O&P Technology Honors U.S. Veterans’ Legacy

According to the U.S. Census Bureau 2010 American Community Survey, there are nearly 21.8 million military veterans living in the United States. Of those, more than nine million—nearly 42 percent—are age 65 and over. Almost 23 percent of the country's total population of adults age 65 and over are veterans. These U.S. veterans have served honorably and courageously in a number of wars and military actions. According to the U.S. Department of Veterans Affairs (VA), the largest number of veterans are from the Vietnam era, followed by Gulf War veterans, veterans who served in peacetime only, Korean War veterans, and World War II veterans (See Veterans by Service, below right). Whether they serve as citizen soldiers in the National Guard or carry out their assigned duties as full-time members of the military, our veterans signed up to defend our country, and they have responded admirably to the call. Some have sacrificed their lives, and others their able-bodied good health. While 13.5 percent of civilians over the age of 18 report having a disability, 25.5 percent of adult veterans report having a disability. Although the total veteran population has been declining since 2000, and projections from the National Center for Veterans Analysis and Statistics (NCVAS) show the trend continuing over the next two decades and beyond, the United States has a responsibility to provide the highest standard of care for its veteran population. What kind of healthcare can these individuals expect—particularly as they arrive at retirement age? Will that care be adequate for their needs? The VA has taken on the task of providing comprehensive healthcare service to U.S. veterans by developing and continuing to evolve a healthcare system that currently serves its enrollees through 152 VA hospitals, 300 Veterans' Centers, and 817 community-based VA outpatient clinics distributed across the United States. According to 2011 VA statistics, 8.57 million veterans were enrolled in the VA Healthcare System, and as of 2012, 3.47 million individuals were receiving VA disability compensation. VA Healthcare System Expands to Meet Veterans' Needs Thousands of wounded warriors from the Gulf Wars alone have benefitted from state-of-the-art prosthetic technology and rehabilitation through the VA and its contracted facilities. Bill Dunham, a customer service representative and patient advocate for Hanger Clinic throughout Oklahoma, is one of them. Dunham was on active duty in Panama in 1989 with an Army Ranger battalion that was sent to capture Manuel Noriega. Wounded in action, Dunham underwent a traumatic transfemoral amputation, and the VA managed his care—from the initial surgery and fit of his prosthesis through rehabilitative care—through independent providers. The VA still works with these facilities to provide follow-up care and new, replacement prostheses, as needed. "The VA has come a long way, particularly in the last ten to 15 years," Dunham says. "The quality of care has increased significantly. When you look back at what things were like for veterans in Vietnam, 15 to 20 years before Panama, there was quite a difference. [The care is] excellent, with teams assigned to the care of each individual patient." Not only has the VA improved its quality of care, but it also has increased accessibility to that care. When Dunham began using the VA healthcare system, he recalls having to drive three-and-a-half hours to reach the nearest VA clinic in Little Rock, Arkansas, from his home in Rogers, Arkansas. However, about five years after his injury, the VA made care more accessible by establishing more clinics and contracting with independent providers. "There are more clinics now than there were when I was first injured, so it's much easier to get to a closer location," he says. "For me, that means a 25-minute drive to Fayetteville, Arkansas. When you're active and you use prosthetic technology, the components will break down sooner or later. They're mechanical, so they eventually wear out. And every time you have a significant change in your weight, you're probably going to need a new socket.... I've been through a number of prostheses since my amputation-I don't even know how many. Overall, the care has been great." Like Dunham, veterans across the country have their choice of O&P care through a VA facility or from an independent provider who may specialize in the veterans' specific amputation level and who may be closer to their homes. Tragedy Fuels Technology Improvements The reality of war is harsh, and the losses are painful, but war often leads to progressive engineering, new healthcare provisions, innovative surgical techniques, and advances in rehabilitation science. Indeed, some of the most sophisticated O&P technologies were developed in response to the needs of