WRAMC’s Amputee Center: When Heroes Need Heroes

Walter Reed Army Medical Center, in Washington, D.C., rises above the compound’s sprawling grounds. From the outside it is a modest building, but it holds some of the most advanced rehabilitation facilities available. Military personnel are at the gate greeting visitors, many of whom have traveled thousands of miles to be near their injured soldiers.

Inside, the atmosphere is not somber but hopeful. Men wearing exercise clothes and crew cuts usher their families into the elevator. Each of the men has a visible prosthesis showing under his shorts.

Patient population

A temporary home to many of the brave American men and women who have been injured while fighting in the conflicts in Iraq and Afghanistan, Walter Reed Army Medical Center (WRAMC) has treated more than 7,600 ill and injured warriors from those conflicts since 2003. The wounded arrive with a variety of injuries, such as limb loss or damage, brain injury and post-traumatic stress disorder. Because of the advances in armor and wound care since the Vietnam and Korean wars, more and more people are rescued on the battlefield. Although there are many whose lives are saved, there are many whose limbs often are not.

In addition to wounded warriors, the medical center treats non-war wounded, including active duty members hurt or ill for other reasons, as well as family members and retirees. On an average day at Walter Reed, there are 160 total inpatients and between 3,000 and 4,000 outpatient visits in Walter Reed’s more than 60 clinics.

WRAMC’s Amputee Center: When Heroes Need Heroes
© 2008/JupiterImages Corporation

Since the conflicts in Iraq and Afghanistan began, there have been 787 amputee patients treated in all Army facilities, according to a June 2 monthly report prepared by Charles Scoville, PT, DPT, COL(R), chief of amputee patient care service at WRAMC. WRAMC, which recently celebrated its 99th anniversary, has treated 575 service members with limb loss from both Operation Iraqi Freedom and Operation Enduring Freedom.

Soldiers are transported to WRAMC for immediate care, often within 48 hours of being injured, and many patients remain at the facility for more than a year. With several options for housing, some soldiers are able to live off-campus with their families and visit WRAMC each day for outpatient treatment and rehabilitation.

“They work hard to get back to a level that meets or exceeds what they did before,” said Patricia Cassimatis, media relations specialist for WRAMC public affairs.

One of the most important aspects of patients’ treatment involves their interaction with each other. Patients are brought to rehab as soon as possible after they arrive at the facility, hobbling on crutches, pushed in a wheelchair or wheeled in a hospital bed. Cassimatis stressed the importance of the first sight of others in the same — or worse — condition. The feeling of camaraderie in the facility is tangible.

As on many days at WRAMC, a newly injured soldier was being evaluated by the rehab team on the day O&P Business News visited the facility. He laid on his stomach on a workout table, propped up on his elbows, fresh blood visible through the bandage where his right calf once was. He spoke with members of the rehab team about his progress. Other soldiers in various stages of rehab offered words of encouragement, and in that moment he was just another guy talking to his buddies. The smile never left his face.

Need for amputee care

Because of advances in body armor, the survival rate from blast injuries is higher than it was in previous conflicts. In addition, medical care and access to field hospitals has improved, as has traumatic first aid training for troops.

“They save each other’s lives,” Cassimatis said. “It’s the guy that hit the ground right next to you who is going to put a tourniquet on and talk you through it until you are on the plane.”

Because of this emergency medical treatment, there is a much higher survival rate, according to Cassimatis.

Patients who are brought to WRAMC for their care remain on active duty throughout their stay. Because of the high level of rehabilitation they receive at the center, some of the soldiers may be redeployed to Iraq and Afghanistan after receiving their prosthetic devices, Cassimatis told O&P Business News.

Scoville was on the front line when it came to building the new Military Advanced Training Center (MATC). Scoville urged the public to understand the immediate need for the project.

“Chuck devoted himself to this building,” Cassimatis said. “He was absolutely key in figuring out the design of the building and arranging deals on equipment.”

Along with its rehab facilities, MATC houses WRAMC’s traumatic brain injury program and a wound clinic. Patients recover from their emotional distress with help from psychologists, psychiatrists, group counselors, Veterans Administration social workers, and Marine Corps and Navy program liaisons, who are available to patients and their family members. Soldiers even have the ability to talk with the units they left overseas when they were injured via conference rooms equipped with video teleconferencing capabilities. Scoville emphasizes the importance of this contact.

