Improved Training Method for Advanced Rehabilitation of Warfighters with Lower Extremity Trauma

With the current military healthcare rehabilitation approach, not all trauma patients achieve the high-level functional skills that enable them to return to active duty or pursue pre-injury activities. Lower-limb trauma patients often spend 6 to 18 months in rehabilitation, yet only a small number (13%) of all Service Members with amputation return to active duty, with a mere 2 percent being able to return to their original occupation. More than half of military amputation patients are deemed fully disabled following extensive rehabilitation. This represents a substantial loss of Service as, during a 6-month period, Service Members made approximately 10,280 visits to 33 DOD outpatient clinics for complex wound care and limb salvage.

The primary goal of lower limb rehabilitation is to help the patient walk in an energy-efficient and symmetrical pattern without the use of an assistive device. Yet, achieving symmetrical ambulation does not always equate to comfortable and safe functioning in challenging environments. To safely navigate everyday activities, Service Members must be able to confidently walk and change direction on a variety of surfaces, manage uneven terrain, crowded environments, stairs, and ramps, all of which can increase the risk of falling. Data show that after standard rehabilitation for amputation or limb salvage, many Service Members struggle with falls, which can exacerbate physical and emotional injury and delay healing. In addition, studies have shown that persistent gait asymmetry of Service Members following lower-extremity trauma is prevalent and results in greater demand being placed on their non-injured limb, which can lead to significantly higher rates of osteoarthritis. Further, the reduced demand on the injured limb leads to osteoporosis and, consequently, increased fracture risk. While advances in orthotic and prosthetic design over the past century have been used widely and successfully to make it easier for lower-limb amputation and salvage patients to walk, many still report significant disability, depressive symptoms, and interference with daily activities. Reports from Service Members indicate that it is very difficult or not possible to perform higher-level activities such as climbing stairs, walking long distances, or running following a combat-related amputation. This reduced functional capability increases the likelihood of falls and fall-related injuries, both of which are associated with serious consequences, including residual limb trauma, fractures, loss of confidence, and increased fear of falling. Importantly, falls and fears of falling are among the key factors that prevent people with lower-extremity trauma from achieving maximal functional capabilities.

These and other factors underscore the need for continued improvement in rehabilitation approaches for Service Members who have undergone lower-limb amputation or salvage procedures. In our previously funded research program, we showed that, through training with a novel technology and method, i.e., postural perturbation training, it is possible to significantly reduce fall risk and the probability of fall-related injuries in active-duty Service Members with lower-limb trauma. This training was undertaken when the Service Member was at the end of conventional therapy. This approach, which has shown to be effective in Service Members with diverse lower-extremity trauma (unilateral amputation, bilateral amputation, and individuals who have received limb salvage procedures), will be adapted and implemented earlier in the rehabilitation process, when Service Members are in standard-of-care rehabilitation programs and just learning to adapt to their new prosthesis or orthosis. The program will determine the efficacy of improving functional capabilities and preventing falls and develop and test the clinical materials necessary to support integration of this novel, advanced, task-specific training protocol earlier in the rehabilitation process. The goals of this work are to augment existing conventional rehabilitation by providing fall-prevention training to help Service Members return to full, high-level functional capabilities and emotional wellness and to shorten the time required to return to active duty or to a productive, active civilian life.

The proposed effort will build on a rehabilitation program developed under two previous DOD funding cycles and determine whether the program can allow more injured Service Members to return to duty without separation from Service. Three main objectives will be achieved over a 3-year timeframe. First, we will improve the user interface to facilitate clinician use of the rehabilitation program. Second, we will determine the functional improvements during and following the acute rehabilitation period. Finally, we will create the educational materials needed for clinical implementation. This work will allow the rehabilitation program to be transitioned to clinical settings at the conclusion of this funded effort.