Return to Combat

A commitment to duty, advances in prosthetics technology, and changes in the rehabilitative model of care are enabling some soldiers with amputations to return to the front lines.

"The only easy day was yesterday." -U.S. Navy SEALs

Corporal Garrett S. Jones, an amputee who was injured in 2007 by an insurgent's bomb during his unit's deployment to Iraq, shows his prosthetic leg at Camp Barber, Helmand Province, Afghanistan. Photograph by Sergeant Ray Lewis courtesy of the U.S. Marines.

Before the wars in Iraq and Afghanistan, it was unusual for a soldier who had lost a limb in the line of duty to return to combat. During the 1980s, only 2.3 percent of all U.S. amputee soldiers returned to active duty, according to the United States Army Institute of Surgical Research. But today, more amputee soldiers are returning to the front lines than ever before. The Pentagon says that 41 American amputee soldiers are currently serving in combat zones worldwide. (Author's note: This figure is current as of September 2010, and was published in the article "Double Amputee Soldier Deploys to Afghanistan," by Todd Pittman, The Associated Press, September 27, 2010, which was picked up by a variety of mainstream media outlets.) The percentage of amputee soldiers who have returned to combat now stands at more than 16 percent. What accounts for this dramatic shift? Their daily struggle is, after all, formidable. As one amputee soldier confides, days as a paratrooper in Afghanistan are not always a "bowl of cherries." This soldier suffers from phantom pain, frequent sores, and pinched nerves. Yet, he, and others like him, continue to put their residual limbs through physical extremes almost every day, persevering in one of the most physically challenging careers that exist, navigating rough terrain, minefields, and enemy fire, all while enduring temperatures that turn their body-armor-clad bodies into "pressure cookers," wrote New York Times blogger Lietuenant Rajiv Srinivasan, from Afghanistan's Kandahar province on November 22, 2010 ( atwar.blogs.nytimes.com/2010/ 11/22/tanks-to-afghanistan-a-soldier-writes ). Amputee soldiers achieve all of this while attempting to build the trust of a wary civilian population in a civil-war torn land that biographer Nancy Goldstone has characterized as politically medieval. Why do they do it?

Since the global war on terrorism began, the latest generation of rigged-out prosthetic feet have become a stock addition to the amputee soldier's kit. Prostheses' strong, yet flexible composites and advanced technologies have trickled down from advancements made in the aerospace industry, and their ascendancy has caused the awkward, stiff prostheses of previous generations to be shunted to the back corners of the closets of history. Rehabilitation itself has also come of age, with the emphasis not simply on ambulation, but on pushing the envelope on physical possibility that in some cases expands the scope of what soldiers could achieve even before their injuries. What hasn't changed, perhaps, is the dedication of the soldiers themselves, whose sworn duty to preserve and protect motivates them to be better, stronger, and faster because they have to be in order to withstand the pressures that their jobs demand.

One Brother in Arms

SSG Joseph Kapacziewski, an Army Ranger, prepares to lead his squad on a morning run in southeast Afghanistan. Kapacziewski reports, "I am actually just as fast as I used to be...." Photograph courtesy of the Department of Defense.

Joseph Kapacziewski has served three combat tours in Afghanistan since his right transtibial amputation. He lost his leg to a grenade in Iraq in 2005, and is now a staff sergeant in the Army Rangers, a special operations force of the U.S. armed services that exacts its own brand of mental and physical toughness. An airborne force, Rangers are better versed in weaponry than the average soldier and are specially trained for rapid deployment on enemy targets and in covert operations. Needless to say, this elite group cannot abide substandard performance in any member of its ranks. Kapacziewski, therefore, had his rehabilitative work cut out for him.

He initially spent 17 months in and out of hospitals, including time spent at Walter Reed Army Medical Center (WRAMC), Washington DC, where surgeons attempted to salvage his limb. The sergeant made the decision to have his leg amputated below the knee in 2007. Before his amputation, he was in a lot of pain and had poor range of motion in his foot and ankle despite several surgeries. "I was miserable," he says. "I was 25 years old at the time; my quality of life was not going to be great." Now, he says, "I am not in nearly as much pain and I am able to do just about everything I did before." He adds, "I am actually just as fast as I used to be, but that is because I put a lot more time and effort into...running." To prove it, he became one of the more than 44,000 entrants who finished the ING New York City Marathon on November 7, 2010.

