Closing the Generation Gap: Serving Veterans of All Ages

Caring for the nation's veterans of military service is a noble tradition that can trace its roots back to 1636, when the Pilgrims of Plymouth Colony were at war with the Pequot Indians, inspiring the Pilgrims to legislate colonial support for any disabled soldier. Though times and methods have changed-and certainly the number of veterans has changed dramatically-the colonial support systems that evolved into the current U.S. Department of Veterans Affairs (VA) program have kept pace. Moment in history bonds warriors. Charles Homer, a Pearl Harbor survivor, reaches out to recovering warrior Pfc. Alejandro Albarran on December 7, 2006, the 65th anniversary of the attack that launched the United States into World War II. Today the VA embraces a staggering mission, even for one of the world's largest integrated healthcare systems. Of the 25 million veterans currently alive, nearly three quarters served during a war or an official period of hostility. According to the VA website, about a quarter of the nation's population-approximately 70 million people-are potentially eligible for VA benefits and services because they are veterans, family members, or survivors of veterans. As healthcare systems have improved, our aging survivor population has increased proportionately, presenting the VA system with veterans of World War II (WWII), Korea, and Vietnam, as well as those from the Iraq and Afghanistan conflicts. According to figures released by the VA in May 2006, 9.2 million veterans are 65 or older, representing 38 percent of the total veteran population. By 2033, the proportion of older veterans will increase to 45 percent. The studies show that the 85-and-older group is the fastest growing segment of the veteran population. The number of veterans aged 85 or older is expected to rise to a peak of 1.4 million in 2033. How does VA cope with this load and achieve balance in serving veterans of different generations and ages? A Mission to Meet Multiple Needs John Milani, CPO, the national clinical manager of O&P practice for all VA facilities, says his primary concern is to ensure quality of care to all veterans who have experienced an amputation, or loss of use of, an extremity by making sure that labs are accredited, staff is certified, and education is continuous. "We offer our patients prosthetic and orthotic devices that will meet their needs and enhance their quality of life. Advanced and emerging technologies are prescribed as much as possible, insofar as is clinically appropriate for the patient. VA patients are evaluated by a VA amputee clinic or brace clinic team, and, based on the clinical evaluation and patient input, a prescription is developed that will be based on the patient's needs and requirements," Milani says. "We are able to offer these services and products to our current veteran patients from previous conflicts [and aging patients], as well as to recent patients from the OEF and OIF [Operation Enduring Freedom and Operation Iraqi Freedom] conflicts. Sgt. Ernesto Godoy, an amputee adjusting to a prosthesis, lowers a shower seat in a "mobility impaired accessible room" at the barracks near Brooke Army Medical Center. Godoy occupies one of the 24 rooms that have been renovated to accommodate wounded soldiers. "Regardless of age, VA patients are provided with a prescription that they are capable of handling and using, which in many cases includes components and designs based on new and emerging technologies." Ed Ayyappa, CPO, director, clinical activities at VA Prosthetic Services in Long Beach, California, agrees that the VA does not stint in its care. "We have certainly been in the forefront historically, and continue to be, in providing microprocessor components such as Otto Bock C-Legs®, Endolite knees, Endolite microprocessor knees, and most recently, the Ossur POWER KNEE", both for traumatic, relatively young amputees such as our Iraq- and Afghanistan-related amputees, for veterans, and also for our older dysvascular or traumatic amputees from previous wars," Ayyappa says. There is a perception, says Ayyappa, that there are thousands of amputees from the OIF/OEF conflicts, while the actual number is between 600 and 700. Most of them are being served in the three major military hospitals (Walter Reed Army Medical Center, Washington DC; Brooke Army Medical Center, Fort Sam Houston, Texas; and the Naval Medical Center, San Diego, California), where they remain on active duty, leaving a relatively small population that has been discharged and distributed throughout the country. Neal Eckrich, prosthetic program manager for the Office of Prosthetics and Clinical Logistics in the VA's Central Office, agrees that the total of 636 war-related amputations from 2001 to July of 2007 is a drop in the bucket compared to the 17,000 amputations the VA has performed during the same period of time, mostly due to diabetes. "The aging veterans still comprise the majority of the VA's workload," he notes. "In fiscal year 2006, OEF/OIF veterans with amputations comprised only 1.2 percent of the total number of veterans with amputations that the VA provided with a new limb or a repair to an existing limb." Polytrauma: A New Term for a New Generation Polytrauma is a term used to