“[The patients can] talk to their units, so the units know they are doing well and they know their unit is doing well,” Scoville said. “Again, psychological healing for both ends. The unit last saw the guy leaving on a stretcher.”

Practical matters

Scoville said that WRAMC was the first facility to fit bilateral patients with Ossur’s Power Knee.

“They said we couldn’t do it, so we had to do it,” he said.

Prosthetists at WRAMC and other medical professionals also have taken other liberties with devices like this, revising the limits of the available technology to best suit their patients’ needs. For example, Power Knee specifications recommend patients be under a certain weight, but “we changed the weight,” he said.

The desire to make advanced prosthetic technology work for injured soldiers is a logical one. Of the 527 injured soldiers who have gone through the medical board process, 99 amputees have returned to active duty or reserve duty — more than 18%. Many of the others decided not to return for reasons other than their injuries.

Programs like WRAMC’s firearms training simulation are used for soldiers who are looking to return to duty and those who are not. Restoring the sense of self, Scoville said, helps prevent the depression and anxiety many amputees feel after amputation.

“If you do a fairly aggressive rehabilitation program, you give them back sense of self and control, they know they can do the things they did before,” he said.

For military amputees, marksmanship is one of the basic skill sets required; retaining those skills gives them the option of returning to duty.

Charles Scoville with the Explanar CAREN system
Charles Scoville with the Explanar, left, which helps amputees perfect their golf swing and build core strength and balance. The CAREN system, right, uses 12 cameras to capture motion and an elevated treadmill to reset the patient’s normal center of balance.
Images reprinted with permission of Bill Pavlou, Jr.

Rehab facilities

The rehab equipment available to MATC patients includes machines that improve movement, balance and strength, as well as a variety of sports and recreational skills. For example, the Explanar, a golf training system where users practice their technique by swinging a weighted club rested on a hoop, offers amputees the ability to not only practice their golf swing, but develop core strength, stability and balance. Each Monday a member of the Professional Golfers’ Association of America visits WRAMC for a few hours and works with the soldiers on their golf swing.

Also playing to the soldiers’ competitive nature is the Treadwall, a climbing wall built like a treadmill, cycling through different colored climbing holds. The record for time spent on this machine is 50 minutes, Scoville said.

Another device the rehabilitation team uses for amputees is the PROPRIO 5000. The Proprio is a computer-monitored platform that senses a patients’ movement and records their response to motion, improving balance, proprioception and core stabilization.

In the Center for Performance and Research Studies, MATC’s sophisticated motion lab, the rehab team measures the patient’s progress through data gathered by force plates and 23 motion-sensor cameras bolted high on the elevated ceiling. The entire room was built within an isolated cement slab to prevent outside movement. One of the largest clinical performance gait labs, the center also houses a dual-force plate treadmill for additional observation.

Markers are placed on the patients, which can detect motion as small as 1/10 mm, and six force plates under the floor — isolated in another cement slab — measure the forces as they walk or run. The information gathered allows members of the team, including the prosthetist and physical therapist, to change not only the patients’ prosthetic devices, but also aspects of their rehabilitation programs.

Another critical part of the rehab process is testing patients wearing their military load-bearing equipment. WRAMC observes both able-bodied soldiers and amputees on the treadmill and measures the physiological costs for each. One factor that is not considered with civilian amputees, however, is significant variation in body weight. The rehab team needs to take into account the amount that a soldier’s body weight fluctuates when adding a helmet, a backpack and other equipment.

“Do you fit the prosthetic device for the 190-pound guy, or do you fit it for the 290-pound guy, who is the same guy depending on the time of day that you measure him,” Scoville said.

The rehabilitation team analyzes how the prosthesis reacts under these conditions and determines the best way for the soldier to adapt.

The high ceilings in the motion lab also allow plenty of room for unrestricted upper extremity amputee testing, including swinging a golf club and throwing a ball overhand.

Using the CAREN System

Perhaps the most impressive rehabilitation device at MATC is the CAREN System, or computer assisted rehab environment, one of two purchases made with a $1.5 million government grant. Only one other in the world is this advanced — not surprisingly, the other is located at Brooke Army Medical Center.

This elaborate machine serves as a way of resetting patients’ normal center of balance, said Charles Scoville, PT, DPT, COL(R), chief of amputee patient care service at WRAMC. The CAREN machine is an elevated treadmill surrounded by an empty moat with a 12-camera capture system. The platform under the treadmill holds four force plates, angles 18· in any direction and moves approximately 3 feet up and down. Yet the treadmill remains true regardless of the angle.

