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Investigating long-term musculoskeletal biomechanics of military veterans post traumatic lower limb amputation

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posted on 2025-05-28, 10:00 authored by Jose Manuel Frias BocanegraJose Manuel Frias Bocanegra

The number of United Kingdom military personnel severely wounded by battlefield injuries increased with the conflicts in Iraq and Afghanistan. Advances in modern battlefield medicine, immediate trauma care, rapid evacuation of injured personnel, and improved soldier and vehicle protection have increased survival rates. However, this has also led to a rise in lower limb amputations. Defence multidisciplinary rehabilitation pathways tailored to an individual’s long-term recovery goals were applied to this unique sample of young, healthy and highly motivated individuals. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE) study tracks the long-term physical and psychosocial outcomes of this severely injured veteran cohort. Gaps remain regarding the impact of endogenous factors like muscle size and strength on gait biomechanics. Previous studies on musculoskeletal health in combat amputees often lack robustness due to small sample sizes and short-term focus, limiting conclusions about the long-term effects of traumatic amputations. These limitations have hindered the development of more comprehensive rehabilitation pathways, which are crucial to addressing the risk of comorbidities, such as osteoarthritis and or sarcopenia, in the intact limbs of ageing amputees.

This thesis addresses these gaps by presenting the first study to examine the long-term multifactorial physical effects of traumatic lower limb amputation on a cohort of young, healthy UK military veterans, now more than a decade post-injury. These veterans sustained severe injuries that would have been largely unsurvivable in earlier conflicts, requiring significant resuscitation and surgical intervention. Prior research provided valuable insights, but there is still much to understand about how endogenous factors related to different levels of amputation affect biomechanics and MSK health, both of which are crucial for daily life.

For the first time, this study investigates muscle size and strength in this population, revealing statistically significant differences and clinically relevant parameters that underscore the complexity of managing traumatic lower limb amputees with the aim of assisting in the purpose of rehabilitation programmes as this cohort ages. The total number of participants recruited was 41, including 31 amputees, with an average of 12.5 years since injury, making this one of the most comprehensive datasets available.

This is the first gait study to use the 6-Minute Walk Test (submaximal performance) in a cohort of veteran traumatic lower limb amputees combined with a 3-dimensional motion capture system, force plates and respiratory exchange analysis. It also uniquely assesses the four key locomotor muscle groups bilaterally in the same individuals across three different injury classifications and evaluates muscle strength parameters, including peak torque, rate of torque development and hamstring-to-quadriceps ratio where limb length and joint availability permit. Additionally, it presents regression equations that estimate muscle volume from in-vivo ultrasound and compares these results with magnetic resonance imaging muscle volume data. Rigorous statistical analysis is used to identify significant variables in muscle size, strength, and gait performance parameters within this unique veteran cohort. Analysis of outliers deviating from cohort means adds insight. The study suggests that muscle strength may not be as strongly correlated to muscle size as expected, indicating the need for further research in neuromuscular function and muscle architecture in severely injured veterans. The work also includes a pilot study of the use of ultrasound shear wave elastography to better characterise skeletal muscle properties in this clinical population. It also highlights the practical challenges of applying benchmark techniques used in the able-bodied to this injured population.

The results demonstrate that, despite the challenges, these amputee cohorts continue to exhibit exceptional health and performance outcomes compared to matched able-bodied controls and other lower limb amputee populations. However, the study also identifies areas for future research, particularly in understanding the complex relationships between muscle size, strength, and functional outcomes in this unique population.

Funding

UK Ministry of Defence 02109101_701561394_Optimising_Rehabilitation_Pathways

History

School

  • Sport, Exercise and Health Sciences

Publisher

Loughborough University

Rights holder

© Jose Manuel Frias Bocanegra

Publication date

2025

Notes

A Doctoral Thesis. Submitted in partial fulfilment of the requirements for the award of the degree of Doctor of Philosophy of Loughborough University.

Language

  • en

Supervisor(s)

Daniel TP Fong ; David J Williams ; Sarah Stapley ; Patrick Wheeler

Qualification name

  • PhD

Qualification level

  • Doctoral

This submission includes a signed certificate in addition to the thesis file(s)

  • I have submitted a signed certificate

Ethics review number

Project ID: 1899