by LTC Romney Andersen, MD; LTC Shelton Davis, MD; COL (Ret) Chuck Scoville, PhD
In this issue of ORTHOPEDICS, Drs Andersen (Orthopedic Surgeon), Davis (Physical Medicine and Rehabilitation), and Scoville (Amputee Patient Care) with the Integrated Department of Orthopedics and Rehabilitation at National Naval Medical Center and Walter Reed Army Medical Center discuss the network of care provided to service members with amputations.
Please describe the rehabilitation team at Walter Reed Army Medical Center/National Naval Medical Center.
The rehabilitation team at Walter Reed Army Medical Center/National Naval Medical Center consists of a diverse group of specialists, including orthopedic surgeons, physiatrists, nurses, physical therapists, occupational therapists, recreational therapists, anesthesiology and pain management specialists, clinical rehabilitation nurse specialists, nurse case managers, biomedical engineers, social workers, dieticians, peer visitors, patients and their families, and prosthetists who fill specific roles in the care of amputees from the point of initial injury through the return to the highest possible level of functional independence. Notably, not every specialist managing an amputee patient is involved in every aspect of their care. Typically, the patient will transition between specialists and services depending on each individual patient’s specific needs that have to be met and the associated short- and long-term goals.
What is the role of the orthopedic surgeon on the rehabilitation team?
The orthopedic surgeon is involved on the front end of care when a service member arrives with an amputation or with a seriously compromised limb that may have to be amputated if salvage does not succeed. On arrival, the surgeon evaluates such patients and discusses care options with them. Limbs are salvaged whenever the patient chooses that route so long as salvage does not compromise his or her health otherwise. The orthopedic surgeon manages all required surgical amputation, remains involved during the acute surgical recovery period, and is thereafter available to consult if problems arise.
Other clinicians taking care of actual or virtual limb loss patients will include nurses, doctors from other specialties (eg, general surgery or physical medical and rehabilitation), physical and occupational therapists, and prosthetists who build the new arms and legs amputees will learn to use. Any one of these professionals working with the recovering patient can request a consult with the orthopedic surgeon if the need for more bone surgery becomes a possibility.
Please describe the orthopedic rehabilitation process.
Rehabilitation for amputees begins immediately and involves a number of clinical professionals. While surgical wounds are healing under the supervision of an orthopedic surgeon and a nursing team on the ward, the amputee is visited in his or her inpatient room by a physical therapist who sets up simple routines for exercise and an occupational therapist who helps the amputee relearn daily life skills. Once the wounds are healed enough, a prosthetist will fit the amputee for prosthetic limbs. This could be within weeks or months of surgery, depending on the surgical involvement of the individual patient.
The average time an amputee spends in rehabilitation before returning to active duty responsibilities or going home as a retiree is anywhere from 6 to 18 months. Family members may spend much of that time at the medical center, and they too are part of the rehabilitation process. The patient may spend 3 to 6 weeks as an inpatient, then be discharged to live nearby and continue care on an outpatient basis. The patient will return daily to the hospital clinics for physical and occupational therapy, amputee clinics, and appointments with surgeons or other doctors as needed. He or she will stand up for the first time, take his or her first steps on prosthetic legs, and go on to try a number of different prosthetics, getting more sophisticated technology as he or she is ready to use it. The patient will learn to again fire a weapon, climb a wall, drive a car, and participate in sports. Adaptive programs that are part of rehabilitation at Walter Reed allow amputees to go on outings as they are ready, to nearby malls for shopping, lakes for fishing, or mountains for skiing. The goal is a return to normal function at home, at work, and in public.
Amputees also may suffer setbacks. Often the orthopedic surgeon is brought back to revise an amputation, excise a neuroma, or clean a site of infection. Heterotrophic ossification may require that new bone growth be removed. This means the patient has to start again with surgical recovery.
How is the rehabilitation process modified for amputees with other injuries (polytrauma)?
The process is pretty much the same if other injuries are involved, just the timeline is different and there may be more clinicians in the support network.
To what extent does research influence military orthopedic rehabilitation programs and treatment?
Throughout history, military conflicts have led to tremendous advances in medical care. This is no different during the Global War on Terrorism. Several significant improvements have been achieved in pain management, prosthetics, and therapeutic interventions for patients with limb loss. As patients seek to return to the highest levels of performance, including returning to active duty and joining their fellow service members in Iraq and Afghanistan, they drive the health-care team to develop new and innovative approaches to care. As needs are identified, research projects are initiated and the results are incorporated into treatment plans. Our research program provides the evidence to continually improve the care provided to our wounded warriors.
Please compare the breadth and intensity of military rehabilitation programs to those elsewhere. What are the benefits of treatment at military-specific facilities?
The personnel at military-specific facilities are focused on the care of the “tactical athlete.” The expectations of the patient and the health-care team are for the return to the highest possible level of function.
In addition to having military health-care providers who have also deployed and have a unique understanding of the patient population, there is a sense of military order with emphasis on the patient’s role as an active participant in the rehabilitation process and the capability for extended rehabilitation toward end goals of highest levels of function. Walter Reed Army Medical Center and National Naval Medical Center serve a unique population. Given the high operation tempo at which many soldiers, marines, airmen, and sailors functioned prior to their injuries, and the desire of a growing number of service members to return to active duty in some capacity both during and at the completion of their rehabilitation process, every effort must be made to provide our amputees with the training and the tools to transition back to active duty or segue as comfortably as possible into civilian life.
To accomplish the long-term transition goals for patients, the Military Advanced Training Center at Walter Reed provides military amputees the opportunity to master different environments and terrain with their new prosthesis. This facility serves as a state-of-the-art amputee training center designed to meet the needs of a service member who is an amputee. Specifically, the center contains a computer-assisted rehabilitative environment known as a “CAREN” system, which simulates different environments and terrains to allow the amputee to develop the strength, balance, and coordination to use the prosthesis in a multitude of environments. Also, the center has a simulated rifle and pistol range to allow the amputee the opportunity to learn to manage and fire a weapon again if his or her desire is to return to active duty. A climbing wall in the center allows the amputee the opportunity to develop appropriate core stabilization strength to use the prosthesis more efficiently. Additionally, because different prosthetic feet, shanks, and knees serve different functions, many of our wounded warriors will be provided with several prostheses and components to accommodate different environments.
Authors
Drs Andersen, Davis, and Scoville are from the Integrated Department of Orthopedics and Rehabilitation at National Naval Medical Center, Bethesda, Maryland, and Walter Reed Army Medical Center, Washington, District of Columbia.
Drs Andersen, Davis, and Scoville have no relevant fi nancial relationships to disclose.
The views expressed herein are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of the Navy, Department of Defense, or United States Government.