describe injuries to multiple body parts and organs that often occur as a result of exposure to blasts and is typical in many of the OIF/OEF wounded warriors. Traumatic brain injury (TBI), spinal cord injury (SCI), and/or post-traumatic stress disorder often occur in combination with amputation. To provide comprehensive, high-quality and interdisciplinary care for patients exhibiting polytrauma, the VA developed four major polytrauma rehabilitation centers in Richmond, Virginia; Minneapolis, Minnesota; Palo Alto, California; and Tampa, Florida, as well as 21 additional polytrauma network sites that serve the existing Veterans Integrated Service Networks (VISNs). Introduced in 2006, VA-developed polytrauma system of care continues to evolve in exciting directions. Cindy Poorman, rehabilitation planning specialist with the Physical Medicine and Rehabilitation (PM&R) National Program Office, is spearheading the development of a new system focused on amputation care, which will be integrated with the polytrauma system. Specialized regional centers will integrate with the existing polytrauma sites that will comprise part of the amputation system of care. Veteran Frank Bianculli, a transtibial amputee, learns to walk down stairs with a microprocessor-controlled Ossur POWER KNEE, while undergoing prosthetic training at James A. Haley VA Hospital in Tampa, Florida. "We are in the process of enhancing the capabilities of all 21 of the polytrauma network sites through training and additional equipment," Poorman explains. "The VA Central Office has dedicated additional funding for both prosthetic equipment as well as state-of-the-art rehabilitation equipment." Poorman anticipates the new amputation system of care is projected to be implemented within the next year. "The objective is to provide the highest quality care to war veterans and also to our older veterans because we are committed to providing state-of-the-art care to both groups," Poorman says. "Things like core stabilization, core strengthening-those are things we can also integrate into the rehabilitation programs for our older population and improve their performance too. "There are a lot of things that will benefit our older population that we're now learning from these young men and women. I think we really have an opportunity to dramatically advance amputation care across the nation. Nowhere in the private sector is there the population that we have in the VA system. It's a very exciting time." It is indeed an exciting time, agrees Eckrich, with things happening so rapidly that "it's impossible for a single person to keep up with all the new developments and advances of technology. But we try to share and spread the word, keeping both our staff and our patients informed. The VA prides itself on providing any new technology that is commercially available to those who have a need for it." Gail Latlief, MD, specializes in PM&R and currently serves as medical director of the comprehensive inpatient rehabilitation program at the Tampa Polytrauma Rehabilitation Center. The new system of enhanced amputation care is eagerly anticipated, says Latlief, and is expected to not only improve amputation care throughout the entire VA system, but also to streamline the whole transition of care from the U.S. Department of Defense (DoD) hospitals to the VA, and thence, out into the community to benefit amputees of all ages. "With any war comes new technology, and with it, more money-not only for technology, but for research and for care of the wounded," Latlief says. "This overflows into our care for all veterans with amputations. We're not cherry picking and directing the money to OIF/OEF veterans." Technological Advances Help Veterans of All Ages Latlief observes, however, that the successful application of new technologies to older veterans was initially unanticipated. Despite the media focus on the younger veterans and the high functional levels they achieve with high-tech prostheses, computerized knees are also used to good effect to improve stability and prevent falls in the elderly, helping them to stay functional and to maintain a home-based lifestyle instead of subsisting in an institution. Jonathan Holsey and Jason Lange take practice serves during sitting volleyball at the Paralympic Military Sports Camp. "If I were in the private sector," Latlief points out, "I wouldn't be allowed to try these things, whereas our VA has actually purchased a POWER KNEE, a C-Leg, a PROPRIO FOOT™. We try these devices on different candidates and see how they work. If they're elderly, we admit them to the inpatient unit where the whole team can test them, videotape them, check them in gait lab, and determine in a very controlled setting how they do with various devices." Latlief says that it is not unusual for them to fit a WWII veteran who has been happily walking for 30-plus years on an old wooden leg that is literally duct-taped together. "Although they're older and more frail, they still have a fabulous gait and they're very functional in the community, even with their heavy wooden leg with its cumbersome corset," she says. "They are candidates for the computerized knees, but they're reluctant to try the new sockets. Often it takes a lot of persuasion." Latlief lets them keep their old leg while a