Research Focus 3 – Application of New Technologies to Advance Rehabilitation and Performance Measures
There are three centers of excellence for amputee care within the Department of Defense: the Center for the Intrepid at Brooke Army Medical Center (San Antonio, TX), the Military Advanced Training Center at Walter Reed National Military Medical Center (Bethesda, MD) and the Comprehensive Combat and Complex Casualty Care (C5) at the Naval Medical Center San Diego (San Diego, CA). All centers have gait analysis laboratories that are used for routine clinical care of these patients with orthopaedic and neurological trauma. However, data collected at each site has remained separate and there needs to be a study to compare and more efficiently integrate data across laboratories. Data compatibility is important in order to evaluate patient progress and in order to pool the Department of Defense rehabilitation experience for comparative analysis. In order to confidently assess data interchangeability from each of the different laboratories, investigations into accuracy, reliability and repeatability will be assessed.
This study will scientifically evaluate the ability to obtain similar kinematic and kinetic gait data at all three labs with the goal of confidently sharing data across all three sites. A direct benefit will be the ability to combine patient data from all three sites for larger data-sets when conducting investigative research. Once it is established that all sites accurately collect 3-dimensional kinetic and kinematic data, able-bodied human participants will be studied in all three laboratories. A repeated-measures experimental design will be used.
There currently exists a large gap between clinical measures that are used to assess cognitive and physical performance and the direct assessment of task performance for individuals on active duty. Presently used tests often only measure a single functional domain in highly controlled environments. Mission readiness, however, often requires an individual be prepared to perform rapid simultaneous physical and cognitive tasks. Thus, a critical gap exists in the ability of clinicians to assess a service member’s recovery and ultimately their ability to return to duty. Specifically, there are not currently any established clinical assessment tools designed to detect concussion associated impairments demonstrated during performance of tasks that include whole body physical activity and cognitive demand. This limitation is regularly faced by the Brooke Army Medical Center’s clinical care staff who are limited in their ability to substantiate patient reports of impairment, identify individuals who are underreporting and quantitatively document recovery.
The purpose of this investigation is to develop an assessment battery for the identification of performance limitations that negatively impact an injured service member’s ability to successfully return to their desired role (Active duty or Civilian).
The proposed complementary and collaborative project will build on recently completed studies and the vast clinical experience at the Brooke Army Medical Center and Walter Reed National Military Medical Center to develop an assessment that will reliably identify physical and cognitive limitations associated with performance of military tasks and return to civilian life following severe trauma. As a result, the assessment battery will have the potential to be used during the rehabilitation process regardless of the patient’s personal goals. A key aspect of the proposed assessment is the inclusion of common functional tasks within a virtual reality environment to allow the controlled and systematic assessment of multiple domains simultaneously in an ecologically valid manner.
Physical therapy is a critical part of the rehabilitation process for persons who have experienced lower extremity trauma. The goals of physical therapy are to re-educate the patient to function safely and efficiently while reducing compensations that may lead to secondary injuries, such as joint degeneration, and low back pain. Future complications may also lead to decreased activity for the patient and increased demand on the healthcare system.
Standard of care physical therapy in a rehabilitation clinic can be limiting. Patients are not necessarily exposed to environments they may encounter in their home, at work, or during recreational activities. This may be due to limitations of the facility, or not wanting to place the patient in situations of unnecessary risk. Additionally, patients may lack confidence in their abilities or their new prosthetic components. These limitations can be addressed in the computer assisted rehabilitation environments (CAREN).
Patients performing physical therapy in the CAREN as an adjunct to standard of care can experience environments and perform tasks within the safety of the system that they might not attempt otherwise. Additionally, patients can progress systematically through repetitive practice of specific tasks and increasing difficulty of applications. This methodology will ideally improve outcomes through increased confidence and improved quality of motion during locomotion.
Service Members who have experienced lower extremity trauma will be recruited to participate in this study. Following the initial gait and metabolic collection test subjects will be randomized into two groups. Group 1 will participate in standard of care rehabilitation and Group 2 will receive CAREN training as an adjunct to standard of care. CAREN training will occur three times per week and each session will be thirty minutes in length. This CAREN training will replace thirty minutes of their otherwise scheduled daily physical therapy. After six weeks of training, all amputee participants will undergo a second gait and metabolic evaluation. For the final six weeks, the groups will switch and Group 1 will receive CAREN as an adjunct to therapy, while Group 2 proceeds with standard of care alone. After the full twelve weeks, all amputee participants will undergo a final gait and metabolic evaluation.