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Since the start of the wars in Afghanistan and Iraq, there have been 866 major limb amputations from combat operations seen at major military medical centers in the United States. These injuries have challenged rehabilitation professionals with many clinical problems. One such challenge is treating patients who sustain multiple limb amputations that involve both an upper extremity (UE) and a lower extremity (LE). This uncommon amputation pattern describes 27 patients of the aforementioned total. This article is a case study of a multiple limb amputee whose primary rehabilitation goal was to walk without the aid of an assistive devise. The primary objective is to discuss how wearing a UE prosthesis affects gait in comparison with not wearing the prosthesis. There were notable temporal-spatial and kinematic differences in the patient's gait while wearing the UE prosthesis when compared with walking without it. For example, while wearing the UE prosthesis, the patient's trunk rotated more toward his intact side but lateral flexion became more symmetric. For this patient, wearing a UE prosthesis had a desirable effect on trunk kinematics while ambulating. [ABSTRACT FROM AUTHOR]

Introduction: Polytrauma, to include major limb amputation, in a military population presents unique rehabilitation challenges with the overarching goal of restoring function leading to the primary question, "Is this Service Member (SM) capable of returning to duty following rehabilitation?" The US military has a vested interest in maximizing injured SMs occupational performance to allow for return to duty. The purpose of this report is to describe marksmanship (shot grouping and weapon qualification) and return to duty outcomes following a course of VRE-based firearm training in a polytrauma patient population., Methods: The medical records, stored in the Armed Forces Health Longitudinal Technology Application (AHLTA), of all patients who received rehabilitative care at the Center for the Intrepid (CFI) to include VRE-based firearms training between 01OCT2015 and 01AUG2016 were manually reviewed for inclusion. Subjects included all adult (18 years and older) SMs (active duty at time of admission) with a diagnosis of polytrauma who had been referred to and treated (received additional services such as physical and or occupational therapy) at the CFI. Approval for this research was received from the Brooke Army Medical Center Department of Clinical Investigation Office of the Institutional Review Board., Results: Medical records of 30 SMs with a polytrauma diagnosis met the inclusion criteria. Mean shot group sizes for the M9 and M4 weapon decreased between initial and post training time points for the M9 zero (p = 0.009) and M4 zero (p = 0.020). There was no significant difference between initial and post training time points at the other shooting distances with either weapon. There was an 89% qualification rate for both the M9 (n = 18) and M4 (n = 19) weapons for those who attempted qualification; 43% of the population (n = 13) did not attempt qualification with either weapon., Conclusion: SMs with polytrauma demonstrated a high rate of weapon qualification (accuracy) following VRE-based firearm training. Shot group size (precision) at short distances with a M9 pistol and M4 rifle also improved with training. While overall marksmanship appeared to improve, high return to duty rates were not directly related to firearm training or marksmanship. Future efforts need to focus on consistent clinical documentation of firearm training procedure and the establishment of psychometric properties for marksmanship outcome measures., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2019.)

Study Design: Prospective, repeated-measures study., Introduction: Understanding individual hand function can assist therapists with the process of determining relevant treatment approaches and realistic therapeutic outcomes. At this point in time, a composite test that assesses both unilateral and bimanual hand function in relation to a functional activity is not available., Purpose of the Study: To establish the reliability and validity of the suitcase packing activity (SPA)., Methods: An expert panel established face and content validity. Eighty healthy, English-speaking volunteers aged between 18 and 45 years were randomly assigned to either 1 or 2 sessions (test-retest reliability). Relative agreement between 2 examiners using an intraclass correlation coefficient (ICC) 3,1 determined interrater reliability. Test-retest reliability was determined by using a repeated-measures analysis of variance and an ICC 3,2 . Concurrent validity was evaluated against 2 well-established hand evaluations using separate tests of correlational coefficients., Results: Face and content validity were established across 4 focus groups. Our results demonstrate good to excellent interrater reliability (ICC 3,1 ≥ 0.93) and good to excellent test-retest reliability (ICC 3,2 ≥ 0.83). SPA scores were moderately correlated with the 2-hand evaluations., Discussion: Through evaluating hand function during participation in a goal-directed activity (eg, packing a suitcase), the SPA exhibits promise in usefulness as a future viable outcome measure that can be used to assess functional abilities following a hand injury., Conclusion: The SPA is a valid and reliable tool for assessing bimanual and unilateral hand function in healthy subjects., Levels of Evidence: Diagnostic level II., (Published by Elsevier Inc.)

