title: Can an integrated orthotic and rehabilitation program decrease pain and improve function after lower extremity trauma?
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  (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?
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopaedics, San Antonio Military Medical Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX, 78234, USA, kattcain2010@yahoo.com.
authors.forename: Katherine M
authors.initials: KM
authors.lastname: Bedigrew
authors.forename: Jeanne C
authors.initials: JC
authors.lastname: Patzkowski
authors.forename: Jason M
authors.initials: JM
authors.lastname: Wilken
authors.forename: Johnny G
authors.initials: JG
authors.lastname: Owens
authors.forename: Ryan V
authors.initials: RV
authors.lastname: Blanck
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Stinner
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Kirk
authors.forename: Joseph R
authors.initials: JR
authors.lastname: Hsu
mesh_terms: D000328:Adult; D000671:Amputation, Surgical; D004185:Disability Evaluation; D004867:Equipment Design; D005260:Female; D006801:Humans; D007869:Leg Injuries / Q000175:diagnosis / Q000503:physiopathology* / Q000601:surgery; D023821:Limb Salvage; D008137:Longitudinal Studies; D008297:Male; D008887:Military Medicine; D008889:Military Personnel; D009989:Orthotic Devices; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D015397:Program Evaluation; D011446:Prospective Studies; D020127:Recovery of Function; D012720:Severity of Illness Index; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D014947:Wounds and Injuries / Q000175:diagnosis / Q000503:physiopathology / Q000534:rehabilitation*
references.citation: J Trauma. 2008 Feb;64(2):295-9
references.pmid: 18301189
references.citation: Foot Ankle Clin. 2010 Mar;15(1):175-86
references.pmid: 20189123
references.citation: J Bone Joint Surg Am. 2005 Aug;87(8):1801-9
references.pmid: 16085622
references.citation: J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S112-5
references.pmid: 22847079
references.citation: J Surg Orthop Adv. 2011 Spring;20(1):8-18
references.pmid: 21477527
references.citation: J Am Acad Orthop Surg. 2011;19 Suppl 1:S1-7
references.pmid: 21304041
references.citation: J Trauma. 2010 Jun;68(6):1476-9
references.pmid: 20068483
references.citation: Arch Phys Med Rehabil. 2002 Nov;83(11):1566-71
references.pmid: 12422327
references.citation: J Orthop Trauma. 1992;6(2):201-8
references.pmid: 1602342
references.citation: N Engl J Med. 2002 Dec 12;347(24):1924-31
references.pmid: 12477942
references.citation: J Orthop Trauma. 2009 Apr;23(4):261-6
references.pmid: 19318869
references.citation: J Trauma Acute Care Surg. 2012 Dec;73(6 Suppl 5):S438-44
references.pmid: 23192067
references.citation: J Bone Joint Surg Am. 1993 Oct;75(10):1431-41
references.pmid: 8408131
references.citation: J Am Acad Orthop Surg. 2012;20 Suppl 1:S42-7
references.pmid: 22865136
references.citation: J Orthop Res. 1999 Jan;17(1):101-9
references.pmid: 10073654
references.citation: J Bone Joint Surg Am. 2013 Jan 16;95(2):138-45
references.pmid: 23324961
references.citation: J Bone Joint Surg Am. 2012 Mar 21;94(6):507-15
references.pmid: 22437999
references.citation: J Gerontol. 1994 Mar;49(2):M85-94
references.pmid: 8126356
references.citation: J Trauma. 2011 Jul;71(1 Suppl):S120-4
references.pmid: 21795870
references.citation: Arch Intern Med. 1998 Mar 23;158(6):626-32
references.pmid: 9521227
references.citation: J Am Acad Orthop Surg. 2006;14(10 Spec No.):S205-10
references.pmid: 17003200
references.citation: J Orthop Trauma. 2014 Apr;28(4):e70-4
references.pmid: 24121984