More than the final score: Development, application, and future research of Comprehensive High-Level Activity Mobility Predictor

Abstract

Since September 11, 2001, the United States has become involved in two major conflicts [1]. As of December 3, 2012, the Congressional Research Service reported that the number of battle-injury amputations from Operation New Dawn, Operation Iraqi Freedom (OIF), and Operation Enduring Freedom (OEF) was 1,715 [2]. Explosions or blasts have produced the highest percentage (54%) of limb injuries seen among wounded servicemembers (SMs) since World War II [3]. Owens et al. reported almost symmetrical distribution between wounds to the upper (51%) and lower limbs (49%) with SMs wounded in action in OIF/OEF from October 2001 through January 2005 [3]. Prior to 2005, approximately 75 percent of major limb amputations occurred to the lower limbs, with 15 percent of SMs sustaining multiple limb loss [4]. By 2009, the numbers had increased such that 82 percent of major limb amputations were to the lower limbs, with 24 percent sustaining multiple limb loss and the majority occurring in bilateral lower limbs. Since 2010, the number of SMs sustaining more than one limb loss has continued to increase, with also greater concomitant injuries [5]. Historically, SMs who sustained a major limb amputation were medically retired from Active Duty (AD) military service [6]. Today, however, expectations have changed and provisions have been established to allow SMs with major limb loss, who so desire, to remain on AD. A report published in 2009 found that 11 percent of SMs with major lower-limb loss who have completed the medical boarding process either qualified for Continuation on AD or Continuation on Active Reserve or were determined to be Fit for Duty [7]; by 2010, the number rose to 16 percent [8]. With military SMs achieving such high levels of activity after major limb loss, it became clear to the rehabilitation community that the outcome measures for this unique patient population needed to be adjusted. In 2006, Pasquina and Fitzpatrick reported the need to develop novel outcome measures for use in assessing patient progress and determining optimal treatment strategies for SMs with lower-limb loss receiving care at Walter Reed Army Medical Center, Bethesda, Maryland [9]. They reported that these patients were quickly exceeding functional outcome expectations and quickly reaching a ceiling effect on existing outcome measurement tools such as the Amputee Mobility Predictor (AMP) or Timed Up and Go Test. They therefore concluded that a need existed to develop a more robust outcome measure geared toward assessing high levels of mobility for this specific population in order to better quantify functional capability, change in function over time, and readiness to return to AD and/or competitive sports. Developing a novel high-level mobility outcome measurement tool would require extensive academic rigor, especially to develop one that was both reliable and valid. The single-topic section of this issue of the Journal of Rehabilitation Research and Development (JRRD) describes the development of the Comprehensive High-Level Activity Mobility Predictor (CHAMP), which we propose the rehabilitation community consider using when providing state-of-the-art care for today's people with amputation who want to return to high-level activity. The CHAMP was developed to be a performance-based assessment instrument to measure high-level mobility of people with lower-limb amputation. In developing the CHAMP, we analyzed existing military, amputation, and nonamputation literature and determined that balance, postural stability, coordination, power, speed, and agility were the most important factors that influenced high-level mobility. We then examined published outcome measures that had been purported for use with individuals with lower-limb amputation and found that the Single Limb Stance, Edgren Side Step Test, T-Test, and Illinois Agility Test best captured these factors. Therefore, we used these measurement tools as the basis for constructing the CHAMP. …