A functional capacity evaluation (FCE) evaluates the ability of an individual to perform activities related to employment. There is no FCE specific to the military population; therefore, a FCE for the military population (FCE-M) was developed to evaluate an injured service member's (SM) ability to return to duty. The FCE-M is herein described along with descriptions of three active duty SMs who completed the evaluation. The three SMs completed all categories of the FCE-M with the first two cases achieving a work-level classification of Heavy-Very Heavy and the third a classification of Medium-Heavy. The FCE-M provides a systematic assessment of performance of highly specified military tasks and may provide value in assessing readiness for returning to duty., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Crossed dominance (CD) is defined as an individual's dominant hand and dominant eye being on opposite sides of the body. CD negatively impacts an individual's ability to accurately aim and fire long-barreled guns. The authors developed and evaluated a hand dominance transfer (HDT) intervention to improve the M16 rifle shooting accuracy, efficiency, and skill transfer. Twenty-four U.S. Army soldiers with CD were taught how to handle and fire an M16 rifle using the nondominant hand. Training was conducted at a military, indoor laser-equipped weapons simulator. Accuracy for shooting 40 rounds at baseline with the nondominant eye and dominant hand (NDE/DH) was 22.12 compared to shooting 30.46 with the dominant eye and nondominant hand (DE/NDH). This difference was statistically significant with p = .000. The transfer of shooting accuracy skill (retention) following the HDT intervention was 33.42 with a comparative p value of .100. Efficiency of shooting 10 rounds at baseline with the NDE/DH was 6.3 compared to shooting 7.3 with the DE/NDH. This difference was not statistically significant (p = .107). The transfer of shooting efficiency skill (retention) was 7.96 with a comparative p value of .349. This study supports shooting with the DE/NDH. HDT could be further developed to address the soldiering skill of shooting an M16.

Injuries are a major impacting factor for a military organization. Injuries may be the result of direct combat, or noncombat, and may be incurred during deployment, other military operations and training. The impact of injuries is the loss of manpower (e.g., lost duty days), medical costs for treatment, and the influence that an injury may have on an individual's quality of life. To address this issue, it is essential to understand the types of injuries that are occurring, and the mechanisms responsible for those injuries, to develop strategies to reduce injury incidence and to allocate the resources required for rehabilitation to return the individual to duty. This article will review the most common medical injury being incurred by our present warfighter; namely, musculoskeletal injuries (MSIs). The number, types, and causal mechanisms of MSIs will be reviewed. Risk factors for MSIs will be identified and the various interventions being used to prevent or mitigate the severity of MSIs will be discussed. Lastly, the programs that have been developed within the U.S. Department of Defense and the U.S. Army for the assessment, care, and rehabilitation of the most severe MSIs incurred while deployed will be described.

Purpose of Review: The purpose of this review is to summarize current trends and rehabilitation programs for musculoskeletal injuries in military personnel returning from deployment., Recent Findings: Musculoskeletal injuries (MSIs) are the leading healthcare problem for military members. Risk factors include participation in sports, carrying heavy loads, older age, female sex, standing for long periods of time, and walking long distances. MSIs may lead to medical discharge from the military. Physical and occupational therapists work at the Combat Support Hospitals to provide rehabilitation care to injured personnel and reduce recovery time by 60% and costs by 123%. The Army Medical Department has developed initiatives to decrease the burden of MSI: musculoskeletal screening and referral tools to assist military medical providers in managing patients with MSI; Pain Management Task Force to optimize care for wounded soldiers; Musculoskeletal Action Plan for injury prevention, early diagnosis and management, and rehabilitation/reintegration following injury; and Musculoskeletal Action Teams to work with military recruits who make up the largest subgroup in the Army with the highest incidence of MSIs., Summary: The US Military is aware of the inherent risks for MSI associated with military training and repeated combat deployments. Rehabilitation efforts have been developed to address the problem.

