Physical Re-education

Multidisciplinary teams at military hospitals create individualized rehabilitation programs for their unique patient population.

Statistics provided by the Armed Forces Health Surveillance Center show that 240 instances of at least one arm or leg amputation were performed on deployed soldiers injured in combat due to the ongoing wars in Iraq and Afghanistan in 2011. This was a significant increase from the 196 cases in 2010. As of December 2011, nearly 1,400 service members have had a major limb amputation due to combat wounds from the dual wars in the Middle East. Twenty percent of those service members lost more than one limb.

Why the sudden uptick?

Why were more amputations performed in 2011 than in 2010, surpassing even the previous high of 205 in 2007, the same year as the troop surge in Iraq? Despite 2011’s record high numbers, there may be a somewhat positive explanation.

  Images: U.S. Air Force photo/Steve White

Advances in battlefield medicine, improved body armor and faster evacuation times have all been cited as possible reasons for the increase of amputation cases, as well as the decrease in fatalities. According to the same Armed Forces Health Surveillance Center (AFHSC) report, while amputations rose in 2011, fatalities declined from 437 in 2010 to 368 in 2011. These improvements have resulted in more soldiers returning home to their families alive, albeit severely injured.

With the help of multidisciplinary teams at Walter Reed National Military Medical Center (WRNMMC) and Center for the Intrepid (CFI), severely injured soldiers can still live quality and impactful lives when they return home.

“The types of injuries we see are due to the differences in the ways we were fighting,” Charles Scoville, PT, chief of amputee patient care services, told O&P Business News. “The conflict could require more troops on the ground for patrol versus riding around on the Humvee. I see changes based on the season, to new locations of improvised explosive devices (IEDs). All of those affect the type of injuries and the numbers we see.”

Military members are trained for lifesaving maneuvers, including how to use a tourniquet and a one-handed tourniquet that will keep injured soldiers alive while they are en route to a higher level of medical care.

“Body armor has absolutely saved lives,” Scoville said. “Advancements in medical practices have saved lives. More soldiers are surviving this conflict than any other conflict. Our care is much quicker. You’re within 15 to 20 minutes of immediate medical care in most instances.”

Unique patient population

To understand the rehabilitation program at WRNMMC, one must first understand the patient population. Most amputations in the US civilian population are due to diabetes, vascular disease or tumors. The majority of traumatic injuries are caused by motor vehicle accidents or industrial accidents.

Most amputees at WRNMMC suffered from a blast type of injury, likely an IED from the ongoing wars in Iraq and Afghanistan, according to Col. Paul Pasquina, MD, chief of the Integrated Department Orthopaedics and Rehabilitation, WRNMMC.

“What makes this program unique? Start with the uniqueness of the patients we take care of,” Pasquina told O&P Business News. “The sheer mechanism of injury makes these patients unique due to their complex wounds.”

The soft tissue and bony damage is more extensive than what is seen in civilian trauma settings. Injured service members often face bone formations within the soft tissue of the residual limb known as heterotopic ossification (HO). According to the article, Advanced Rehabilitation Techniques for the Multi-Limb Amputee, co-written by Pasquina, HO “may occur in up to 64% of combat amputees.”

“The rehabilitation is fairly intense,” David Laufer, chief of orthotics and prosthetics, WRNMMC told O&P Business News. “We get them off the battlefield and about 4 weeks later they’re in a prosthesis. We get a lot of volumetric changes in lower extremity and upper extremity. We have high instances of HO. A socket that was comfortable on Friday may not be comfortable on Monday. It depends on the level and seriousness [of the injury].”

Injured service members are often struck by elements of an IED blast that can traumatically contaminate their wounds and cause broken bones to proximal and/or opposite limbs. This can make it a challenge for Pasquina and his team to determine how much of the residual limb will survive an amputation.

“That’s typically declared over weeks or sometimes over a month,” Pasquina said. “These types of injuries are unique. What we see are large number of comorbid injuries. Traumatic brain injury, PTSD, anxiety, depression, and behavioral health issues, sensory loss, paralysis from nerve injuries, all of these comorbidities form a unique patient population. To further distinguish this group, they are a younger age group.”

