Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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chose a graphic representation of spatiotemporal and bio- mechanical differences between carbon fiber and nominal stiffness IDEO braces. 28 This is an acceptable method for presenting measures of central tendency and variance and even preferred at times to depict continuous phenomena. However, this form of data presentation is also not condu- cive to the calculation of magnitude of effect. Bedigrew et al compared differences in physical perfor- mance and perceptive measures at 3 assessment points; immedi- ately postinjury, post physical therapy before bracing and again following bracing with additional physical therapy. 14 This
group reported effect size (calculated as a difference in means) in all study measures. Effect sizes for differences in physical performance measures immediately postinjury compared to post bracing and therapy were considerable, ranging from 24 to 166% improvements. Effect sizes for pain scores were generally improved (i.e., reduced pain) following bracing and therapy by a magnitude of 23 to 35%. Patients entering into rehabilitation late experienced reduced magnitude of effect to 16 to 45% for physical performance and 27 to 38% for perceptive measures. Although these outcomes were of a relatively reduced effect compared to their early-entry peers, these were still statistically signi
ficant ( p ≤ 0.05) as well as clinically important. In total, 82 comparisons were eligible for effect size anal- ysis per this review ’s protocol. Of these, 64 involved use of an IDEO. More speci fically, IDEO was compared relative to either a comparator (or no brace) or IDEO con figuration (i.e., strut stiffness) was modi fied and compared. Within the subset of IDEO involved comparisons, 37.5% were of a large magnitude of effect, 25% were of medium magnitude, and the remaining 37.5% were of a small effect size. For instance, Haight et al studied differences in IDEO strut stiffness between sound and involved limbs and to unimpaired control limbs. 24 Effect size (Cohen ’s d ) was 0.03 (small) regarding peak knee extension moment between control and experimental subjects ’ involved limb while using a compres- sive IDEO brace. Oppositely, effect size was 5.9 (large) when comparing the differences in ankle range of motion between sound and involved sides when a stiff IDEO brace was utilized. Esposito et al identi fied 5 statistically significant kine- matic comparisons. 25 Of these, comparisons between com- pliant and more rigid IDEO strut designs were larger than those comparing nominal with stiff strut designs. Speci fi- cally, 3/3 kinematic comparisons were of medium effect size when comparing compliant with nominal and stiff IDEO struts, whereas 2/2 signi ficant comparisons between nominal and stiff strut designs resulted in small effects. During functional performance tasks, IDEO use resulted in large effects in self-selected walking velocity regardless of comparator and again had large effects on speed over uneven terrain and the 40-yd dash compared to a Blue Rocker orthosis (Allard USA, Rockaway, New Jersey). Medium effects were observed during stair climbing and in the four-square step test when IDEO was used in compari- son with the Blue Rocker and a no brace condition. 26 When
non-IDEO braces or no brace was used all signi ficant com- parisons were of a small magnitude of effect. Conversely, when IDEO was used during these tasks, 25% of signi ficant comparisons were of a medium or large magnitude of effect. Empirical Evidence Statements The following four evidence statements were formulated and supported by moderate-level evidence: (1) In service personnel under 40 years of age, injured with high-energy lower extremity trauma, potentially confounded by post-traumatic ankle osteoarthritis, fitting, and use of IDEO with RTR physical therapy following limb salvage surgery may allow return to active duty for a limited population of high- functioning patients. 1,13,15 –17,23
(2) In service personnel under 40 years of age, injured with high-energy lower extremity trauma, potentially confounded by post-traumatic ankle osteoarthritis, TABLE IV. Internal and External Validity of Included Studies Author (Year) Study Design
Internal Validity External Validity 1 2
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total 1 2 3 4 5 6 7 8 Total Patzkowski (2011) O6 n/a n/a n/a n/a n/a • • • • Low • • • • • • • High Owens (2011) O4 n/a n/a n/a n/a n/a • • • • • Low
• • • • • • • High Patzkowski (2012) O3 n/a n/a n/a n/a n/a • • • • • • Low
• • • • • • • High Patzkowski (2012) O3 n/a n/a n/a n/a n/a • • • • • • • • Low • • • • • • • High Patzkowski (2012) E1 • • • n/a
• • • • • • • • • Moderate • • • • • • • • High Harper (2014) E5 n/a n/a n/a n/a • • • • • • • • • • • High • • • • • • • • High Blair (2014) O1 n/a n/a n/a n/a n/a • • • • • • • Moderate • • • • • • • High Esposito (2014) E2 •
• • •
• • • • • • • Moderate • • • • • • • • High Bedigrew (2014) E3 n/a n/a n/a n/a • • • • • • • • • • Moderate • • • • • • • High Harper (2014) E5 n/a n/a n/a n/a • • • • • • • • • • • High • • • • • • • • High Sheean (2014) O1 n/a n/a n/a n/a n/a • • • • • • • • Moderate • • • • • • • High Haight (2015) E2 •
• • • • • • • • Low
• • • • • • • • High “n/a” indicates this particular criteria is not applicable for the given study design. The symbol “•” indicates that the criteria was satisfied. A blank space (no symbol) indicates that the particular criteria was not satis fied.
MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 73 Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis Yüklə 1,64 Mb. Dostları ilə paylaş:
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