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Purpose: This study sought to measure and identify factors associated with satisfaction with care among veterans. The metrics were colelcted for those receiving prosthetic limb care at the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) care settings and at community-based care providers., Methods: A longitudinal cohort of veterans with major upper limb amputation receiving any VA care from 2010 to 2015 were interviewed by phone twice, 1 year apart. Care satisfaction was measured by the Orthotics and Prosthetics User's Survey (OPUS) client satisfaction survey (CSS), and prosthesis satisfaction was measured by the OPUS client satisfaction with device (CSD), and the Trinity Amputation and Prosthetic Experience Scale satisfaction scales. The Quality of Care index, developed for this study, assessed care quality. Bivariate analyses and multivariable linear regressions identified factors associated with CSS. Wilcoxon Mann-Whitney rank tests and Fisher exact tests compared CSS and Quality of Care items at follow-up for those with care within and outside of the VA and DoD., Results: The study included 808 baseline participants and 585 follow-up participants. Device satisfaction and receipt of amputation care in the prior year were associated with greater satisfaction with care quality. Persons with bilateral amputation were significantly less satisfied with wait times. Veterans who received amputation care in the VA or DoD had better, but not statistically different, mean (SD) CSS scores: 31.6 (22.6) vs 39.4 (16.9), when compared with those who received care outside the VA or DoD. Those with care inside the VA or DoD were also more likely to have a functional assessment in the prior year (33.7% vs 7.1%, P = .06), be contacted by providers (42.7% vs 18.8%, P = .07), and receive amputation care information (41.6% vs 0%, P =.002). No statistically significant differences in CSS, Quality of Care scores, or pain measures were observed between baseline and follow-up. In regression models, those with higher CSD scores and with prior year amputation care had higher satisfaction when compared to those who had not received care., Conclusions: Satisfaction with prosthetic limb care is associated with device satisfaction and receipt of care within the prior year. Veterans receiving amputation care within the VA or DoD received better care quality scores than those receiving prosthetic care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the 12 months of this study. Findings from this study can serve as benchmarks for future work on care satisfaction and quality of amputation rehabilitative care., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article. This work was funded by the Office of the Assistant Secretary of Defense for Health Affairs, through the Orthotics and Prosthetics Outcomes Research Program Prosthetics Outcomes Research Award (W81XWH-16-675 2-0065) and the U.S Department of Veterans Affairs (VA RR&D, A2707-I and VA RR&D A9264A-S)., (Copyright © 2021 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

Background: The goal of the US Department of Veterans Affairs (VA) Amputation System of Care (ASoC) is to enhance the quality and consistency of amputation rehabilitation care for veterans with limb loss., Objective: The ASoC provides specialized expertise in amputation rehabilitation incorporating the latest practices in medical management, rehabilitation, and artificial limbs in order to minimize disability and to enable the highest level of social, vocational, and recreational success for veterans with amputation., Discussion: The ASoC serves veterans with limb amputation from any etiology. Between 2009 and 2019, the VA experienced a 34% increase in the number of veterans with amputation who received care. During the same 10-year period, the percentage of veterans with major limb amputation seen in an outpatient amputation specialty clinic each year increased from 4.8 to 26%. This article highlights how the mission of the ASoC has been accomplished over the past decade through prioritization and implementation of key strategic initiatives in learning organization creation, trust in VA care, modernization, and development of a high-performance network with enhanced access and customer service., Conclusions: This synopsis of the VA amputation care program serves as a model of amputation care that can be utilized outside the federal sector and has the potential to serve as a systems-based example for providing longitudinal care to other populations within the VA., Competing Interests: Author disclosures The authors report no actual or potential conflicts of interest with regard to this article., (Copyright © 2020 Frontline Medical Communications Inc., Parsippany, NJ, USA.)

Between 2015 and 2017, the US Department of Veterans Affairs and the US Department of Defense developed a clinical practice guideline for rehabilitation of lower limb amputation to address key clinical questions. A multidisciplinary workgroup of US Department of Veterans Affairs and US Department of Defense amputation care subject matter experts was formed, and an extensive literature search was performed which identified 3685 citations published from January 2007 to July 2016. Articles were excluded based on established review criteria resulting in 74 studies being considered as evidence addressing one or more of the identified key issues. The identified literature was evaluated and graded using the National Academies of Science GRADE criteria. Recommendations were formulated after extensive review. Eighteen recommendations were confirmed with four having strong evidence and workgroup confidence in the recommendation. Key recommendations address patient and caregiver education, consideration for the use of rigid and semirigid dressings, consideration for the use of microprocessor knees, and managed lifetime care that includes annual transdisciplinary assessments. In conclusion, this clinical practice guideline used the best available evidence from the past 10 yrs to provide key management recommendations to enhance the quality and consistency of rehabilitation care for persons with lower limb amputation.

