Effect of Severe Distal Tibia, Ankle, and Mid- to Hindfoot Trauma on Meeting Physical Activity Guidelines 18 Months After Injury

Published:August 20, 2021DOI:



      To examine the effect of severe lower extremity trauma on meeting Physical Activity Guidelines for Americans (PAGA) 18 months after injury and perform an exploratory analysis to identify demographic, clinical, and psychosocial factors associated with meeting PAGA.


      Secondary analysis of observational cohort study.


      A total of 34 United States trauma centers


      A total of 328 adults with severe distal tibia, ankle and mid- to hindfoot injuries treated with limb reconstruction (N=328).



      Main Outcome Measures

      The Paffenbarger Physical Activity Questionnaire was used to assess physical activity levels 18 months after injury. Meeting PAGA was defined as combined moderate- and vigorous-intensity activity ≥150 minutes per week or vigorous-intensity activity ≥75 minutes per week.


      Fewer patients engaged in moderate- or vigorous-intensity activity after injury compared with before injury (moderate: 44% vs 66%, P<.001; vigorous: 18% vs 29%; P<.001). Patients spent 404±565 minutes per week in combined moderate- to vigorous-intensity activity before injury compared with 224±453 minutes postinjury (difference: 180min per week; 95% confidence interval [CI], 103-256). The adjusted odds of meeting PAGA were lower for patients with depression (adjusted odds ratio [AOR], 0.45; 95% CI, 0.28-0.73), women (AOR, 0.59; 95% CI, 0.35-1.00), and Black or Hispanic patients (AOR, 0.49; 95% CI, 0.28-0.85). Patients meeting PAGA prior to injury were more likely to meet PAGA after injury (odds ratio, 2.0; 95% CI, 1.20-3.31).


      Patients spend significantly less time in moderate- to vigorous-intensity physical activity after injury. Patients with depression are less likely to meet PAGA. Although the causal relationship is unclear, results highlight the importance of screening for depression.


      List of abbreviations:

