Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma?
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Patients with severe lower extremity trauma have significant disability 2 years after injury that worsens by 7 years. Up to 15% seek late amputation. Recently, an energy-storing orthosis demonstrated improved function compared with standard orthoses; however, the effect when integrated with rehabilitation over time is unknown.
(1) Does an 8-week integrated orthotic and rehabilitation initiative improve physical performance, pain, and outcomes in patients with lower extremity functional deficits or pain? (2) Is the magnitude of recovery different if enrolled more than 2 years after their injury versus earlier? (3) Does participation decrease the number considering late amputation?
We prospectively evaluated 84 service members (53 less than and 31 > 2 years after injury) who enrolled in the initiative. Fifty-eight sustained fractures, 53 sustained nerve injuries with weakness, and six had arthritis (there was some overlap in the patients with fractures and nerve injuries, which resulted in a total of > 84). They completed 4 weeks of physical therapy without the orthosis followed by 4 weeks with it. Testing was conducted at Weeks 0, 4, and 8. Validated physical performance tests and patient-reported outcome surveys were used as well as questions pertaining to whether patients were considering an amputation.
By 8 weeks, patients improved in all physical performance measures and all relevant patient-reported outcomes. Patients less than and greater than 2 years after injury improved similarly. Forty-one of 50 patients initially considering amputation favored limb salvage at the end of 8 weeks.
We found this integrated orthotic and rehabilitation initiative improved physical performance, pain, and patient-reported outcomes in patients with severe, traumatic lower extremity deficits and that these improvements were sustained for > 2 years after injury. Efforts are underway to determine whether the Return to Run clinical pathway with the Intrepid Dynamic Exoskeletal Orthosis (IDEO) can be successfully implemented at additional military centers in patients > 2 years from injury while sustaining similar improvements in patient outcomes. The ability to translate this integrated orthotic and rehabilitation program into the civilian setting is unknown and warrants further investigation.
Level of Evidence
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Blair JA, Patzkowski JC, Blanck RV, Owens JG, Hsu JR, Skeletal Trauma Research Consortium (STReC). Return to duty after integrated orthotic and rehabilitation initiative. J Orthop Trauma. 2013 Oct 10 [Epub ahead of print].
- Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347:1924–1931. CrossRef
- Cross JD, Ficke JR, Hsu JR, Masini BD, Wenke JC. Battlefield orthopaedic injuries cause the majority of long-term disabilities. J Am Acad Orthop Surg. 2011;19(Suppl 1):S1–7.
- Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiple falling older adults. Arch Phys Med Rehabil. 2002;83:1566–1571. CrossRef
- Doukas WC, Hayda RA, Frisch HM, Andersen RC, Mazurek MT, Ficke JR, Keeling JJ, Pasquina PF, Wain HJ, Carlini AR, MacKenzie EJ. The Military Extremity Trauma Amputation/Limb Salvage (METALS) study: outcomes of amputation versus limb salvage following major lower-extremity trauma. J Bone Joint Surg Am. 2013;95:138–145. CrossRef
- Engelberg R, Martin DP, Agel J, Swiontkowski MF. Musculoskeletal function assessment: reference values for patient and non-patient samples. J Orthop Res. 1999;17:101–109. CrossRef
- Georgiadis GM, Behrens FF, Joyce MJ, Earle AS, Simmons AL. Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation. J Bone Joint Surg Am. 1993;75:1431–1441.
- Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol. 1994;49:M85–94. CrossRef
- Kazis LE, Miller DR, Clark J, Skinner K, Lee A, Rogers W, Spiro A 3rd, Payne S, Fincke G, Selim A, Linzer M. Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study. Arch Intern Med. 1998;158:626–632. CrossRef
- Krueger CA, Wenke JC, Ficke JR. Ten years at war: comprehensive analysis of amputation trends. J Trauma Acute Care Surg. 2012;73:S438–444. CrossRef
- MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 2006;14:S205–210.
- MacKenzie EJ, Bosse MJ, Pollak AN, Webb LX, Swiontkowski MF, Kellam JF, Smith DG, Sanders RW, Jones AL, Starr AJ, McAndrew MP, Patterson BM, Burgess AR, Castillo RC. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005;87:1801–1809. CrossRef
- Masini BD, Waterman SM, Wenke JC, Owens BD, Hsu JR, Ficke JR. Resource utilization and disability outcome assessment of combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom. J Orthop Trauma. 2009;23:261–266. CrossRef
- Owens BD, Kragh JF Jr, Wenke JC, Macaitis J, Wade CE, Holcomb JB. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64:295–299. CrossRef
- Owens JG. Physical therapy of the patient with foot and ankle injuries sustained in combat. Foot Ankle Clin. 2010;15:175–186. CrossRef
- Owens JG, Blair JA, Patzkowski JC, Blanck RV, Hsu JR, Skeletal Trauma Research Consortium (STReC). Return to running and sports participation after limb salvage. J Trauma. 2011;71:S120–124. CrossRef
- Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Blair JA, Hsu JR. Can an ankle-foot orthosis change hearts and minds? J Surg Orthop Adv. 2011;20:8–18.
- Patzkowski JC, Blanck RV, Owens JG, Wilken JM, Kirk KL, Wenke JC, Hsu JR, Skeletal Trauma Research Consortium (STReC). Comparative effect of orthosis design on functional performance. J Bone Joint Surg Am. 2012;94:507–515. CrossRef
- Patzkowski JC, Owens JG, Blanck RV, Kirk KL, Hsu JR, Skeletal Trauma Research Consortium (STReC). Deployment after limb salvage for high-energy lower-extremity trauma. J Trauma Acute Care Surg. 2012;73:S112–115. CrossRef
- Sanders R, Pappas J, Mast J, Helfet D. The salvage of open grade IIIB ankle and talus fractures. J Orthop Trauma. 1992;6:201–208. CrossRef
- Stinner DJ, Burns TC, Kirk KL, Ficke JR. Return to duty rate of amputee soldiers in the current conflicts in Afghanistan and Iraq. J Trauma. 2010;68:1476–1479. CrossRef
- Wilken JM, Darter BJ, Goffar SL, Ellwein JC, Snell RM, Tomalis EA, Shaffer SW. Physical performance assessment in military service members. J Am Acad Orthop Surg. 2012;20(Suppl 1):S42–47. CrossRef
- Can an Integrated Orthotic and Rehabilitation Program Decrease Pain and Improve Function After Lower Extremity Trauma?
Clinical Orthopaedics and Related Research®
Volume 472, Issue 10 , pp 3017-3025
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- 1. Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA
- 2. Center for the Intrepid, Fort Sam Houston, TX, USA
- 3. Hanger Clinic, Tacoma, WA, USA
- 4. University Orthopaedic Associates of New Jersey, Somerset, NJ, USA
- 5. Carolinas Medical Center, Charlotte, NC, USA