  Col. Paul Pasquina
  Col. Paul Pasquina

The servicemen and servicewomen stationed at WRNNMC are rarely older than 35 years. Most, according to Pasquina, are in their early 20s. This brings its own set of challenges.

“Sense of body image is important,” Pasquina said. “Many of these young men and women are still forming relationships. Many have not yet determined a career path.”

Patient needs and goals

Maj. Terrance T. Fee, DPT, OCS, CFI, Orthotics and Rehabilitation Department, works alongside injured service members with limb loss in an outpatient program. Fee meets with members of the multidisciplinary team once a week to discuss each patient and where they stand in the rehabilitation process. Prior to meeting a new patient, Fee and the multidisciplinary team meet in the afternoon one day a week to discuss the patient’s history and potential challenges due to existing injuries.

“We are an outpatient facility so we get soldiers after transitioning from inside the house,” Fee said. “We receive updates from our inpatient staff and discuss the patient’s progress and any wound concerns,” Fee said. “If there are other issues, they are addressed and discussed at the meeting as well. Good communication among the whole team is crucial. We present a united front, keeping in mind that we are always working toward patient goals.”

The team gathers with the patient during interdisciplinary rounds immediately following their meeting and determines initial evaluation days and a rehabilitation schedule. Fee and the multidisciplinary team individualize the rehabilitation program to address the patient’s specific needs and goals. According to Fee, most of the patients he sees on a regular basis are highly motivated.

“Their only job is to do their rehab,” Fee said. “We get these patients a lot longer than folks do in other trauma centers. A patient could have physical therapy for 2 hours, then occupational therapy for another hour. They could have several appointments in one day. It’s a full day. Everyone on the multidisciplinary team at CFI has an opportunity to interact with the patient.”

Occupational therapy

The occupational therapy side takes a slightly different approach than physical therapy. Max Hammer, OT, WRNMMC, re-educates the upper extremity amputee veteran, for example, on how to use their remaining muscles and extremities to determine potential motor muscle sites in preparation for myoelectric or body powered prosthetics.

“Once the prosthetics team fits the patient with prosthetics, we educate the person on how to use the prosthesis, whether it is myoeletric or body powered, for everyday tasks,” he said.

Most therapists will sit down with the patient and ask what they hope to accomplish with and without prostheses. Occupational therapists must know what will work for the patient at all times, including when the patient is not donning the prosthesis.

“Prosthetics will fail and you have to teach a patient what to do when something goes wrong,” he sad. “I have to get them to function in both worlds.”


During rehabilitation, veteran amputees practice tasks such as picking up small objects, lacing their shoes, holding utensils, buttoning their clothing and even handling firearms.

“We do have a person who is highly knowledgeable in using firearms and often I will sit in on the session and allow that person to teach the patient how to handle the weapon properly,” Hammer said.

For lower extremity amputees, Hammer stresses the importance of balance during everyday activities for his patients. Not only does a bilateral transfemoral amputee, for example, have to relearn how to walk in a straight line, he must do it in a living room crossing over a carpet onto a hardwood floor while maneuvering around chairs and tables.

“Can you balance yourself and do a task [at the same time]?” Hammer asked. “Tasks include something you do every day, such as standing in front of a sink, standing in front of a counter or doing a task while standing on one or both legs that have been amputated. There is also getting in and out of a chair. There are a lot of tests for developing a patient’s balance.”

Advanced care

The goal of any center of excellence or comprehensive military medical program is to provide comprehensive care — interdisciplinary in nature — that not only addresses the patient, but the patient’s family as well. The program must take care of an individual from the time of their injury to their integration back to society or employment. There is also an educational component to care that goes beyond educating families and patients. Because there is a constant turnover, medical staffs need to be continually educated on the latest technological and medical developments. As doctors and specialists leave the military or retire, military hospitals must quickly replace their expertise.

Keeping up with research is a critical component to any comprehensive military medical program, according to Pasquina.

“Not doing research or not exploring new technology fails the people we try to take care of,” Pasquina said. “We have great advances, but we see on a daily basis the limitations we have to offer our patients. We are always striving to deliver more.”