      AOR (adjusted odds ratio), CI (confidence intervals), METALS (Military Extremity Trauma Amputation/Limb Salvage), MET (metabolic equivalent), OUTLET (Outcomes After Severe Distal Tibia, Ankle, and/or Foot Trauma), PAGA (Physical Activity Guidelines for Americans), PPAQ (Paffenbarger Physical Activity Questionnaire), PTSD (posttraumatic stress disorder)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bosse MJ
        • MacKenzie EJ
        • Kellam JF
        • et al.
        An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.
        N Engl J Med. 2002; 347: 1924-1931
        • MacKenzie E
        • Bosse M
        • Pollak A
        • et al.
        Long-term persistence of disability following severe lower-limb trauma: results of a seven-year follow-up.
        J Bone Joint Surg Am. 2005; 87: 1801-1809
        • Doukas WC
        • Hayda RA
        • Frisch HM
        • et al.
        The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study: outcomes of amputation versus limb salvage following major lower-extremity trauma.
        J Bone Joint Surg Am. 2013; 95: 138
        • Beckenkamp PR
        • Lin CW
        • Engelen L
        • Moseley AM
        Reduced physical activity in people following ankle fractures: a longitudinal study.
        J Orthop Sports Phys Ther. 2016; 46: 235-242
        • Ekegren CL
        • Climie RE
        • Simpson PM
        • et al.
        Physical activity and sedentary behavior 6 months after musculoskeletal trauma: what factors predict recovery?.
        Phys Ther. 2020; 100: 332-345
        • Piercy KL
        • Troiano RP
        • Ballard RM
        • et al.
        The Physical Activity Guidelines for Americans.
        JAMA. 2018; 320: 2020-2028
        • Biswas A
        • Oh PI
        • Faulkner GE
        • et al.
        Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis.
        Ann Intern Med. 2015; 162: 123
        • Willey JZ
        • Moon YP
        • Sacco RL
        • et al.
        Physical inactivity is a strong risk factor for stroke in the oldest old: findings from a multi-ethnic population (the Northern Manhattan Study).
        Int J Stroke. 2017; 12: 197-200
        • Willey JZ
        • Voutsinas JA
        • Sherzai A
        • et al.
        Trajectories in leisure-time physical activity and risk of stroke in women in the California Teachers Study.
        Stroke. 2017; 48: 2346-2352
        • Johnson CB
        • Davis MK
        • Law A
        • Sulpher J
        Shared risk factors for cardiovascular disease and cancer: implications for preventive health and clinical care in oncology patients.
        Can J Cardiol. 2016; 32: 900-907
        • Pandey A
        • LaMonte M
        • Klein L
        • et al.
        Relationship between physical activity, body mass index, and risk of heart failure.
        J Am Coll Cardio. 2017; 69: 1129-1142
        • Andrew N
        • Wolfe R
        • Cameron P
        • et al.
        The impact of sport and active recreation injuries on physical activity levels at 12 months post-injury.
        Scand J Med Sci Sports. 2014; 24: 377-385
        • Ekegren CL
        • Beck B
        • Climie RE
        • Owen N
        • Dunstan DW
        • Gabbe BJ
        Physical activity and sedentary behavior subsequent to serious orthopedic injury: a systematic review.
        Arch Phys Med Rehabil. 2018; 99: 164-177
        • Ceroni D
        • Martin X
        • Lamah L
        • et al.
        Recovery of physical activity levels in adolescents after lower limb fractures: a longitudinal, accelerometry-based activity monitor study.
        BMC Musculoskelet Disord. 2012; 13: 131
        • Archer KR
        • Heins SE
        • Abraham CM
        • Obremskey WT
        • Wegener ST
        • Castillo RC
        Clinical significance of pain at hospital discharge following traumatic orthopedic injury: general health, depression, and PTSD outcomes at 1 year.
        Clin J Pain. 2016; 32: 196-202
        • MacKenzie EJ
        • Bosse MJ
        Factors influencing outcome following limb-threatening lower limb trauma: lessons learned from the Lower Extremity Assessment Project (LEAP).
        J Am Acad Orthop Surg. 2006; 14: S205-S210
        • Castillo RC
        • Huang Y
        • Scharfstein D
        • et al.
        Association between 6-week postdischarge risk classification and 12-month outcomes after orthopedic trauma.
        JAMA Surg. 2019; 154e184824
        • Connelly JB
        • Chell S
        • Tennant A
        • Rigby AS
        • Airey CM
        Modelling 5-year functional outcome in a major traumatic injury survivor cohort.
        Disabil Rehabil. 2006; 28: 629-636
        • MacKenzie EJ
        • Bosse MJ
        • Kellam JF
        • et al.
        Early Predictors of long-term work disability after major limb trauma.
        J Trauma. 2006; 61: 688-694
        • Archer KR
        • Abraham CM
        • Obremskey WT
        Psychosocial factors predict pain and physical health after lower extremity trauma.
        Clin Orthop Relat Res. 2015; 473: 3519-3526
        • Castillo RC
        • Wegener ST
        • Heins SE
        • Haythornthwaite JA
        • MacKenzie EJ
        • Bosse MJ
        Longitudinal relationships between anxiety, depression, and pain: results from a two-year cohort study of lower extremity trauma patients.
        Pain. 2013; 154: 2860-2866
        • Winning A
        • Gilsanz P
        • Koenen KC
        • et al.
        Post-traumatic stress disorder and 20-year physical activity trends among women.
        Am J Prev Med. 2017; 52: 753-760
        • Monane R
        • Sanchez GJ
        • Kronish IM
        • Edmondson D
        • Diaz KM
        Post-traumatic stress disorder symptoms and aversive cognitions regarding physical activity in patients evaluated for acute coronary syndrome.
        Eur J Prev Cardiol. 2018; 25: 402-403
        • Bosse MJ
        • Teague D
        • Reider L
        • et al.
        Outcomes After Severe Distal Tibia, Ankle, and/or Foot Trauma: comparison of limb salvage versus transtibial amputation (OUTLET).
        J Orthop Trauma. 2017; 31: S48-S55
        • Major Extremity Trauma Research Consortium (METRC)
        Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: comparison of limb salvage and transtibial amputation (OUTLET).
        J Bone Joint Surg Am. 2021 May 12; ([Epub ahead of print])
        • Ainsworth BE
        • Leon AS
        • Richardson MT
        • Jacobs DR
        • Paffenbarger RS
        Accuracy of the College Alumnus Physical Activity Questionnaire.
        J Clin Epidemiol. 1993; 46: 1403-1411
        • Simpson K
        • Parker B
        • Capizzi J
        • et al.
        Validity and reliability of question 8 of the Paffenbarger Physical Activity Questionnaire among healthy adults.
        J Phys Act Health. 2015; 12: 116-123
        • Strath SJ
        • Bassett DR
        • Swartz AM
        Comparison of the college alumnus questionnaire physical activity index with objective monitoring.
        Ann Epidemiol. 2004; 14: 409-415
        • Sesso HD
        • Paffenbarger RS
        • Ha T
        • Lee IM
        Physical activity and cardiovascular disease risk in middle-aged and older women.
        Am J Epidemiol. 1999; 150: 408-416
        • Paffenbarger RS
        • Lee IM
        • Leung R
        Physical activity and personal characteristics associated with depression and suicide in American college men.
        Acta Psychiatr Scand. 1994; 89: 16-22
        • Nowak Z
        • Plewa M
        • Skowron M
        • Markiewicz A
        • Kucio C
        • Osiadło G
        Paffenbarger Physical Activity Questionnaire as an additional tool in clinical assessment of patients with coronary artery disease treated with angioplasty.
        Kardiol Pol. 2010; 68: 32-39
        • Mancuso CA
        • Duculan R
        • Girardi FP
        Healthy physical activity levels below recommended thresholds two years after lumbar spine surgery.
        Spine. 2017; 42: E241
        • Lee IM
        • Paffenbarger RS
        • Hsieh C
        Physical activity and risk of developing colorectal cancer among college alumni.
        J Natl Cancer Inst. 1991; 83: 1324-1329
      1. Compendium of Physical Activities. Available at: Accessed December 30, 2019.