Joseph Sadowski (right), CPO, performs an initial fitting of vacuum-assisted suction suspension prostheses on Marine Corporal Luke McDermott, a vehicle commander. Corporal McDermott was serving in Marjah, Afghanistan, when his vehicle struck an improvised explosive device (IED). Photograph courtesy of Joseph Sadowski.

After his amputation surgery, Kapacziewski transferred to Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, to undergo rehabilitation at its state-of-the-art Center for the Intrepid (CFI). A strong sense of camaraderie pervades the patient population at CFI, and the sergeant's natural competitive streak found an outlet with peers during grueling hours of physical therapy. "Guys in there would challenge me during workouts to make things a competition," he recalls, adding that it could get boring during the long hours of training, with three hours in the morning and three hours again in the afternoon. He says, "You always want to do better than the guy next to you, so at the end of it, you both probably got more out of the workout than if you were just doing it by yourself."

Justin Laferrier, PT, quickly became a significant force in Kapacziewski's rehabilitation progress. The sergeant says Laferrier didn't make distinctions between a person with a disability and an able-bodied person; Laferrier's philosophy became key to Kapacziewski's success. "It didn't matter how sore I was," Kapacziewski says. "It didn't matter if I was feeling sorry for myself one day. He pushed me every single day, every single hour.... He knew my goals and he knew what I needed to do, and he would not let me leave for the day until I accomplished what he thought I should.... It was great." Kapacziewski marks Laferrier as the single most influential person on his rehabilitation team because of the PT's exceptional gifts as a motivator.

Once Kapacziewski returned to combat for his first tour in Afghanistan, he felt like he was living in a fish bowl. "When I got back to my unit, of course I had a lot of eyes on me," he says. "The big thing for me was not only to be able to perform everything, but to sort of outperform other people at those tasks, to sort of suck it up and not make excuses. If I was not doing well at something, then I would just spend more time and more effort [on] it.... I try not to make excuse[s]; I try to overcome." As a squad leader, Kapacziewski demanded and received "110 percent confidence [in my ability] because I'd never be able to forgive myself if someone got hurt [in the field] because of my prosthetic leg." Since then, he's proven himself many times over and says that now most "people don't even give [my prosthetic leg] a second thought."

Sadowski

Joseph Sadowski is a prosthetist for the Department of Veterans Affairs (VA) and works in the CFI patient care program that allows for a "seamless transition" (a department catchphrase) from active duty soldier to veteran once the patient retires. At CFI, soldiers with amputations who plan to return to active duty are taught to self-diagnose and maintain their own prostheses while in the field. "We teach them how to align, how to adjust, how to use socks appropriately," Sadowski explains, adding that for paratrooping at night, Kapacziewski knows how to pad his prosthesis for impact on obscure terrain. In case of failure, "He carries additional feet and sockets in his rucksack," Sadowski notes. When soldiers initially redeploy, they bring enough gear to sustain them for at least six months. They send text and e-mail messages to their prosthetists from the field if they need additional supplies, explains Mike Corcoran, CPO, a prosthetist at WRAMC employed by Medical Center Orthotics & Prosthetics, Silver Spring, Maryland. But more importantly, he adds, the soldiers who redeploy are, "fully focused on their task, not 'Can I run? Can I do this?' They're not thinking about their prosthesis, [and] that's success [to me]."

Corcoran

Less visible but equally motivational to Kapacziewski's rehabilitation has been his sense of obligation to return to the front lines and "finish what we started," he says, because "what we do over there really makes a difference." He says that for him and, he believes, other soldiers like him who redeploy, "Even though they do get hurt over there, they want to honor that commitment to duty. They want to honor that commitment to their country...to their service...and to their brothers in arms."

Standing Firm For long-distance running, Kapacziewski uses the Flex-Foot Cheetah by Össur. His dynamic foot choice is the Pathfinder II by Ohio Willow Wood, Mt. Sterling, Ohio. It's his "everyday" foot, and by everyday he means, "for my missions, my fast roping, my jumping out of airplanes...."

