Optimizing Gait Rehabilitation for Veterans with Non-Traumatic Lower Limb Amputation

本研究的重点是改善步行对称性，以达到优化步行能力，减少残疾的目的 非创伤性下肢截肢（LLA）的退伍军人。目前80%以上的LLA是非创伤性的， 由诸如糖尿病和外周动脉疾病的病理并发症引起。尽管 随着退伍军人总截肢率的下降，非创伤性LLA的人口正在增长。 例如，从2000年到2004年，相对截肢率下降了34%。然而，由于增加 在同一时期，患有糖尿病的退伍军人人数， 初始LLA增加了23%。在LLA之后，过度的步态不对称是常见的。不对称步态 特征是至关重要的，因为过度的不对称可能会增加残疾的严重程度 非创伤性LLA患者所经历的疼痛，并导致继发性疼痛（腰痛和 骨关节炎），步态效率差，身体表现下降，以及皮肤完整性受损。 残肢与创伤性LLA患者相比，非创伤性LLA患者的步态表现较差， 创伤性LLA还因年龄较大、病前功能较低、合并症的存在 频繁的伤口发展，以及残肢的延迟愈合。虽然改善步态对称性是一个 传统的假肢康复的目标，持续多年的步态不对称后，LLA强调， 目前的康复做法在实现这一目标方面效果不佳。作为改善步态的一种手段 对称性，本研究旨在确定使用两种方法的错误操作步态训练的有效性 在一项三组随机化研究中，与当前标准治疗相比， 对照试验错误操作步态训练干预将在8个训练课程中进行（每周2次， 4周），54名退伍军人（每个干预组18名，对照组18名），他们患有非创伤性，单侧， 经胫骨左前降支目前还不清楚哪种形式的错误操作步态训练对改善 非创伤性LLA退伍军人的持续步态对称性。错误增强步态训练是一种很有前途的 和新的干预，包括夸大现有的运动错误，以迫使神经肌肉 系统纠正错误。虽然这种形式的步态训练在小型研究中改善了步态对称性， 慢性中风或创伤性截肢的个体，它尚未在老年退伍军人中进行评估， 创伤性LLA。相比之下，错误纠正训练涉及通过过度纠正来减少运动错误。 不对称错误增强和错误纠正步态训练都是基于运动学习 分布式实践、任务特异性和反馈原则。每一种错误操纵干预 与传统的包括重复行走的LLA步态训练相比， 对运动质量的反馈最少，并且通常无人监督。因此，本研究的主要目的 确定错误操作步态训练对改善步态对称性的有效性。第二个目标是 评价改善身体功能次要指标的疗效信号。最后，本研究将 探讨错误操作步态训练对残肢皮肤健康和假肢接受腔适配性的影响。 在错误操作步态训练中独特地使用运动学习原理来改善步态对称性 解决了非创伤性LLA后的慢性步态不对称问题。这项研究的结果将 提高康复知识，为步态训练的临床转化提供必要依据 基于运动学习原则的协议，用于非创伤性LLA的退伍军人高危人群。

The focus of this study is to improve walking symmetry in order to optimize walking ability and reduce disability for Veterans with non-traumatic lower limb amputation (LLA). Over 80% of current LLAs are non-traumatic, resulting from complications of pathologies, such as diabetes mellitus and peripheral artery disease. Despite current declines in total amputation rate among Veterans, the population with non-traumatic LLA is growing. For example, from 2000 to 2004 the relative amputation rate decreased by 34%. However, due to an increase in the number of Veterans with diabetes during the same period, the population of Veterans with diabetes and initial LLA increased by 23%. Following LLA, excessive gait asymmetry is common. Asymmetric gait characteristics are of critical importance as excessive asymmetry may increase the severity of disability experienced by people with non-traumatic LLA and contribute to secondary pain conditions (low back pain and osteoarthritis), poor gait efficiency, declines in physical performance, and compromised skin integrity of the residual limb. Compared to individuals with traumatic LLA, the poor gait performance of those with non- traumatic LLA is further compounded by older age, lower premorbid function, presence of comorbidities, frequent wound development, and delayed healing in the residual limb. While improving gait symmetry is a goal of conventional prosthetic rehabilitation, persistence of gait asymmetry for years after LLA highlights the ineffectiveness of current rehabilitation practices in achieving this goal. As a means of improving gait symmetry, this study aims to determine the efficacy of error-manipulation gait training using two approaches (error-augmentation and error-correction) compared to current standard-of-care in a three-arm randomized controlled trial. Error-manipulation gait training intervention will be delivered in eight training sessions (2x/week, 4 weeks) with 54 Veterans (18 per intervention group, 18 in control group) who have non-traumatic, unilateral, transtibial LLA. It is unclear which, if either, form of error-manipulation gait training is efficacious for improving persistent gait symmetry in Veterans with non-traumatic LLA. Error-augmentation gait training is a promising and novel intervention that involves exaggerating an existing movement error to force the neuromuscular system to correct the error. While this form of gait training improved gait symmetry in small studies of individuals with chronic stroke or traumatic amputation, it has yet to be evaluated in older Veterans with non- traumatic LLA. In contrast, error-correction training involves reducing movement errors by overcorrecting for asymmetry. Both error-augmentation and error-correction gait training are based upon motor learning principles of distributed practice, task specificity, and feedback. Each of these error-manipulation interventions have potential advantages over traditional gait training following LLA which involves repeated bouts of walking with minimal feedback on movement quality and is often unsupervised. Therefore, the primary aim of this study is to determine the efficacy of error-manipulation gait training to improve gait symmetry. A secondary aim is to evaluate signals of efficacy for improved secondary measures of physical function. Lastly, this study will explore changes to residual limb skin health and prosthesis socket fit following error-manipulation gait training. The unique use of motor learning principles in error-manipulation gait training to improve gait symmetry addresses the problem of chronic gait asymmetry following non-traumatic LLA. The results of this study will advance rehabilitation knowledge and provide necessary evidence for the clinical translation of gait training protocols based in motor learning principles for the at-risk population of Veterans with non-traumatic LLA.