Expanding Clinical Skills and Knowledge: Rehabilitative Care for Wounded Warriors Meets Unique Challenges

By Miki Fairley
helmet-clad soldier

The military service members and veterans who received injuries resulting in limb loss while serving in Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) are a unique generation of warfighters. In previous conflicts, gunshot wounds accounted for about one-third of deaths, but in these recent conflicts they account for only 4.6 percent, according to a 2010 study. Explosive devices, including improvised explosive devices (IEDs), account for three-quarters of all combat casualties, with limb injuries reported to comprise about half of all combat wounds sustained during OIF and OEF.

Better battlefield medical practices, quicker evacuation to safer locations for medical care, and improved body armor have resulted in lives saved that would have been lost in previous conflicts. However, blast injuries cause a cluster of comorbidities including a far larger number of traumatic brain injuries (TBIs) than in the past, along with vision, hearing, and balance issues; soft tissue injuries; and heterotopic ossification. Healthcare professionals and researchers have had to forge new roads to provide the complex, multidisciplinary care required in treating this new warfare scenario.

Challenges of Polytrauma

The interconnectedness of polytraumatic injuries affects almost every aspect of patient care, including prosthetics and orthotics. For instance, TBIs, hearing and vision deficits, and balance difficulties can affect communication between the patient and prosthetist, the type of socket design and componentry selected, gait training, and the patient's ability to remember and follow instructions.

amputee competing in mud run

U.S. Army Spc. Edward Lychick, who has a left transfemoral amputation, competes during the U.S. Marine Corps Ultimate Challenge Mud Run with the help of his teammates, who are all members of Operation Enduring Warrior (OEW). Photograph by U.S. Air Force Staff Sgt. Jodi Martinez.

Multiple limb loss presents one of the biggest challenges. "Designing a suspension that enables a patient using two prosthetic arms to don and doff a lower-limb prosthesis is a unique challenge," says Mike Corcoran, CPO, co-owner of Medical Center Orthotics and Prosthetics, Silver Spring, Maryland. His company is contracted to provide lower-limb prosthetic services at Walter Reed National Military Medical Center (WRNMMC), Bethesda, Maryland.

Often the care team and the prosthetist have to come up with creative solutions together. Corcoran recalls a patient with bilateral transfemoral amputations, a transhumeral amputation, and some missing fingers on his sound-side hand. They devised a suspension system using a shuttle lock. They also added DACRON® loops at the socket brims-"sort of like a bag handle"-that the patient could grab with a couple of fingers and pull the sockets up while he was lying down. The patient uses transfemoral prostheses with microprocessor knees and often uses shorty prostheses around the house. Corcoran made some hooks on the prostheses to hook on the wheelchair to help the patient get up into the chair when using the shorties.

TBIs and vision deficits present other challenges, Corcoran says. "In some cases, a patient with a TBI may forget instructions almost immediately, so it's repetition after repetition. For someone who is blind, we need to teach them how to don and doff the prosthesis without visual cues."

NOT EVERY G.I. IS A JOE

In some aspects, women veterans' and service members' prosthetic needs and goals are different from those of men's, resulting in more dissatisfaction with prosthetic fit and componentry. The Disabled American Veterans (DAV) "has received numerous calls from women veterans complaining about the quality of VA prosthetic care," said Joy J. Ilem, DAV deputy national legislative director, in a statement before the Committee on Veterans' Affairs of the U.S. House of Representatives on April 30, 2015.

The statement noted that special prosthetic needs occur in women, especially during pregnancy. Weight fluctuations likely require more frequent prosthetic modifications and adjustments during and after the pregnancy, and women with transfemoral amputations undergoing cesarian section need a higher abdominal incision than normal to avoid irritation by the socket brim.

"Women veterans needing prosthetic items would be better served by VA if it appointed a clinical advisor that has special expertise in prosthetics and women's health who would be available for consultation and develop a guide on various vendors and options for items needed by women," the statement added.

Patricia Hayes, PhD, chief consultant for Women Veteran's Health, Veterans Health Administration, "stressed that the agency is committed to improving its services but acknowledged that there's much more to do," according to an article in the Washington Post on September 5, 2015. Hayes said that agency officials are working to reeducate staff and change the male-dominated culture with campaigns, including posters and videos that say, "This is not your father's VA," and pictures of women in combat gear with the slogan, "Not every GI is a Joe," according to the article. Also, more VA hospitals have opened women's health centers, Hayes noted.

Corcoran remembers a particular patient with a TBI. Much of that patient's brain was severely damaged and he had a titanium reconstruction replacing part of his skull. "He was [initially] uncommunicative and needed considerable care from his caregiver, his mother, but over a two-year period, he recovered much of his cognitive ability and was able to have a normal conversation and even recover a sense of humor," Corcoran says. "He even married and had a child. To see him recover so much was incredible."

Physical stability is a vital factor for patients with limb loss, Corcoran says. Patients with transfemoral amputations are initially prescribed a microprocessor knee for stability to make it as safe as possible while minimizing the patient's energy expenditure during ambulation, he explains. Patients with multiple amputations are especially at risk of falls, and their fall injuries can be compounded if they don't have arms to help break their fall. "Amputees fall all the time-it's not if they fall, it's when they fall. So we want stable feet, stable knees," Corcoran says.