Nolt

Lonnie Nolt, MSME, a right transtibial amputee and a Pathfinder II user himself, is on the design team that created the second generation of the Pathfinder. He says part of the challenge in the redesign involved making it more durable without adding more weight. The foot's performance makes it well-suited for military applications, he says, because it's both energy returning and shock absorbing. Regardless of how "you land on the foot," he explains, whether "you land on it vertically...on the toe...on the heel, [or] if you come down on the side of it, there's shock absorption, there's compression, which...is...desirable for high activity."

Nolt adds that the foot's triangular shape is instrumental in its performance since the toe springs are elevated off the foot plate, leaving plenty of room for the foot to compress. Pathfinder's composite of carbon and glass fibers provide optimum flexibility and return and are also key to its design, according to Nolt, as well as a self-adjusting pneumatic heel spring that can be fine-tuned to the user's exact needs and preferences via a hand pump.

Rehabilitation Comes of Age

One challenge that prosthetists at CFI face concerns the changing landscape of the residual limb. Injuries received in combat are traumatic, with limbs most likely impacted by explosives. Sadowski explains that the blast often has a thermal element and is more than simply "shrapnel flying through the air.... You actually have fire associated with this, so oftentimes you are dealing with...skin grafts, [and] heavy duty scar tissue." In addition, the residual limb changes shape daily since the soldiers come in having lost body mass as a result of their injuries, and then bulk up as healing and rehabilitation ensue.

Kapacziewski's limb has graft tissue as well as nerve impingement. With his patient's complex injury and physical presentation, Sadowski had to continually redesign sockets and components because Kapacziewski, "was pushing his envelope physically, and he was pushing my envelope clinically, because I'd get him fit and he'd be fine and he'd take off and start pounding on his body, pounding on his limb, and then come back a day later and say, 'well, it hurts.'"

Special forces Sergeant 1st Class John (Mike) Fairfax sits in a helicopter after carrying out a mission spent in an Afghan riverbed. Photograph courtesy of WRAMC.

Sadowski says that at CFI they keep their patients in test sockets longer than is common practice, and continually refine the sockets. He explains that this approach is not always practical in the private sector due to logistical issues. He adds, "We can see patients multiple times a day, five days a week...[and continually] update the prosthesis as the residual limb reduces in volume or remodels...[with an eye toward] maximizing the patient's [functional] level." According to Corcoran, soldiers typically undergo anywhere from eight months to two years of rehabilitation.

State-of-the-art physical therapy and adaptive sports programs at both WRAMC and BAMC open soldiers' eyes to possibilities even they didn't know existed before their injuries. During the recent Neuroprosthetics conference held at Worcester Polytechnic Institute, Massachusetts, CFI Medical Director, Col. Jennifer Menetrez, MD, said in her keynote address, "It's not about what they could do before. It's about all the things they didn't realize they could do that they now are forced to try."

Sadowski explains that CFI focuses its rehabilitation efforts on enabling "patients to exceed their own expectations." The team's approach encourages patients to "see how far we can push this," Sadowski says. Patients are asked, "Do you want to ski? Do you want to cycle? Do you want to rock climb? Do you want to run?" CFI has an adaptive scuba diving program, for instance, so that once patients are swimming, there are still further, perhaps even more rewarding goals that continue to motivate soldiers through the rehabilitation process, he says, adding that the team's goals are more holistic and far-reaching than simply getting the patient ambulatory again. One reason why "we can send guys back into combat should they choose to go," he explains, is because the team works with patients' motivations and then encourages them to consider beyond what they thought was possible. A common refrain heard from patients, he says is, "Wow, I can do this; I never knew I could."

The Computer Assisted Rehabilitation Environment (CAREN) engages patients in virtual reality simulation exercises. Photograph by Dwayne Snader, medical photographer BAMC.