Study Design: Internet survey., Purpose: To describe current practice patterns in hand therapy to 1) gain insights into beliefs of certified hand therapists (CHTs) related to initiating a hand dominance transfer, 2) describe CHTs' clinical decision-making strategies, and 3) describe research priorities related to hand dominance transfer in hand therapy., Participants: Five hundred sixty-three members of the American Society of Hand Therapists., Methods: The online Internet survey contained 30 questions related to four categories: 1) demographics of clinicians, 2) beliefs about hand dominance transfer, 3) clinical strategies and decision making, and 4) a research agenda related to hand dominance transfer. Data were sorted, compiled, and analyzed descriptively., Results: Respondents were primarily occupational therapists working as full-time staff therapists treating between nine and 15 patients per day with orthopedic injuries to the dominant upper extremity caused by trauma. The overwhelming majority of respondents (92.7%) believed that motivation is a factor in the success of the hand dominance transfer. Most respondents (83%) do not directly initiate a hand dominance transfer. The number one reason (64%) for not initiating a dominance transfer is that CHTs believe that their patients will regain full recovery of injured hand over time. If a transfer is initiated, the number one task addressed is handwriting (62%); the most commonly recommended piece of adaptive equipment was the handsfree can opener (63.8%); 72% educate on the risk of overuse injury to the noninjured (intact) limb. Most respondents agreed or strongly agreed that more research needs to be done related to hand dominance transfer, specifically related to return to work rates, interventions using virtual reality, and assessments using neuroimaging technologies., Level of Evidence: 3b., (Published by Elsevier Inc.)

The aim of this study was to quantify stability of nondominant handwriting kinematics and legibility in participants with functional loss of the previously dominant hand. Twelve adult volunteers provided two handwriting samples 6 weeks apart. Handwriting tasks (Compose a Sentence, Copy Alphabet, Copy Date, Copy Sentence, and Draw Circles) were performed in cursive writing on standard white, lined paper taped to a digitizer to record kinematic and kinetic variables of velocity, displacement, force, and on-paper time. Results showed minimal performance variability within subjects and marked variability between subjects, as well as variability between tasks for all participants. Stylistic stability of the handwriting samples was assessed by two independent evaluators. These evaluators matched all handwriting samples at test to retest times with 89%-100% accuracy, suggesting value in the "whole" handwriting sample and emphasizing the idiosyncratic nature of handwriting. Results suggest that handwriting skill stability in the previously nondominant hand varies across subjects and task demands.

ABSTRACT This paper describes the purposeful integration of dynamical systems theory, the occupational therapy task-oriented approach, and Framework II to inform clinical reasoning. Dynamical systems theory provides the clinician with information about how systems interact to influence motor behavior. The task-oriented approach helps the practitioner to clinically improve motor behavior. Framework II gives the clinician guidance in terms of scope of practice and an overarching goal of intervention. Ideological similarities between these three resources for clinical reasoning include client-centeredness, an emphasis on occupation, and interaction between person, task, and environment. The process of clinical reasoning is illustrated using an integrated practice model applied to a clinical example of an adult with a hand injury requiring transfer of hand dominance.

NARRATIVE REVIEW: This article is a narrative review of the psychometric properties (reliability and validity) and other characteristics (cost, time to administer, and year of publication) of commercially available manual and finger dexterity assessments used for adults in the United States. Complete research articles related to dexterity assessments were gathered from online database searches and individually critiqued for scientific rigor based on reliability and validity. Articles relating to 14 dexterity assessments were reviewed. All but three tools had established reliability, seven tools had all five forms of validity established, and two had only face and content validity. The results of this review provide information to those interested in fine motor skill acquisition, impairment, or functional recovery after injury. Therapists may use this information to choose the best assessment instrument to evaluate a patient's recovery of function over time. This review adds to the evidence-based, best-practice literature related to assessment and outcome measurements of patients with limited dexterity function participating in rehabilitation.

Context: There are discrepancies regarding the efficacy of neural gliding exercises for the management of carpal tunnel syndrome (CTS)., Objective: To conduct a systematic review assessing the efficacy of neural gliding in comparison to alternative nonsurgical treatment for the management of CTS., Evidence Acquisition: A computerized search was performed in April 2008. Criteria for inclusion required that studies (1) were written in English, (2) examined the efficacy of neural gliding techniques for treatment of CTS, and (3) included at least one of the selected patient-oriented outcomes. Effect sizes, relative risk, and 95% confidence intervals were calculated to compare neural gliding to alternative treatment., Evidence Synthesis: Six studies met inclusion criteria. For all variables, none were consistently favorable toward neural gliding over alternative treatment. However, comparisons across studies revealed a possible trend toward improved outcomes with the use neural gliding., Conclusions: The efficacy of neural gliding is not clear. More research is necessary to determine the population that may respond optimally to this treatment.