Time to weigh in on obesity and associated comorbidities in combat-wounded amputees

The lower limb-loss rehabilitation continuum (LLRC) - a framework for program design and implementation

Purpose: The multistep journey to prosthetic device-enabled functioning following amputation requires a structured approach for optimal care delivery, but such program structures and outcomes are inadequately characterized. The study is responsive by describing an implementation framework for lower limb loss rehabilitation and evaluating its utility.Materials and methods: The lower limb loss rehabilitation continuum framework (LLRC) was developed using literature-based continuum of care and amputation phase concepts as well as input from limb loss rehabilitation stakeholders. LLRC structure includes five sequential steps (Postsurgical Stabilization (PS), Preprosthetic Rehabilitation (PPR), Limb Healing and Maturation (LHM), Prosthetic Fitting (PF), Prosthetic Rehabilitation (PR)) between six touchpoints of patient-healthcare interaction (Surgery, Preprosthetic Rehabilitation Admission and Discharge, Functioning Evaluation and Prescription, Prosthetic Rehabilitation Admission and Discharge). The utility of this framework was evaluated through LLRC program implementation in a semiurban US setting and program functioning and process outcomes assessment from an IRB-approved, retrospective observational study about patients with unilateral lower-limb amputations completing this program.Results: Program functional (FIM gain; efficiency) scores were greater for PPR(32.6(8);3.1) compared with PR(24.3(8.5);3.8). Program completion duration was 149.7(63.4) days. LHM(75.8(58.5) days) and PF(51.4(24.3) days) were the longest steps. PR duration was significantly longer(p = 0.033) for the transfemoral level.Conclusion: The LLRC framework is useful for the design and implementation of structured limb loss rehabilitation programs.IMPLICATIONS FOR REHABILITATIONThe lower limb-loss rehabilitation continuum (LLRC) is a novel implementation framework with a five-step structure from limb loss to completion of prosthetic rehabilitation between six touchpoints of patient-healthcare interaction, with standardized terminology and baseline and outcome metrics. The utility of the program was demonstrated by successful program development in a suburban health setting and actionable process outcomes and superior functioning outcomes compared with literature.The LLRC can be adapted by health systems, institutions, and care providers for program development. Programs can expect high FIM gains and efficiency for Preprosthetic rehabilitation and Prosthetic rehabilitation steps. With an LLRC completion time of 5 months, long Limb healing and maturation and Prosthetic fitting steps present areas of opportunity for improvement.

A Comprehensive, Multidisciplinary Assessment for Knee Osteoarthritis Following Traumatic Unilateral Lower Limb Loss in Service Members

INTRODUCTION

Knee osteoarthritis (KOA) is a primary source of long-term disability and decreased quality of life (QoL) in service members (SM) with lower limb loss (LL); however, it remains difficult to preemptively identify and mitigate the progression of KOA and KOA-related symptoms. The objective of this study was to explore a comprehensive cross-sectional evaluation, at the baseline of a prospective study, for characterizing KOA in SM with traumatic LL.

MATERIALS AND METHODS

Thirty-eight male SM with traumatic unilateral LL (23 transtibial and 15 transfemoral), 9.5 ± 5.9 years post-injury, were cross-sectionally evaluated at initial enrollment into a prospective, longitudinal study utilizing a comprehensive evaluation to characterize knee joint health, functionality, and QoL in SM with LL. Presences of medial, lateral, and/or patellofemoral articular degeneration within the contralateral knee were identified via magnetic resonance imaging(for medically eligible SM; Kellgren-Lawrence Grade [n = 32]; and Outerbridge classification [OC; n = 22]). Tri-planar trunk and pelvic motions, knee kinetics, along with temporospatial parameters, were quantified via full-body gait evaluation and inverse dynamics. Concentrations of 26 protein biomarkers of osteochondral tissue degradation and inflammatory activity were identified via serum immunoassays. Physical function, knee symptoms, and QoL were collected via several patient reported outcome measures.