Pasquina cited advances in upper extremity prostheses, including the Modular Prosthetic Limb (MPL) developed by the Johns Hopkins Applied Physics Lab. The MPL is controlled through the patient’s thoughts and has 22 degrees of dexterity, nearly as much as a human arm. The MPL was used for the first time by an upper extremity combat amputee on Jan. 24.

“It’s very exciting,” Pasquina said. “What we learn will push the engineers to find something that is commercially available to all folks with upper extremity limb loss.”

Appropriate care

Although military research yields new technological advancements in prosthetics, from the patient care perspective, the focus is on whatever technology will make them most functional. Sometimes that requires advanced technology, but sometimes basic technology is more appropriate. According to Scoville, the level of technology depends on the activities the patient is participating in and planning on performing.

“We’ve been to Pakistan, the Republic of Georgia, Estonia, Colombia and Thailand, and what we emphasize in each place we go is that it is not the application of the most expensive technology, it’s the application of the most appropriate technology,” Scoville said. “You do not necessarily need fancy stuff to accomplish a lot of the goals you’re trying to accomplish.”

Peer mentorship

“Some patients set a goal to walk, others want to run,” Fee said. “This is a fairly young active population, that’s what they know, that’s what they want get back to. Peer mentorship is huge here; everyone sees what other patients are doing. We have adaptive sports here; they challenge each other and are pretty aggressive.”

Peer mentorship is beneficial to not only the patient but the rehabilitation team as well. Fee allows other patients who are further along in the rehabilitative process to demonstrate different techniques.

“We work with people who are just getting started; some people are several months in,” Fee said. “It benefits the entire team when patients share with each other different techniques. They share with each other what works and what doesn’t. It is to our benefit to have many folks in similar circumstances in the same location.”

At WRNMMC, Scoville sees a similar camaraderie among the injured veterans, even when they are battling through frustratingly long rehabilitation days.

“The patients, like anyone, will go through various high and low points,” he said. “ I have 170 guys on campus and a lot of their issues are worked out among one another. When they’re in therapy they’re generally upbeat. They have days when they’re not upbeat and days when it’s not going well. They may wake up one morning and the socket is uncomfortable or they may wake up and the leg slides on and they go for a run. They are like anyone in terms of peaks and valleys.”

The role of family

The primary goal of rehabilitation is to gradually build independence for the patient. According to Pasquina, one of the medical lessons learned from the Vietnam War was the importance of family involvement in an injured service member’s rehabilitation.

“During Vietnam, people went through a lengthy evacuation system,” Pasquina said. “It took them days, weeks or months to get back to the United States.”

  Max Hammer
  Max Hammer

When injured service members returned to the US, after a long rehabilitation stay overseas, they simply went home to be with their family. Unfortunately, many injured veterans may not have been fully adjusted to their home surroundings and were very dependent on family members. Military veterans, who served during wartime and held vital responsibilities during their time overseas, could not bathe or dress themselves. Highly independent service members found themselves in very dependent situations, according to Pasquina.

“That was something that was a negative aspect in Vietnam,” Pasquina said. “Now we have incorporated families into rehabilitation programs. Injured service members who arrive at WRNMMC are greeted not only by medical staff but by their families. Families fly here and meet them by their bedside during inpatient rehabilitation. They stay on campus during outpatient rehab.”

A service member with multiple limb loss who has a young spouse and a young child endures a significant amount of stress.

“In the military, you are family,” Scoville said. “They all have brothers, military-wise. They have that family, as well as immediate family. All those play a role in supporting the rehabilitation and recovery process.” — by Anthony Calabro

For more information:

  • Armed Forces Health Surveillance Center. Medical Surveillance Monthly Report. 2012; 19(1):16.
  • Fortnoy, S. WRNMMC uses new, brain-controlled prosthetic arm. Available at: Accessed Feb. 17, 2012.
  • Harvey Z, Loomis GA, Mitsch S, Murphy IC, Griffin SC., Potter BK., Pasquina P. Advanced rehabilitation techniques for the multi-limb amputee. Journal of Surgical Orthopaedic Advances. 2012; 21(1):50-57.

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