A recently developed technique, the Northwestern University Flexible Sub-Ischial Vacuum (NU-FlexSIV) Socket, is designed to improve socket comfort for highly active individuals with transfemoral amputations. According to the Northwestern University Prosthetics-Orthotics Center (NUPOC), the socket has lower proximal trimlines that do not impinge on the pelvis; is flexible so muscles can move comfortably within the socket as they contract during activity and to improve sitting comfort; and is held securely to the residual limb by vacuum pump suction as well as compression of an undersized liner and socket. The socket includes a highly compressive, cylindrical fabric-covered silicone liner, a flexible inner socket, and a shorter rigid outer socket with vacuum applied between the liner and inner socket.

Multidisciplinary Team Covers the Bases

The multidisciplinary team approach, utilized throughout the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) to provide specialized amputation care, is a powerful resource to meet the challenge of comorbidities presented in polytrauma patients-with each patient presenting unique types and degrees of comorbidities.

"Typically the VA prosthetist is part of the amputation care team so he or she is not working on an individual basis," says Leif Nelson, assistant chief for clinical care, Extremity Trauma and Amputation Center of Excellence (EACE), New York, the leading advocate for research and treatment of DoD and VA patients with extremity trauma and amputations. Other team members typically include a physical medicine and rehabilitation physician, and physical and occupational therapists.

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"In the VA, we have the Amputation System of Care (ASoC), which is an integrated care model of the different specialties," Dr. Joseph Miller, national director, orthotic & prosthetic services, VA, explains. "We meet as a team with the veteran and discuss their care, whether it's prescribing the prosthesis or their rehab needs, as contrasted with the more segmented approach in the private sector."

"Besides the core team, and depending on the complexity of the case, we have the ability in many centers with amputation care teams to bring in ad hoc members," Nelson adds. For instance, the team could bring in a dermatologist to do laser hair reduction to decrease skin irritation, breakdown, and help prevent infection. If scars are interfering with good socket fit, laser scar revision can be an option.

"From my office in the EACE, we work very closely with the VA Amputation System of Care as well as with O&P Clinical Services," Nelson adds. "In the EACE, we are studying the kind of core competencies needed in amputation care so that in both wartime and peacetime we can maintain those skillsets...." Trained staff will be ready if there is a future influx of service members and veterans with traumatic amputations, he says.

amputee preparing for softball game

A member of The Wounded Warrior Amputee Softball Team prepares for a game. Photograph by U.S. Army Staff Sgt. Bernardo Fuller.

Miller and Nelson emphasize considering the patient holistically, "fitting the technology to the patient, and not the patient to the technology."

Motivation: Keeping the Momentum Going

The intense motivation of the young wounded warriors to regain function and return to military service or civilian life, as well as the quality of care from a highly motivated multidisciplinary team at the former Walter Reed Army Medical Center (WRAMC), Washington, are highlights Dennis Clark, CPO, remembers. Clark is president of Clark & Associates Prosthetics and Orthotics, O&P1, and OPGA, all based in Waterloo, Iowa. He provided prosthetic services at WRAMC from September 2003 to May 2005, caring for about 300 soldiers during that time.

There was camaraderie and competition. "The soldiers would meet each day in physical therapy, pushing each other to do better, pushing to improve their functional status, competing with each other," Clark recalls.

"They had incredible motivation. There were some unilateral patients with a two-mile run time that was less than when they were able-bodied. It wasn't the prosthesis that made them run faster; they were just so motivated. All of them were in physical training and constantly striving to do better and better and better."

Col. Gregory D. Gadson walks with his new prostheses

Col. Gregory D. Gadson walks with his new prostheses in the clinic as his son looks on. He asked to remain on active duty after losing his legs to an IED in Iraq in 2007 and became the first person with bilateral lower-limb amputations to assume the garrison command of a major installation. Photograph by Craig Coleman.

Clark notes that the care team also addressed psychosocial aspects, helping patients to reintegrate into the communities with activities such as shooting on a range and kayaking. "The care team was so dedicated, so committed to these men and women."

Those young soldiers were also the first Internet and social media-oriented generation, Clark points out, so they kept up on all the new prosthetic technology and shared that information and their experiences with one another.

"As time goes on, patients become more involved in their prosthetic care and component choices," Corcoran says. "At Walter Reed, there are new patients and those who have been here for a couple of years. They include all levels of function and [they] talk among themselves about treatment and components and are very attuned to available technology. We just guide the process along."

However, maintaining strong motivation can be a challenge. "The vets I have dealt with after Walter Reed seem to have more tempered expectations," says Zach Harvey, CPO, co-regional manager at Creative Technology Orthotic & Prosthetic Solutions, Denver. "Generally, they understand when their device is not working and are a little less excited about new technology versus replacing what they know works." He adds, "However, sometimes fitness levels are ever-increasing and our challenge is optimizing design for competition, such as with Paralympic athletes."

