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

优化非创伤性下肢截肢退伍军人的步态康复

• 批准号: 10531848
• 负责人: Cory L Christiansen
• 金额: --
• 依托单位: VA EASTERN COLORADO HEALTH CARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-11-01 至 2025-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10531848
• 关键词: Acute; Address; Age; Amputation; Ankle; Auditory; Characteristics; Chronic; Control Groups; Data; Degenerative polyarthritis; Development; Diabetes Mellitus; Educational Intervention; Etiology; Exhibits; Feedback; Financial compensation; Gait; Goals; Health; Hip region structure; Impaired healing; Impairment; Incidence; Individual; Intervention; Knee; Knowledge; Lead; Length; Limb structure; Low Back Pain; Lower Extremity; Measures; Mechanics; Motor; Movement; Nervous system structure; Older Population; Outcome; Pathology; Patient Self-Report; Pattern; Performance; Peripheral arterial disease; Persons; Physical Function; Physical Performance; Physical activity; Populations at Risk; Prosthesis; Prosthetic rehabilitation; Protocols documentation; Randomized Controlled Trials; Rehabilitation therapy; Secondary pain; Secondary to; Severities; Signal Transduction; Skin; Specificity; Supervision; Testing; Training; Training Programs; Transcutaneous Oximetry; Translating; Traumatic Amputation; Veterans; Volition; Walking; Work; World Health Organization; arm; base; biobehavior; chronic stroke; clinical translation; comorbidity; control theory; disability; efficacy evaluation; experience; follow-up; gait correction; gait rehabilitation; gait symmetry; group intervention; improved; limb amputation; limb loss; limb movement; military veteran; motor control; motor learning; neuromuscular system; novel; physically handicapped; primary endpoint; primary outcome; prosthetic socket; residual limb; residual limb health; response; secondary outcome; standard of care; treadmill; wound

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.

本研究的重点是改善步行对称性，以优化步行能力并减少残疾 适用于接受非创伤性下肢截肢 (LLA) 的退伍军人。目前超过 80% 的 LLA 都是非创伤性的， 由糖尿病和外周动脉疾病等病理并发症引起。尽管 目前退伍军人的总截肢率有所下降，但患有非创伤性 LLA 的人数正在增加。 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中，患有糖尿病的退伍军人人口和 初始 LLA 增加了 23%。 LLA 后，过度步态不对称很常见。步态不对称 特征至关重要，因为过度不对称可能会增加残疾的严重程度 患有非创伤性 LLA 的人会经历这种情况，并导致继发性疼痛（腰痛和 骨关节炎）、步态效率差、身体机能下降以及皮肤完整性受损 残肢。与患有创伤性 LLA 的个体相比，非 LLA 患者的步态表现较差 年龄较大、病前功能较低、合并症的存在进一步加剧了创伤性 LLA 伤口频繁发展，残肢愈合延迟。虽然改善步态对称性是 传统假肢康复的目标，LLA 后多年步态不对称的持续存在凸显了 当前的康复实践在实现这一目标方面无效。作为改善步态的一种手段 对称性，本研究旨在使用两种方法确定错误操纵步态训练的有效性 （误差增强和误差校正）与三臂随机试验中当前的护理标准相比 对照试验。错误操纵步态训练干预将通过八次训练课程进行（每周 2 次， 4 周），54 名退伍军人（每个干预组 18 名，对照组 18 名）患有非创伤性、单侧、 经胫骨 LLA。目前尚不清楚哪种形式的错误操纵步态训练能够有效改善 非创伤性 LLA 退伍军人的持续步态对称。误差增强步态训练是一种有前途的方法 以及新颖的干预措施，包括夸大现有的运动错误，以迫使神经肌肉 系统来纠正错误。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 患有慢性中风或创伤性截肢的个体，尚未在患有非中风的老年退伍军人中进行评估 创伤性LLA。相反，纠错训练涉及通过过度纠正来减少运动错误 不对称。误差增强和误差校正步态训练均基于运动学习 分布式实践、任务特异性和反馈的原则。这些错误操纵干预措施中的每一个 与 LLA 后的传统步态训练（涉及重复行走）相比，具有潜在优势 对运动质量的反馈很少，并且通常无人监督。因此，本研究的首要目的 目的是确定错误操纵步态训练对改善步态对称性的功效。次要目标是 评估改善身体功能二级指标的功效信号。最后，本研究将 探索错误操作步态训练后残肢皮肤健康和假肢接受腔贴合度的变化。 运动学习原理在错误操纵步态训练中的独特运用，以改善步态对称性 解决非创伤性 LLA 后慢性步态不对称的问题。这项研究的结果将 推进康复知识的进步，为步态训练的临床转化提供必要的依据 基于运动学习原则的协议，适用于患有非创伤性 LLA 的退伍军人高危人群。