Regenerative rehabilitation is the synergistic integration of principles and approaches from the regenerative medicine and rehabilitation fields, with the goal of optimizing form and function as well as patient independence. Regenerative medicine approaches for repairing or replacing damaged tissue or whole organs vary from utilizing cells (e.g., stem cells), to biologics (e.g., growth factors), to approaches using biomaterials and scaffolds, to any combination of these. While regenerative medicine offers tremendous clinical promise, regenerative rehabilitation offers the opportunity to positively influence regenerative medicine by inclusion of principles from rehabilitation sciences. Regenerative medicine by itself may not be sufficient to ensure successful translation into improving the function of those in the most need. Conversely, with a better understanding of regenerative medicine principals, rehabilitation researchers can better tailor rehabilitation efforts to accommodate and maximize the potential of regenerative approaches. Regenerative rehabilitative strategies can include activity-mediated plasticity, exercise dosing, electrical stimulation, and nutritional enhancers. Critical barriers in translating regenerative medicine techniques into humans may be difficult to overcome if preclinical studies do not consider outcomes that typically fall in the rehabilitation research domain, such as function, range of motion, sensation, and pain. The authors believe that encouraging clinicians and researchers from multiple disciplines to work collaboratively and synergistically will maximize restoration of function and quality of life for disabled and/or injured patients, including U.S. Veterans and Military Service Members (MSMs). Federal Government agencies have been investing in research and clinical care efforts focused on regenerative medicine (NIH, NSF, VA, and DoD), rehabilitation sciences (VA, NIH, NSF, DoD) and, more recently, regenerative rehabilitation (NIH and VA). As science advances and technology matures, researchers need to consider the integrative approach of regenerative rehabilitation to maximize the outcome to fully restore the function of patients., Competing Interests: The authors declare no competing interests.

High-energy lower extremity trauma is a consequence of modern war and it is unclear if limb amputation or limb salvage enables greater recovery. To improve function in the injured extremity, a passive dynamic ankle-foot orthosis, the Intrepid Dynamic Exoskeletal Orthosis (IDEO), was introduced with specialized return to run (RTR) therapy program. Recent research suggests, these interventions may improve function and return to duty rates. This systematic literature review sought to rate available evidence and formulate empirical evidence statements (EESs), regarding outcomes associated with IDEO utilization. PubMed, CINAHL, and Google Scholar were systematically searched for pertinent articles. Articles were screened and rated. EESs were formulated based upon data and conclusions from included studies. Twelve studies were identified and rated. Subjects (n = 487, 6 females, mean age 29.4 year) were studied following limb trauma and salvage. All included studies had high external validity, whereas internal validity was mixed because of reporting issues. Moderate evidence supported development of four EESs regarding IDEO use with specialized therapy. Following high-energy lower extremity trauma and limb salvage, use of IDEO with RTR therapy can enable return to duty, return to recreation and physical activity, and decrease pain in some high-functioning patients. In higher functioning patients following limb salvage or trauma, IDEO use improved agility, power and speed, compared with no-brace or conventional bracing alternatives., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

This article explores unique considerations that face both women living with limb loss and their health care providers. This demographic of patient has a higher rate of artificial limb rejection, thus challenging providers to address needs for cosmesis and function that varies from those of male counterparts. Health care providers for women with amputations, such as the Veterans Affairs, must evolve health care delivery, research practices, and work jointly with industry in order to meet the needs of this population., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

We recently demonstrated that postmenopausal women have an augmented blood pressure response to voluntary apnea compared to premenopausal women. Both obstructive sleep apnea (OSA) and healthy aging are associated with increased oxidative stress, which may impair cardiovascular function. Restoring physiological responses could have clinical relevance since transient surges in blood pressure are thought to be an important stimulus for end-organ damage in aging and disease. We tested the hypothesis that acute antioxidant infusion improves physiological responses to voluntary apnea in healthy postmenopausal women (n = 8, 64 ± 2 year). We measured beat-by-beat mean arterial pressure (MAP), heart rate (HR), and brachial artery blood flow velocity (BBFV, Doppler ultrasound) following intravenous infusion of normal saline and ascorbic acid (~3500 mg). Subjects performed maximal voluntary end-expiratory apneas and changes (Δ) from baseline were compared between infusions. The breath hold duration and oxygen saturation nadir were similar between saline (29 ± 6 sec, 94 ± 1%) and ascorbic acid (29 ± 5 sec, 94 ± 1%). Ascorbic acid attenuated the pressor response to voluntary apnea (ΔMAP: 6 ± 2 mmHg) as compared to saline (ΔMAP: 12 ± 2 mmHg, P = 0.034) and also attenuated forearm vasoconstriction (ΔBBFV: 4 ± 9 vs. -12 ± 7%, P = 0.049) but did not affect ΔHR. We conclude that ascorbic acid lowers the blood pressure response to voluntary apnea in postmenopausal women by inhibiting vasoconstriction in the limb vasculature. Whether ascorbic acid has similar effects in OSA patients remains to be prospectively tested., (© 2015 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.)