new one is made. She admits them to the hospital for two to eight weeks to allow the necessary time for adjustment, education, and trials with the new leg before they are comfortable enough to give up the old one. The rewards are satisfying for all, she reports. "It gives them a sense of pride that they are standing on two feet. Their self-worth is improved when people don't look down on them. We try to keep them out of power wheelchairs and power scooters if we can because that's what they want. They want to keep walking. "Not all VA facilities have what I have at hand-the ability to admit someone for several weeks for intensive rehabilitation," Latlief warns. "It's hard to take someone who has two legs lost above the knee and is elderly and blind-and train them as an outpatient, especially if they have to get someone to drive them 70 miles back and forth for care. Having the capacity to admit them is paramount for someone like that." While old and young amputees present different and well-understood challenges, there are unexpected discoveries, too. "We're finding something curious in the very fresh trauma that keeps coming out of this war," Latlief says. "An unusual number of unexplained cases of heterotopic ossification, which appears as huge chunks of bone growing into the soft tissue of the residual limb very early after the amputation. They're actively looking at that at the military hospitals because we've all noticed it. There are a number of theories floating around, but we're not sure of the cause. We are not seeing it in fresh amputees who have been hit by a car, for example, or lost their limb as the result of a work-related injury. Although we've all seen some cases of heterotopic ossification, it has been fairly rare until this war." Growing Interest in Recreation Latlief points out that not all younger soldiers are interested in sports, despite the media emphasis on Paralympics contenders. The VA is involved in many sports activities for amputees and encourages participation in equestrian sports, kayaking, rowing, and sailing, as well as extreme sports such as rock climbing, wave boarding, and biking. "Blaze sports" such as wheelchair tennis, basketball, track and field, rugby, and swimming are increasingly popular. "For those who only want to go to the beach, get into their swimming pools, or play with their family, we'll accommodate them with swimming legs, running legs, kayak hands, or whatever it takes," Latlief says. "Although the younger individuals are very much into athleticism and fitness, VA has been providing recreational prostheses as far back as World War II and continues to provide recreational prostheses for its patients," notes Milani. "Many Vietnam era veterans still play racquetball, ski, swim, and run, using recreational prostheses." Advice to Independent Prosthetic Contractors Who Serve VA Patients Milani advises prosthetic practitioners serving VA patients to follow the prescription developed in VA amputation and brace clinics. He also advises contacting the chief of prosthetics at the local VA facility in writing for prior approval before making any changes. "It is our goal to provide our patients with the best technology available to enhance the patient's quality of life and overall capacity to function at a higher level," Milani says. "If the prosthetist recommends an alternative to the prescription, we would welcome that suggestion in writing so it can be properly approved." Jason Lange, an outpatient at the Tampa VA, participates in a running drill for track at the Paralympic Military Sports Camp. Ayyappa stresses the need for education and certification among private-sector prosthetists who wish to serve the VA. "Certification-not only of individual prosthetists, but also their facilities-is increasingly important. We're placing more emphasis on that because it's one standard that reflects quality care." The VA itself sets an example, notes Ayyappa, with approximately 58 labs that are accredited by the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABC) and/or Board for Orthotist/Prosthetist Certification (BOC). "We have 16 labs that are accredited by NCOPE (National Commission on Orthotic and Prosthetic Education), and 72 percent of our clinicians hold ABC or BOC practitioner certifications," he says. "That's far greater than most people think. "But while we have a great deal of expertise and competency within VA, we also utilize contractors from outside VA. They represent the bulk of what is being done, and that may be as high as 90 percent of prosthetic services." He encourages independent practitioners to continue to pursue training that will allow them to treat patients with high technology prostheses, including microprocessor, myoelectric, and electromagnetic devices. "That's a big issue-education, education, education," Ayyappa says. "Focus on what the patient needs and what will improve their life. That's what we do-and what we want to continue to do." Photos courtesy of U.S. Army, by Michael Dulevitz and Elaine Wilson. Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.

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Inexpensive Prosthetic Lauded

Civilian Casualties from Iraq: Caring for the Forgotten Wounded

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