RESULTS

KOA was identified in 12 of 32 (37.5%; KL ≥ 1) SM with LL; however, 16 of 22 SM presented with patellofemoral degeneration (72.7%; OC ≥ 1). Service members with versus without KOA had a 26% reduction in the narrowest medial tibiofemoral joint space. Biomechanically, SM with versus without KOA walked with a 24% wider stride width and with a negative correlation between peak knee adduction moments and minimal medial tibiofemoral joint space. Physiologically, SM with versus without KOA exhibited elevated concentrations of pro-inflammatory biomarker interleukin-7 (+180%), collagen breakdown markers collagen II cleavage (+44%), and lower concentrations of hyaluronic acid (-73%) and bone resorption biomarker N-telopeptide of Type 1 Collagen (-49%). Lastly, there was a negative correlation between patient-reported contralateral knee pain severity and patient-reported functionality and QoL.

CONCLUSIONS

While 37.5% of SM with LL had KOA at the tibiofemoral joint (KL ≥ 1), 72.7% of SM had the presence of patellofemoral degeneration (OC ≥ 1). These findings demonstrate that the patellofemoral joint may be more susceptible to degeneration than the medial tibiofemoral compartment following traumatic LL.

The Influence of Physical and Mental Health Mediators on the Relationship Between Combat-Related Traumatic Injury and Ultra-Short-Term Heart Rate Variability in a U.K. Military Cohort: A Structural Equation Modeling Approach

INTRODUCTION

Combat-related traumatic injury (CRTI) adversely affects heart rate variability (HRV). The mediating effect of mental and physical health factors on the relationship between CRTI, its severity and HRV has not been previously studied and investigated.

MATERIALS AND METHODS

A cross-sectional mediation analysis of the ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) prospective cohort study was performed. The sample consisted of injured and uninjured British male servicemen who were frequency-matched based on their age, rank, role-in-theater, and deployment to Afghanistan (2003-2014). CRTI and injury severity (the New Injury Severity Scores [NISS] [NISS < 25 and NISS ≥ 25]) were included as exposure variables. HRV was quantified using the root mean square of successive differences (RMSSD) obtained using pulse waveform analysis. Depression and anxiety mediators were quantified using the Patient Health Questionnaire and Generalized Anxiety Disorder, respectively. Body mass index and the 6-minute walk test (6MWT) represented physical health measures. Two mediation pathways between exposure and outcome variables were examined in comparison with the uninjured group using structural equation modeling.

RESULTS

Of 862 servicemen, 428 were injured and 434 were uninjured with the mean age at assessment of 33.9 ± 5.4 (range 23-59) years. Structural equation modeling revealed that depression, anxiety, and body mass index did not significantly mediate the relationship between injury/injury severity and RMSSD. However, the 6MWT significantly mediated the relationship between CRTI and RMSSD (27% mediation). The indirect effect of 6MWT on the relationship between injury severity (NISS ≥ 25 vs. uninjured) and RMSSD was -0.06 (95% CI: -0.12, -0.00, P < .05).

CONCLUSIONS

The findings suggest that greater physical function may improve HRV following CRTI. Longitudinal studies are warranted to further validate these findings.

Prosthesis nonuse and discontinuation in United States veterans with major limb amputation: Results of a national survey

BACKGROUND

Prosthesis use in persons with amputation can improve mobility and functional independence. Better understanding of the reasons for and outcomes associated with prosthesis nonuse is important to optimize function and long-term health in persons with amputation.

OBJECTIVES

Study objectives were to describe the rate, reasons for, and factors associated with never using or discontinuing prosthesis use in United States (US) veterans with amputation.

STUDY DESIGN

Cross-sectional study design.

METHODS

The study used an online survey to assess prosthesis use and satisfaction in veterans with upper-limb and lower-limb amputation. Survey participation invitations were distributed by email, text message, and mail to 46,613 potential participants.

RESULTS

The survey response rate was 11.4%. After exclusions, an analytic sample of 3,959 respondents with a major limb amputation was identified. The sample was 96.4% male; 78.3% White, with mean age of 66.9; and mean of 18.2 years since amputation. The rate of never using a prosthesis was 8.2%, and the rate of prosthesis discontinuation was 10.5%. Functionality (62.0%), undesirable prosthesis characteristics (56.9%), and comfort (53.4%) were the most common reasons for discontinuation. After controlling for the amputation subgroup, the odds of prosthesis discontinuation were higher for those with unilateral upper-limb amputation, female gender, White race (compared with Black race), diabetes, above-knee amputation, and lower prosthesis satisfaction. Prosthesis satisfaction and quality of life were highest for current prosthesis users.

