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.

这项研究的重点是改善步行对称性，以优化步行能力并降低残疾 对于具有非创伤下肢截肢（LLA）的退伍军人。超过80％的当前LLA是非创伤的， 由病理并发症（例如糖尿病和周围动脉疾病）引起的。尽管 当前，退伍军人的总截肢率下降，非创伤性LLA的人群正在增长。 例如，从2000年到2004年，相对截肢率降低了34％。但是，由于增加 在同一时期的糖尿病的退伍军人人数中，患有糖尿病和的退伍军人人口 初始LLA增加了23％。 LLA之后，常见步态不对称性过多。不对称步态 特征至关重要，因为过度不对称可能会增加残疾的严重性 由非创伤性LLA的人体验并导致继发性疼痛状况（下背部疼痛和 骨关节炎），步态效率差，身体性能下降以及皮肤完整性受损 残留肢体。与患有创伤性LLA的个体相比，非 - 创伤性LLA进一步加剧了年龄较大，病前功能较低，合并症的存在， 频繁的伤口发育，残留肢体延迟愈合。在改善步态对称性的同时是 LLA突出显示的常规假体康复的目标，步态不对称的持久性多年 目前的康复实践无效实现这一目标。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来确定错误操纵步态训练的功效 （误差和错误纠正）与当前的三臂随机标准相比 对照试验。错误操作步态训练干预将在八次培训课程中进行（2倍/周， 4周），有54名退伍军人（每个干预组18个，对照组18个），单方面，单方面， transtibial lla。目前尚不清楚哪种错误操作步态训练的形式有效地改善 具有非创伤性LLA的退伍军人的持续步态对称性。误解步态训练是一个有前途的 和新的干预措施，涉及夸大现有运动误差以迫使神经肌肉 系统以纠正错误。尽管这种形式的步态训练改善了步态对称性 患有慢性中风或创伤性截肢的人，在非老年退伍军人中尚待评估 创伤性LLA。相比之下，错误校正训练涉及通过过度校正来减少运动错误 不对称。错误提高和错误纠正步态训练都是基于运动学习的 分布式实践，任务特异性和反馈的原则。这些错误操作干预措施中的每一个 在LLA之后，与传统步态训练具有潜在的优势，该训练涉及重复步行 由于对运动质量的反馈最少，而且通常是无监督的。因此，这项研究的主要目的 是为了确定错误操作步态训练的功效以改善步态对称性。第二个目标是 评估有效性的信号，以改善身体机能的次级措施。最后，这项研究将 在错误操作步态训练后，探索对残留肢体皮肤健康和假体插座的变化。 运动学习原理在错误操作步态训练中的独特使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 提前康复知识，并为步态训练的临床翻译提供必要的证据 基于非创伤性​​LLA退伍军人的运动原理的协议。