In response to hypoxia, a net vasodilation occurs in the limb vasculature in young healthy humans and this is referred to as "hypoxia-induced vasodilation". We performed two separate experiments to determine (1) if hypoxia-induced forearm vasodilation is impaired in older men (n = 8) compared to young men (n = 7) and (2) if acute systemic infusion of ascorbic acid would enhance hypoxia-induced vasodilation in older men (n = 8). Heart rate, mean arterial pressure, oxygen saturation, minute ventilation, forearm vascular conductance (FVC, Doppler ultrasound), and cutaneous vascular conductance (CVC, laser Doppler flowmetry) were recorded continuously while subjects breathed 10% oxygen for 5 min. Changes from baseline were compared between groups and between treatments. The older adults had a significantly attenuated increase in FBF (13 ± 4 vs. 30 ± 7%) and FVC (16 ± 4 vs. 30 ± 7%) in response to 5 min of hypoxia. However, skin blood flow responses were comparable between groups (young: 35 ± 9, older: 30 ± 6%). In Experiment 2, FVC responses to 5 min of breathing 10% oxygen were not significantly different following saline (3 ± 10%) and ascorbic acid (8 ± 10%) in the older men. Ascorbic acid also had no physiological effects in the young men. These findings advance our basic understanding of how aging influences vascular responses to hypoxia and suggest that, in healthy humans, hypoxia-induced vasodilation is not restrained by reactive oxygen species., (© 2014 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of the American Physiological Society and The Physiological Society.)

Nonballistic, active range of motion exercises have been advocated as more effective than static stretching for increasing range of motion, yet no published data exist to support this claim. This study compared the effect of nonballistic, repetitive active knee extension movements performed in a neural slump sitting position with static stretching technique on hamstring flexibility. Forty healthy, adult volunteer subjects with limited right hamstring flexibility (i.e., minimum of 15 degrees loss of active knee extension measured with femur held at 90 degrees of hip flexion) were randomly assigned to one of three groups. Group 1 (static stretch) performed a 30-second stretch twice daily. Group 2 (active stretch) performed 30 repetitions of active knee extension while sitting in a neural slump position twice daily. Group 3 served as a control. Hamstring flexibility was determined by an active knee extension test before and after 6 weeks of stretching. Goniometric measurement of knee joint flexion angle was obtained from videotape recording of the active knee extension test. A 3 (group) x 2 (test) repeated measures analysis of variance and subsequent Tukey post hoc testing revealed no significant difference in knee joint range of motion gains between the static (mean = 8.9 degrees) and active stretch (mean = 10.2 degrees). Both stretch groups' knee joint range of motion improved significantly (p < .05) more than the control group. We conclude that 6 weeks of nonballistic, repetitive active knee extensions (30 repetitions, twice daily) performed in a neural slump sitting position improves hamstring flexibility in uninjured subjects, but is no different compared with static stretching (30 seconds, twice daily).

Stress radiography of the ankle commonly is used to evaluate talar tilt in patients with a history of inversion ankle sprains. Manual and instrumented procedures have been variously described in the literature. No reports have documented normative talar tilt as measured using the Telos ankle stress device in a large clinical population. In addition, little has been done to examine the value of using graded displacement forces compared with a single displacement force. Bilateral Telos examinations from 113 consecutive patients taken during a 4-year period were evaluated for this study. No measurable talar tilt was observed in 65.8% of the ankles in this study. Talar tilt ranged from 1.7 degrees to 24.9 degrees in injured ankles. In patients with quantifiable talar tilt, all had greater talar tilt at the 15 kPa force than at all other forces. Because of the variability in talar tilt in injured and comparison ankles, clinical conclusions regarding injury severity cannot be made on measured talar tilt alone. The analysis suggests that inversion stress examination is helpful in documenting gross talar instability, but the discriminant value of the procedure to determine the anatomy and severity of lateral ligament injury is tenuous.

The Sexual Decision-Making Inventory (SDMI) was developed to measure levels of sexual decision making based on the developmental concepts of Object Relations Theory. The inventory asks subjects to report on their thoughts and feelings at the time they decided to have sex in their most recent sexual relationship. The inventory was tested in a pilot study involving 45 male and 49 female undergraduates. A factor analysis was performed on the SDMI and six levels of sexual decision making were defined: Object Constancy, Ambivalence, Need for Merger, Need Gratification, Low Self-esteem, and Narcissistic Gratification. Endorsement of items on these subscales was related to perceptions of the relationship. In a second study involving 79 male and 135 female undergraduates, subjects completed the SDMI, the Bell Object Relations Self-report Inventory, and a questionnaire concerning perceptions of the relationship in which the sexual decision was made. Object Constancy was positively correlated to object relations, satisfaction with the relationship, and durability of the relationship; Ambivalence, Need Gratification, and Low Self-esteem were negatively correlated with object relations, satisfaction with the relationship, and durability of the relationship; Narcissistic Gratification was negatively correlated with object relations and most aspects of the relationship with interesting exceptions such as sexual satisfaction. Sex differences demonstrated that females were more likely to endorse items on the Object Constancy subscale; whereas males were more likely to endorse items on the Ambivalence, Need Gratification, and Narcissistic Gratification subscales. There were no sex differences, however, in quality of general object relations.