        • Tucker JM
        • Welk GJ
        • Beyler NK
        Physical activity in U.S. adults: compliance with the physical activity guidelines for Americans.
        Am J Prev Med. 2011; 40: 454-461
        • Ellington JK
        • Bosse MJ
        • Castillo RC
        • MacKenzie EJ
        • Leap Study Group
        The mangled foot and ankle: results from a 2-year prospective study.
        J Orthop Trauma. 2013; 27: 43-48
        • Dickens JF
        • Kilcoyne KG
        • Kluk MW
        • Gordon WT
        • Shawen SB
        • Potter BK
        Risk factors for infection and amputation following open, combat-related calcaneal fractures.
        J Bone Joint Surg Am. 2013; 95: e24
        • Bevevino AJ
        • Dickens JF
        • Potter BK
        • Dworak T
        • Gordon W
        • Forsberg JA
        A model to predict limb salvage in severe combat-related open calcaneus fractures.
        Clin Orthop. 2014; 472: 3002-3009
        • Bennett PM
        • Stevenson T
        • Sargeant ID
        • Mountain A
        • Penn-Barwell JG
        Outcomes following limb salvage after combat hindfoot injury are inferior to delayed amputation at five years.
        Bone Joint Res. 2018; 7: 131-138
        • Greenspan L
        • McLellan BA
        • Greig H
        Abbreviated Injury Scale and Injury Severity Score: a scoring chart.
        J Trauma Acute Care Surg. 1985; 25: 60-64
        • Kroenke K
        • Spitzer RL
        • Williams JBW
        • Löwe B
        The Patient Health Questionnaire Somatic, Anxiety, and Depressive Symptom Scales: a systematic review.
        Gen Hosp Psychiatry. 2010; 32: 345-359
        • Blanchard EB
        • Jones-Alexander J
        • Buckley TC
        • Forneris CA
        Psychometric properties of the PTSD checklist (PCL).
        Behav Res Ther. 1996; 34: 669-673
        • Keller S
        • Bann CM
        • Dodd SL
        • Schein J
        • Mendoza TR
        • Cleeland CS
        Validity of the Brief Pain Inventory for use in documenting the outcomes of patients with noncancer pain.
        Clin J Pain. 2004; 20: 309
        • Green SB
        How many subjects does it take to do a regression analysis.
        Multivar Behav Res. 1991; 26: 499-510
        • Roshanaei-Moghaddam B
        • Katon WJ
        • Russo J
        The longitudinal effects of depression on physical activity.
        Gen Hosp Psychiatry. 2009; 31: 306-315
        • Farmer ME
        • Locke BZ
        • Mościcki EK
        • Dannenberg AL
        • Larson DB
        • Radloff LS
        Physical activity and depressive symptoms: the NHANES I Epidemiologic Follow-up Study.
        Am J Epidemiol. 1988; 128: 1340-1351
        • Bedillion MF
        • Ansell EB
        • Thomas GA
        Cancer treatment effects on cognition and depression: the moderating role of physical activity.
        Breast. 2019; 44: 73-80
        • Haedtke C
        • Smith M
        • VanBuren J
        • Klein D
        • Turvey C
        The relationships among pain, depression and physical activity in patients with heart failure.
        J Cardiovasc Nurs. 2017; 32: E21-E25
        • Joshi N
        • Khanna R
        • Shah RM
        Relationship between depression and physical activity, disability, burden, and health-related quality of life among patients with arthritis.
        Popul Health Manag. 2014; 18: 104-114
        • Turner AP
        • Hartoonian N
        • Hughes AJ
        • et al.
        Physical activity and depression in MS: the mediating role of behavioral activation.
        Disabil Health J. 2019; 12: 635-640
        • Farah WH
        • Alsawas M
        • Mainou M
        • et al.
        Non-pharmacological treatment of depression: a systematic review and evidence map.
        Evid Based Med. 2016; 21: 214-221
        • Li JM
        • Zhang Y
        • Su WJ
        • et al.
        Cognitive behavioral therapy for treatment-resistant depression: a systematic review and meta-analysis.
        Psychiatry Res. 2018; 268: 243-250
        • Chase JAD
        Interventions to increase physical activity among older adults: a meta-analysis.
        Gerontologist. 2015; 55: 706-718
        • Jaffe KM
        • Jimenez N
        Disparity in rehabilitation: another inconvenient truth.
        Arch Phys Med Rehabil. 2015; 96: 1371-1374
        • Flores LE
        • Verduzco-Gutierrez M
        • Molinares D
        • Silver JK
        Disparities in health care for Hispanic patients in physical medicine and rehabilitation in the United States: a narrative review.
        Am J Phys Med Rehabil. 2020; 99: 338-347
        • Shafi S
        • de la Plata CM
        • Diaz-Arrastia R
        • et al.
        Ethnic disparities exist in trauma care.
        J Trauma. 2007; 63: 1138-1142
        • Troiano RP
        • Berrigan D
        • Dodd KW
        • Mâsse LC
        • Tilert T
        • Mcdowell M
        Physical activity in the United States measured by accelerometer.
        Med Sci Sports Exerc. 2008; 40: 181-188

      CHORUS Manuscript

      View Open Manuscript