CFI's virtual reality dome, known as the Computer Assisted Rehabilitation Environment (CAREN), is equipped with a tilting motion platform and treadmill, where patients stand and face a curved 300-degree screen that takes them on an action-packed journey into a virtual world. Strapped into a harness, patients can adjust to a new prosthesis and work on balance, proprioception, and coordination issues without worrying about falling. Patients enhance muscle coordination and build strength while weight-shifting in a row boat on a virtual lake in an aquatic scenario. For those who are just starting out on new prostheses, an urban scenario mimics the sights of a crowded cityscape, with bustling sidewalks that confront patients with sudden obstructions that continually demand changes in direction and split-second timing.

"We can take those individuals through alternate scenarios in a safe, controlled environment and help them through the physical impacts of having to perform in those environments," Sadowski says. In addition to CAREN, Kapacziewski took advantage of CFI's state-of-the-art Firearms Training Simulator (FATS) to regain range of motion in his hand and forearm, which suffered from median nerve damage.

Better, Stronger, Faster A person with an amputation expends far more energy maneuvering on a prosthetic leg than he or she would with a natural leg, so amputee soldiers who return to combat must work harder than their able-bodied brothers and sisters in arms to achieve similar results. According to Sadowski, it's a question of physiology and physics because "there's always an energy loss with prosthetic feet.... Few [are] 100 percent efficient." From a biomechanical point of view, he adds, as "an amputee, the muscle length is now altered.... Instead of having a nice long gastrocsoleus muscle group and a posterior compartment of the limb, you now have a muscle that's greatly reduced in its length [and] as a result, the contraction is different and not as powerful...." Therefore, he asserts, amputee soldiers have to "be in better shape.... [They] have to exert much more energy to do the same activities."

Amputee soldiers who return to combat are a tough breed. For them, the rewards of the job are enough to make up for the enormous physical challenges posed daily. As Kapacziewski says, "For us, this is what we do. It's our passion."

What this Army Ranger has been able to accomplish in combat, argues Sadowski, is changing the perception of what the amputee soldier can achieve both on and off the field. The sergeant's heroism, he says, is providing others with new opportunities, dispelling old myths, and even changing the definition of the word "disability" itself. "When you can run as fast with a prosthesis than you could before your injury," Sadowski questions, "[are you] really disabled?"

Pam Martin can be reached at linkEmail('pam','opedge.com');

Advantages of the Newest Generation of Prostheses

Recent technological advances made in prostheses' materials, components, and design have, in part, enabled some of the remarkable feats that amputees can now achieve in the field. For transfemoral amputees, a more natural gait is the by-product of the latest microprocessor knee iterations, such as the X2 by Otto Bock HealthCare, Duderstadt, Germany, and the Rheo Knee by Össur, Reykjavik, Iceland. According to Otto Bock, the X2 is the first microprocessor knee to allow for running as well as walking, so users don't have to switch to an alternate leg. Funded by the Military Amputee Research Project (MARP), the X2 is a transitional device until Otto Bock's slated release of the X3 in late 2011 or early 2012. The X3 will feature even more bells and whistles including an environmental seal, water resistance, recharging-while-in-use, and immersion capabilities, according to Kevin Kelley, international project coordinator, Otto Bock HealthCare Products, Vienna, Austria. Both the X2 and the X3 allow for walking backwards, increased load capacity and battery life (as compared to the C-Leg), and are controlled remotely. Genium, the scaled-down, civilian version of the X2, is scheduled for a mid-2011 market release.

Powered by an actuator, Össur's Rheo Knee has an advantage over hydraulic systems because it's not vulnerable to the extreme heat that can be found in the Afghan desert: "There's no fluid [in the motor]...so it's not losing viscosity," Mike Corcoran, CPO, explains. Another reason soldiers choose it for combat duty is its compact size. "There's a lot of space underneath it for a high activity, dynamic foot [that is] essential for agility." Since water can be hazardous to microprocessor electronics, the shorter knee also allows soldiers to submerge in eight to ten inches of water, unlike other legs with controls closer to ground level, Corcoran notes. The system can be turned off when not in use to save its charge, and should the battery power down, the prosthesis won't lock. Instead, the system defaults to free swing mode, which is better "if you want to hustle somewhere, [and are] looking for more function...because there's little resistance in bending the knee," Corcoran adds.

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