He continues, "At a place like Walter Reed, there are a lot of extrinsic motivating factors. For one, lots of professionals are looking in on one's rehab. Two, there are a lot of other patients in the same boat that are a reflection of where one is at in his or her rehab. Three, there's a lot of community support: organizations, visiting celebrities, politicians, [and] athletes. Once gone from the hospital, self-motivation kicks in and there is a lot of variation on how a person deals with their 'new normal.' This depends on who that individual is in terms of personality, responsibilities, values, and interests."

When Harvey has encountered barriers working with veteran patients, he tries to keep in communication with the patient's healthcare team or connect the patient with a network of therapists and physicians if he or she doesn't have one. For example, if a patient who stopped wearing a prosthesis wants to try again, Harvey suggests the patient attends physical therapy before starting the fitting process. "Once receiving the prosthesis, putting a person on a wear schedule is a simple yet effective way to build confidence. Routine follow-up, even if it's a phone call scheduled six months out, is an effective way to ensure that outcome was not just a short-term success. Calling in an energetic peer visitor for motivation has been effective for a couple of patients in the past."

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"Maintaining [patient] motivation is really important for us at VA since we have a responsibility to provide lifelong care," Nelson says. "I think the key is continually reevaluating their individual goals." Adaptive sports as part of their rehabilitation plan is one of the most helpful means, he adds. "It takes them out of the hospital and into the community." The VA utilizes recreational therapists to provide patients with opportunities for therapeutic recreation. As an example, Nelson mentions Heroes on the Hudson, an adaptive sports clinic in New York City that offers veterans the chance to learn adaptive kayaking and sailing. "We also have amputee support groups, peer visitor programs, and programs to help transitional veterans with vocational and educational training."

Research Leads the Way to Better Outcomes

To meet the level of care needed by current and future populations of service members and veterans with amputations, the military continues to be engaged in research to improve outcomes.

Jason Wilken, MPT, PhD, is the director of Brooke Army Medical Center's Military Performance Laboratory (MPL), San Antonio, which provides injured service members with the best technology available to analyze and interpret movement dysfunctions. "The objective of the Military Performance Laboratory is twofold," Wilken says. "One is to support the clinical mission and the other is to do prospective larger-scale research studies." One of the major areas of emphasis is larger-scale outcomes assessments involving both patient-reported and objectively measured outcomes across the entire patient population being seen at the MPL and proximal facilities, he explains. Larger datasets can show trends in clinical care, help identify factors that predict successful outcomes, and help form clinical practice standards, he adds.

amputee preparing for softball game

A Special Forces soldier returned to combat in Afghanistan following a transfemoral amputation. Photograph courtesy of Mike Corcoran.

"There also is the Wounded Warrior Recovery Project under way, which is a long-term research study being conducted by the Naval Health Research Center, [San Diego,] to track these patients in the longer term to better understand their outcomes to make sure they get the support they need," Wilken says.

The MPL and the Center for the Intrepid (CFI) at San Antonio Military Medical Center work together on outcomes assessments of prosthetic manufacturers' componentry, especially products whose development has been funded by the DoD, explains John Fergason, CPO, chief prosthetist at the CFI. First, they look at whether the product performs according to the manufacturer's claims. Even then, it may not be the best choice for certain types of duty and environments, such as those involving sand, water immersion, and high temperatures.

"There are so many prosthetic feet now on the market that it's a bit overwhelming to stay on top of which we think are the right application for an individual patient," Fergason says. "Obviously, none of them are going to be appropriate for everybody and maybe not even one of them is appropriate for most people, while another one may be appropriate for a lot of people."

The MPL also supports CFI prosthetic care and decision making, for instance, by doing gait evaluations to understand the biomechanics of why a patient may be having difficulty with a prosthesis or to help decide on the right activity-specific foot for what a particular patient wants to do. Research findings are being disseminated at scientific and professional meetings and have been published in research journals.

An extensive education program for the prosthetic and orthotic service in the VA disseminates information on the latest research and componentry, Nelson explains. The VA ASoC and the EACE conduct annual training seminars that include the rehabilitation team, "so that everyone learns collectively as a team about these different scenarios, methodologies, and technologies."

Bimonthly education conference calls on O&P-related topics are made through the EACE Prosthetic and Orthotic Education Committee, and the ASoC conducts monthly education calls.

"A few years ago we started the Federal Amputation Interest Group," Nelson says. "It's a discussion group of 650 members from the VA, DoD, and academia that provides an opportunity for providers across the country to share their experience and expertise or seek others' experience and expertise. The goal is to provide the best care for service members and veterans no matter where they reside."

Future Directions

"We don't know what the next war will bring, meaning that it could be completely different types of munitions, such as sound wave or radio frequency injuries, which could bring a whole new set of comorbidities," Miller says. "We have the staff, but we may have to relearn how we treat these injuries and do rehabilitation." (Author's note: These technologies exist and are being further developed.)

"[T]he EACE is shaping the continued plan for the future of amputation care working closely with both the DoD and VA," Nelson says.

Miller adds, "We have responsibility for veterans' lifelong care."

Miki Fairley is a freelance writer based in southwest Colorado. She can be contacted via e-mail at .