: Bracing to Improve Function

There are many bracing options for patients with functional limitations of the lower extremity following trauma. The first question that the provider must ask when evaluating a patient with a foot and ankle functional limitation because of weakness or pain is, "what are the patient's expectations?" One option for the patient who desires to return to a higher level of function is a novel, custom dynamic orthosis (CDO) that, when coupled with an advanced rehabilitation program, has improved outcomes in patients following lower extremity trauma who have plateaued after traditional rehabilitation pathways. Although this CDO and rehabilitation program has demonstrated success following lower extremity trauma in heterogenous patient populations, research is ongoing to identify both ideal referral diagnoses or injury characteristics, and to further optimize outcomes with the use of the CDO.

Passive-dynamic ankle-foot orthosis improves medium-term clinical outcomes after severe lower extremity trauma

Introduction

Individuals with delayed below-knee amputation have previously reported superior clinical outcomes compared with lower limb reconstruction. The UK military have since introduced a passive-dynamic ankle-foot orthosis (PDAFO) into its rehabilitation care pathway to improve limb salvage outcomes. The aims were to determine if wearing a PDAFO improves medium-term clinical outcomes and what influence does multidisciplinary team (MDT) rehabilitation have after PDAFO fitting? Also, what longitudinal changes in clinical outcomes occur with MDT rehabilitation and how do these results compare with patients with previous lower extremity trauma discharged prior to PDAFO availability?

Methods

We retrospectively evaluated levels of mobility, activities of daily living, anxiety, depression and pain in a heterogeneous group of 23 injured UK servicemen 34±11 months after PDAFO provision. We also retrospectively analysed 16 patients across four time points (pre-PDAFO provision, first, second and final inpatient admissions post-PDAFO provision) using identical outcome measures, plus the 6 min walk test.

Results

Outcomes were compared with previous below-knee limb salvage and amputees. Before PDAFO, 74% were able to walk and 4% were able to run independently. At follow-up, this increased to 91% and 57%, respectively. Mean depression and anxiety scores remained stable over time (p>0.05). After 3 weeks, all patients could walk independently (pre-PDAFO=31%). Mean 6 min walk distance significantly increased from 440±75 m (pre-PDAFO) to 533±68 m at last admission (p=0.003). The ability to run increased from 6% to 44% after one admission.

Conclusions

All functional and most psychosocial outcomes in PDAFO users were superior to previous limb salvage and comparable to previous below-knee amputees. The PDAFO facilitated favourable short-term and medium-term changes in all clinical outcome measurements.

Multisite Evaluation of a Custom Energy-Storing Carbon Fiber Orthosis for Patients with Residual Disability After Lower-Limb Trauma

BACKGROUND

The Intrepid Dynamic Exoskeletal Orthosis (IDEO) is a custom energy-storing carbon fiber ankle-foot orthosis developed for lower-extremity trauma patients. Studies conducted at the military treatment facility where the IDEO was developed demonstrated benefits of the IDEO when used with the Return to Run Physical Therapy (RTR PT) program. The current study was designed to determine if results could be replicated at other military treatment facilities and to examine whether early performance gains in patient-reported functional outcomes remained at 12 months.

METHODS

Study participants included service members who had functional deficits that interfered with daily activities at least 1 year after a traumatic unilateral lower-extremity injury at or below the knee. Participants were evaluated before receiving the IDEO, immediately following completion of RTR PT, and at 6 and 12 months. Agility, strength/power, and speed were assessed using well-established performance tests. Self-reported function was measured using the Short Musculoskeletal Function Assessment (SMFA). The Orthotics and Prosthetics Users' Survey was administered to assess satisfaction with the IDEO. Of 87 participants with complete baseline data, 6 did not complete any physical therapy and were excluded from the analysis. Follow-up rates immediately following completion of the RTR PT and at 6 and 12 months were 88%, 75%, and 79%, respectively.

RESULTS

Compared with baseline, improvement at completion of RTR PT was observed in all but 1 performance test. SMFA scores for all domains except hand and arm function were lower (improved function) at 6 and 12 months. Satisfaction with the IDEO was high following completion of RTR PT, with some attenuation at the time of follow-up.

CONCLUSIONS

This study adds to the evidence supporting the efficacy of the IDEO coupled with RTR PT. However, despite improvement in both performance and self-reported functioning, deficits persist compared with population norms.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.