returning wounded warriors. Some of the young men and women returning from Iraq and Afghanistan with traumatic injuries sustained through exposure to improvised explosive devices or other destructive weapons have helped to pioneer developments in prosthetic technology by being among the first to test the devices and provide feedback. Their successes have helped pave the way for these technologies to become available to the civilian population as well. Microprocessor knees and intelligent ankles that adapt to variations in terrain are excellent examples of technologies that have advanced considerably over the last 15 years, fueled by the wounded warriors who have returned from the continuing hostilities in the Middle East. Created for young veterans who returned from battle with one or more traumatic amputations and wounded warriors wanting to return to active duty despite their injuries, these devices were then adapted to benefit civilians and older veterans. There have also been amazing advances in microprocessor-controlled prosthetic feet. They can be expensive, and they're not for everyone, but for those who are good candidates for them—such as active, older adults who enjoy wilderness hiking and similar pursuits—they are a good option. While the entry into the marketplace of a high-tech prosthetic device is often accompanied by a high price tag, these technologies become more affordable as they evolve and proliferate. Today, not only does the VA provide the most sophisticated, state-of-the-art devices to its enrollees, the Centers for Medicare & Medicaid Services (CMS) approves coverage for some of these devices to enrollees who are evaluated and deemed appropriate candidates using a validated tool such as the Amputee Mobility Predictor, developed by Robert Gailey Jr., PhD, PT. We are currently witnessing a significant leap forward in upper-limb prosthetic technology. Teams are striving to turn prototypes of two prosthetic arms developed through the Defense Advanced Research Projects Agency's (DARPA) Revolutionizing Prosthetics (RP) Program into commercially available realities. According to DARPA leader Geoffrey Ling, MD, PhD, who was interviewed for a May 2011 article in The O&P EDGE , the DEKA "Luke Skywalker" arm is headed toward commercialization. "Hopefully by the end of this year we'll have a commercially produced arm," Ling is quoted as saying. "This is no longer a science fair project; we're really on the way. We want this to get to as many people as we can." Stewart Coulter, PhD, project manager for the DEKA's high-capability Luke prosthesis (currently dubbed the Gen 3 Arm), echoed Ling's enthusiasm. "I'm very excited about the changes that we've been able to make as a result of the feedback [from test subjects]. We're really looking forward to getting the new version out there and have people take advantage of that." At the same time, the other prosthetic limb project to come out of the DARPA RP program, the Modular Prosthetic Limb (MPL), created and unveiled at the Johns Hopkins University Applied Physics Lab (JHU APL), Laurel, Maryland, was on the verge of human testing. The arm is potentially capable of neural control, with an interface to the brain, and its unique modular design makes it adaptable to a wide range of injuries. Especially exciting is the level of commitment by the U.S. Food and Drug Administration (FDA) and CMS in fueling the progress of the MPL toward commercial availability, as reported in the same May 2011 article in The O&P EDGE: "Program leaders laud the FDA selection of the MPL as the pilot medical device for its new Innovation Pathway, a program which in early March added CMS as a collaborator in supporting and expediting the development of unique new technologies. "'It is unprecedented,' Ling exclaims, to have both the FDA and Medicare/Medicaid trying to see how they can coordinate their efforts with a developer. This was really a golden opportunity to all come together.'" While the RP program was originally conceived as a four-year effort, DARPA expanded the program to include a three-year testing and development phase to make sure the arm becomes available for human use. The test phase is currently in its second year. (Editor's note: To read the latest news about the two DARPA prosthetic arm projects, read " DARPA's RP Arms Progress, Nurture Related Wonders " in this issue.) With such high-powered energy and intelligence focused on bringing life-changing, new technology to those who have lost a limb, our wounded warriors can take pride not only in their sacrifices, but also in the efforts and devices their losses have inspired. The result is superior outcomes for all. Kevin Carroll, MS, CP, FAAOP, is the vice president of prosthetics for Hanger Clinic. He can be reached at kcarroll@hanger.com

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