Fleischmann, David MD; Michalewicz, Betty MS; Stedje-Larsen, Eric MD; Neff, John MD; Murphy, Jennifer PhD; Browning, Kara MPH; Nebeker, Bonnie CTR; Cronin, Andy MD; Sauve, William MD; Stetler, Christopher MD; Herriman, Laurel BA; McLay, Robert MD, PhD
DAVID FLEISCHMANN, MD, BETTY MICHALEWICZ, MS, ERIC STEDJE-LARSEN, MD, JOHN NEFF, MD, JENNIFER MURPHY, PhD, KARA BROWNING, MPH, BONNIE NEBEKER, CTR, ANDY CRONIN, MD, WILLIAM SAUVE, MD, CHRISTOPHER STETLER, MD, LAUREL HERRIMAN, BA, AND ROBERT McLAY, MD, PhD, are affiliated with the General Medical Education, Naval Medical Center San Diego, San Diego, California.
Disclosure: The authors declare no conflict of interest.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Correspondence to: David Fleischmann, MD, 2856 Escala Circle, San Diego, CA 92108; e-mail: email@example.com
Among the thousands of US Service members wounded in Iraq, many have sustained multiple traumas and developed physical and mental injuries. The term “polytrauma” refers to concurrent injury to the brain and several body areas or organ systems that result in physical, cognitive, and psychosocial impairments. Although many therapeutic modalities are available for patients with polytrauma, only a few modalities simultaneously address global rehabilitation, including pain, vestibular impairment, and cognitive symptoms. The sport of surfing involves aspects of hydrotherapy, strength training, balance rehabilitation, and group supportive therapy. Recent adaptations have been made that allow those with severe injuries and missing limbs to learn how to surf.
This case examines a 21-year-old active duty US Army soldier who had been exposed to a blast injury that culminated in a bilateral transfemoral amputation, severe burn injuries, traumatic brain injury (TBI), mild depression, and severe pain. After multiple surgeries, the patient was treated with physical therapy for strength and balance, opiates for pain, and psychotherapy for acute care. Although the patient's symptoms improved significantly from his baseline, he continued to experience severe symptoms, including limited use of prosthetic limbs; use of morphine, tramadol, and oxycodone; and residual symptoms of decline in well being. Approximately 1 year after his injury, the patient enrolled in Surf Clinic, a surf therapy program at Naval Medical Center San Diego (NMCSD), which required him to improve his proficiency in walking, balancing, and vestibular functions, and to gain muscular strength, aerobic endurance, concentration, and timing of wave movements.
In addition, the patient was exposed to a supportive environment with veteran mentors and other wounded warriors who had faced similar struggles. After 6 months in the surf clinic, the patient's balance exceeded that that of his peers who had not participated in the clinic; he was one of few patients at our facility with transfemoral amputations who was able to walk on bilateral prosthetic limbs full time; he significantly reduced his narcotics for pain control; his depression resolved; and he reported temporal relief from TBI.
Our case illustrates the potential for implementing the sport of surfing as a multimodal treatment for patients with polytrauma. Further research and rehabilitation developments are needed to determine whether surf therapy can be used in distributions other than amputees, specifically in individuals who plateau with traditional care.
The patient, a 21-year-old active duty US Army soldier, was the victim of a blast injury in Southern Baghdad, Iraq. He sustained extensive shrapnel injury after an explosion extensively burned both lower limbs. In the same explosion, a truck partially rolled on top of his lower limbs above the knee leaving him stranded with nearby fire. At the scene, the patient, responsive and agitated, called over nearby soldiers to assist him. With their help, he partially amputated his own crushed lower limb to escape.
The patient was medically evacuated to an intensive care unit in Germany where he received 3 units of blood, a chest tube for punctured lung, an open heart thoracotomy, and multiple orthopedic surgeries disinfecting and closing his transfemoral bilateral amputations. When stabilized, he was transferred to outpatient care at Walter Reed Army Medical Center. Weeks later, he was medically evacuated to NMCSD for outpatient medical care and rehabilitation. Screening by Physical Medicine and Rehabilitation, Pain Management services, and Exercise Physiology was conducted. He was started on morphine, oxycodone, ultram, and gabapentin for leg pain, phantom limb pain, and shrapnel wound pain in his hands and attended the regular physical therapy/vestibular clinic. Patient was also seen by psychology staff who noted that he had TBI and mild depression. Patient was given no medications for these problems at this time. Traditional therapy improved abdominal core movements and overall muscular strength. After approximately 12 months of treatment, the patient still had issues with walking and balance, TBI, depression, and pain.