Scoville demonstrates the technology with a stick, about 1.5 feet long attached on both ends to small round stoppers.

“If you try to balance a stick [vertically in the palm of] your hand and hold it there without moving, it is difficult to do. If I set this stick on the CAREN platform, it will stay dead upright and not move as the platform goes through any type of motion.”

Working with patients

If a patient takes a step and starts to fall, the platform returns the foot to the center of gravity and keeps him upright; the patient can continue moving forward on the treadmill. This reteaches the patient to feel the sensation of falling only when that foot is not centered, which the CAREN system prevents.

Scoville also ensured that this system would hold patients’ interest. Three giant projection screens face CAREN users. Software features various scenarios the rehab team can implement depending on patient needs. For a patient having trouble shifting his weight, the CAREN operator sets him up on a boat; by shifting his weight in each direction, he steers the boat around buoys, maneuvering around waves and even a shark. This scenario is timed, and the patient enjoys beating his own score and other patients’ scores.

This virtual video game serves a practical function too: the patient concentrates on moving the boat around obstacles, but also effectively learns to shift his weight on his new prosthesis, Scoville said.

For other patients, the rehab team focuses on more psychological aspects of treatment. The CAREN operator can place a patient on a city street, alone at first. As the scenario progresses, other people join him on this street. Cars drive alongside the sidewalk where he walks. A car may backfire as he passes. While the patient avoids these hurdles wearing physiological markers, the operator monitors his reactions for a state of hypervigilance.

This elaborate training device was well worth the cost, Scoville told O&P Business News, because “We can’t do the ordinary.”

– Stephanie Z. Pavlou, staff writer for O&P Business News


Life preparation

The first of the simulation rooms at MATC helps patients relearn a basic American necessity: driving. General Motors has provided an actual car chassis to accompany the vehicle simulator, Scoville said, which is typically used as a tool to teach amputees to get in and out of a car and to use hand controls. The WRAMC team also uses it to prepare military amputees for the return to civilian driving.

“In combat, there is a sticker on the back of the vehicle that reads, ‘Stay back 50 m, Convoy ahead.’ If someone comes up and drives next to you, it’s not good … so you drive erratically,” Scoville said. “When you come back to the States and someone [drives] next to you, there is anxiety.”

The simulator also features physiological monitors to measure patients’ reactions to various situations.

“If they are driving with a car next to them and their pulse rate is running 160 beats a minute, you haven’t normalized their driving yet,” he said.

WRAMC offers a variety of recreational activities for its patients, including fishing, kayaking and hunting trips, a SCUBA program, and Friday night dinners, as well as other events. When the Pope visited the United States this year, 20 WRAMC patients were at Washington Nationals Park to meet him.

Added assistance

Another program available to patients brings man’s best friend to WRAMC. It began with visitors who brought their therapy dogs to see patients, then evolved to include a full-time WRAMC pet — a chocolate labrador retriever named Deuce — and now includes two additional dogs. Several patients even have their own personal service dogs.

Outside organizations also help patients with their rehabilitation. WRAMC works with the Amputee Coalition of America to provide a veteran peer mentoring program, where Vietnam and Korean war veterans share their experiences with newly injured soldiers. (For more information about the peer visitor program, see “On Similar Journeys: Military Peer Visitors,” in the Jan. 15 issue of O&P Business News.)

Throughout the different areas of the WRAMC, the rehab team gathers feedback about the program in a number of ways. In addition to ongoing conversations among the patients and their physicians, therapists and technicians, weekly sessions with family members determine any issues they may be having with the patients’ treatment. Patients and their visitors also have the opportunity to write their thoughts in any one of the suggestion boxes around the facility. Several of these suggestions eventually become new programs that are implemented for the patients.

Originally, the MATC was built with funding that had been allotted for a Heidelberg construction site, and patient care is covered under the funding for the global war on terrorism. Funding has changed in recent years, however.

“The initial concept of the military was you lost a limb and you were no longer in the military,” Scoville said. “We changed that mindset.”

For more information:

  • www.wramc.army.mil
  • Pavlou SZ. On similar journeys: Military peer visitors. O&P Business News. 2008;17(2):34-39.

Stephanie Z. Pavlou is a staff writer for O&P Business News.

Leave a Reply

Your email address will not be published.