CONCLUSIONS

This study adds new understanding regarding the rate and reasons for prosthesis nonuse in veterans and highlights the important relationship between prosthesis discontinuation and prosthesis satisfaction, quality of life, and satisfaction with life.

Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use.

MATERIALS AND METHODS

A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed.

RESULTS

The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) (p < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization.

CONCLUSIONS

The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

The relationship between combat-related traumatic amputation and subclinical cardiovascular risk

BACKGROUND

The relationship between acute combat-related traumatic injury (CRTI) to coronary flow reserve (CFR) and subclinical cardiovascular risk have not been examined and was the primary aim of this study.

METHODS AND RESULTS

UK combat veterans from the ADVANCE cohort study (UK-Afghanistan War 2003-14) with traumatic limb amputations were compared to injured non-amputees and to a group of uninjured veterans from the same conflict. Subclinical cardiovascular risk measures included fasted blood atherogenic index of plasma (AIP), triglyceride-glucose index (TyG; insulin resistance), the neutrophil-lymphocyte ratio (NLR) and high-sensitivity C-reactive protein (hs-CRP; vascular inflammation), body mass index (BMI) and visceral fat volume (dual-energy X-ray absorptiometry) and 6-min walk distance (6MWD; physical performance). The subendocardial viability ratio (SEVR), to estimate CFR, was calculated using arterial pulse waveform analysis (Vicorder device). In total 1144 adult male combat veterans were investigated, comprising 579 injured (161 amputees, 418 non-amputees) and 565 uninjured men. AIP, TyG, NLR, hs-CRP, BMI, total body fat and visceral fat volume were significantly higher and the SEVR and 6MWD significantly lower in the amputees versus the injured-non-amputees and uninjured groups. The SEVR was lowest in those with above knee and multiple limb amputations. CRTI (ExpB 0.96; 95% CI 0.94-0.98: p < 0.0001) and amputation (ExpB 0.94: 95% CI 0.91-0.97: p < 0.0001) were independently associated with lower SEVR after adjusting for age, rank, ethnicity and time from injury.

CONCLUSION

CRTI, traumatic amputation and its worsening physical deficit are associated with lower coronary flow reserve and heightened subclinical cardiovascular risk.

Morbidity and Mortality in Non-Obese Compared to Different Classes of Obesity in Patients Undergoing Transtibial Amputations

This study assesses the effect of obesity classes on outcomes and inpatient-hospital-cost compared to non-obese individuals undergoing below-knee amputations (BKAs). Retrospective matched-case controlled study performed on data from NIS Database. We identified three groups: N-Ob (BMI < 29.9 kg/m2; n = 3104), Ob-I/II (BMI: 30 to 39.9 kg/m2; n = 3107), and Ob-III (BMI > 40; n = 3092); matched for gender, comorbidities, tobacco use and elective vs. emergent surgery. Differences in morbidity, mortality, hospital length of stay (LOS), and total inpatient cost were analyzed. Blood loss anemia was more common in Ob-III compared to Ob-I/II patients (OR = 1.2; 95% CI = 1.1−1.4); blood transfusions were less commonly required in Ob-I/II (OR = 0.8; 95% CI = 0.7−0.9) comparatively; Ob-I/II encountered pneumonia less frequently (OR = 0.9; 95% CI = 0.4−0.9), whereas myocardial infarction was more frequent (OR = 7.0; 95% CI = 2.1−23.6) compared to N-Ob patients. Acute renal failure is more frequent in Ob-I/II (OR = 1.2; 95% CI = 1.0−1.3) and Ob-III (OR = 1.8; 95% CI = 1.6−1.9) compared to the N-Ob cohort. LOS was higher in N-Ob (13.1 ± 12.8 days) and Ob-III (13.5 ± 12.4 d) compared to Ob-I/II cohort (11.8 ± 10.1 d; p < 0.001). Mortality was 2.8%, 1.4%, and 2.9% (p < 0.001) for N-Ob, Ob-I/II, and Ob-III, respectively. Hospital charges were $22,025 higher in the Ob-III cohort. Ob-I/II is protective against peri-operative complications and death, whereas hospital cost is substantially higher in Ob-III patients undergoing BKAs.