Tim Jeffers: Defined by Determination
April 2007 Issue
In May 2006, an improvised explosive device (IED) exploded in Iraq, leaving 22-year old Marine Corporal Tim Jeffers with severe wounds to two-thirds of his body. Today, through sheer determination to regain his former life at the Department of Veterans Affairs (VA) Palo Alto Health Care System in California, Jeffers walks and even jokes.
Jeffers lost his right eye, the fourth finger on his right hand, and both of his legs above the knee. He sustained head and abdominal injuries and had to have part of the skull above his missing right eye removed. It is a miracle that he survived.
When I first saw Jeffers as a patient, he was four months into recovery from his injuries. Within three minutes of our first conversation, he asked when he would get his Otto Bock C-Legs®. Here was a young man with a large decubitus on his coccyx, bilateral 20-degree hip flexion contractures, and no strength to pull himself to a sitting position demanding that I supply him with prosthetic appliances. My first thought was, "Here's someone I can work with."
|From left: Louis Givens, CPO; Tim Jeffers; Marine Corps commandant Gen. Hagee; and Gunnery Sgt. Dietschman (in back).|
VA prosthetics and physical therapy designed an exercise and stretching program to help Jeffers regain strength, stretch out the contractures, and develop sitting balance. Within just four weeks, Jeffers was using his upper and lower body to pull himself into a sitting position. Encouraged by his progress, I decided to fabricate him a set of prosthetic appliances.
I contacted and consulted with a colleague whose practice specializes in working with traumatic injuries. After reviewing the positives and the not-so-positives, we decided that short leg prosthetic devices, or "stubbies," would be a good starting point. Stubbies would allow Jeffers to move around the mat and develop lower-body strength. It would also help him improve his standing balance.
Factors to Consider
Though Jeffers met every goal we set for him, there were still other factors to consider. His right hand was contracted and missing the fourth finger, which would make it difficult for him to don and doff appliances on his own. Also, due to his abdominal injuries, his core strength was still lacking. And finally, because shrapnel had embedded in scars in a 360-degree pattern around the distal third of his residual limb, he had developed heterotrophic ossification (HO), which is common in traumatic blast injuries.
|Jeffers adjusts his swim legs.|
We considered all of these factors when fabricating Jeffers' appliances. At this point, a wet fit was not practical because Jeffers' residual limb was still shrinking. His abdominal musculature was still weak, making it difficult to don the appliance while standing. The sockets required an intimate fit (suction) for maximizing proprioception, as this is preferable for bilateral amputees when ambulating.
We started with bilateral, short-leg prosthetic appliances with rocker-bottom soles to assist with forward progression. For suspension, we used Ossur Seal-In" liners with green-dot suction valves. The idea was to mist the liner seal with alcohol, and gravity would feed the residual limb into the socket. Because the HO was below the bell of the liner (the seal), we believed that there would be minimal pressure at the distal end, below the seal. We abandoned this process because the liner's outer material offered too much resistance to the flexible inner socket material. We also tried using Alp's fitting lotion, but the outcome was the same. In the end, we decided that pulling him into the socket manually worked best and saved time.
The short leg appliances were designed to facilitate strength training and refine Jeffers' balance by standing with a walker. One of the exercises that helped his strength was to have him place his trunk on a rolling stool and use the stubbies to propel himself forward. This was also an exercise in how to control the appliances. After a week, he progressed to standing with a walker for balance. Within two days, he was ambulating 300 yards, lapping the therapy department. At that point, we removed the rocker soles and replaced them with Kingsley SACH feet. This presented more of a challenge for him to get over the toe, but it gave him a realistic feel for what it would be like to ambulate with prosthetic feet.
Ready for Prosthetic Progress
After nine weeks, Jeffers had progressed to the point where he was ready for appliances with knees and feet. The VA fabricated a set of lightweight graphite sockets with C-Knees. Limb length was not a problem; however, there was still a problem with numerous shrapnel fragments embedded in the distal third of his residual limb. His abdominals were still weak, and tight hip flexor muscles caused anterior pelvic rotation.
|Far right in pool with Jeffers is Renee Cohara.|
We chose C-Knees because the integrated stance flexion, stance extension feature could be adjusted to meet Jeffers' needs. As a result of contracted hip flexors when Jeffers stands, his posture resembled an S curve (lumbar lordosis)-his upper torso arched posteriorly, his lower abdomen protruded anteriorly, and his gluteals extended posteriorly.
To bring his center of gravity over his base of support, we used an abdominal binder midway across his gluteals. To achieve forward progression, he leaned his body forward, hiked the hip to unload the knee, and then leaned his upper body backward to progress the shin. By adjusting the flexion dampening to a minimal setting, we reduced the force required to flex the hip and extend the knee, which resulted in a smoother, more natural gait. Because of his unconventional posture and gait, the C-Knee offered us alignment capabilities that may not have been available with a conventional knee.
The goal of rehabilitation is for the patient to be functional in all aspects of his activities of daily living (ADL). For bilateral amputees, sitting can be a challenge. The above-knee amputee is taught to back up until the knee of shin is against the front of the chair, reach back, grasp the chair back or chair arm, then ride the knee to a sitting position. Patients lacking confidence and strength usually unweight the weaker limb to flop to a sitting position.
Unlike the unilateral amputee, the bilateral is lacking a patella tendon crossing the sound knee. With unilaterals, the patella tendon helps control the rate of descent when sitting and may help with sitting alignment. To facilitate sitting, we chose a knee that allowed us the ability to control the patient's rate of descent (knee fail rate). There are a number of fluid-controlled units that offer this feature; they are commonly known as swing and stance knee units.
The prosthetic foot is not a major concern at this time because of Jeffers' current functional level (F1). We used the Otto Bock Axtion® to prevent voiding the knee unit's manufacturer's warranty and because we liked the heel action and smooth rollover.
We have fabricated several sets of rigid sockets with flexible inner liners due to volume changes brought on by alterations in medication and normal atrophy. The inner socket offered excellent proprioception and allowed us to better cope with volume changes by adding windows to the frame if needed. We made an adjustment from Proflex™ to silicon-based Proflex because it is less sticky.
To address the problems caused by HO and the shrapnel affecting Jeffers' residual limbs, exercise was required to raise his heart rate and increase his stamina. To increase his ability to exercise, we fabricated a set of short swim appliances. The short lever arm would offer less resistance over the entire surface of the residual limbs, avoiding distal pressure. We use variable sized swim fins to increase and decrease resistance as needed.
Jeffers is making great progress. He is ambulating independently on the parallel bars, although he still has a way to go to achieve his goal of full independence. One of his other goals is to return to skateboarding. With his determination and the help of the VA healthcare system and his rehabilitation team, his future looks bright.
Louis Givens, CPO, is chief of the Prosthetics Laboratory, Level One Polytrauma Center, at the Veterans Affairs Palo Alto Health Care System in California.