Approximately 1 year after sustaining his injury, the patient enrolled in a surf therapy program established in 2008 called NMCSD Surf Clinic. This treatment center provided local military traumatic amputees with an environment and means by which to engage in physical activities they enjoyed and which challenged them physically, mentally, and emotionally. It included vestibular instruction, water safety, swimming, paddling, and wave riding and focused on the physical and psychological skills needed for these activities, including balance, muscular strength, aerobic endurance, and skills in concentration and timing of wave movement. Discussions among veteran mentors, who were also wounded warriors, local lifeguards, and new program participants took place while waiting for waves.
After 6 months in this program, engaging once a week for 3 hr per session for 6 months, the patient reported significant progress. His improvement in balance exceeded that of his peers with the same condition. He was the only patient at that time with bilateral transfemoral amputations who was able to walk on two prostheses as a primary means of movement. He was able to discontinue narcotics (Figure 1). His depression completely resolved, and he reported complete relief from symptoms on days during which he went surfing. He also reported that participation in the surf clinic had significantly improved his general well being and stress level.
We presented a case of a polytrauma patient who initially had problems with pain, mobility, balance, and psychological symptoms. All these symptoms had been resistant to traditional treatment. After starting in a regime that used surfing as therapeutic intervention, he saw improvements in many areas. Although not all symptoms resolved, his overall well being improved. This suggests that surfing may be a useful modality by which to engage patients with polytrauma.
It is impossible to determine causality from a single case. However, there are several potential mechanisms by which surfing may have helped this patient. Pain management was most likely established through endogenous opioid pathways that increased with exercise.1 It is unclear why the patient reported greater improvements in pain with surfing than with other forms of exercise; it may, however, go along with theories of long-term potentiation. The patient clearly enjoyed—and was excited by—his time surfing. Pleasurable experiences are associated with increases in norepinephrine and serotonin, and these pathways may, in turn, feed back on long-term potentiating and pain.2
The most encouraging aspect of surfing as therapy may be its impact on vestibular function. Traditional vestibular rehabilitation involves the use of a balance platform. Although this platform may be helpful, many patients feel they “max the machine” early on. In other words, the rehabilitation challenges are not as strenuous as the tasks a patient may face in the real world. Surfing allows additional progress. The task of surfing is similar to that encountered on a traditional balance board, with the additional feature of movement. This may more closely approximate the problem of walking with a prosthetic, and other complicated vestibular issues. New developments will be required to recreate the vestibular challenge of walking without the ocean. At least in this case, the patient was able to show greater, real-world progress after mastering the art of surfing.
How surfing may have improved psychological symptoms is also an interesting topic. Surfing combines two modalities often used today to assist in mental health: components of group therapy and exercise. Trauma survivors involved in the program congregate on shore to learn the mechanics of surfing and also to communicate with each other while they wait to catch the next wave. Group therapy and adult survivors with stress disorder in a randomized clinical trial have been shown to be effective in reduction of symptomatology.3 Interspersed with the waiting and talking are the strenuous exercise and excitement of actually catching a wave. Large muscular movements can increase the body's serotonin norepinephrine and dopamine neurotransmitters.
Excitement is also independently associated with increases in both of these neurotransmitters.4 These neurotransmitter systems are commonly decreased in depression,5 and it is possible that surfing helps to normalize these systems.
All in all, this case illustrates the potential of surfing as a multimodal treatment for patients with polytrauma. Additional research and development is needed to see whether the therapeutic benefit, including vestibular balance enhancement, pain resolution, and behavioral improvement seen in this case, is attributable to the surfing intervention, and whether therapeutic use of new types of balance devices and prostheses could translate the surfing experience and benefits to rehabilitation centers not located near the ocean (Figure 2).
1. Mahler DA, Murray JA, Waterman LA, et al. Endogenous opioids modify dyspnoea during treadmill exercise in patients with COPD. Eur Respir J 2009;33:771–777.
2. Rogan MT, Stäubli UV, Ledoux JE. Fear conditioning induces associative long-term potentiation in the amygdala. Nature 1997;390:604–607.
3. Ginzburg K, Butler LD, Giese-Davis J, et al. Shame, guilt, and posttraumatic stress disorder in adult survivors of childhood sexual abuse at risk for human immunodeficiency virus: outcomes of a randomized clinical trial of group psychotherapy treatment. Nerv Ment Dis 2009;197:536–542.
4. Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science 1967;156:21–37.
5. Dishman RK. Brain monoamines, exercise, and behavioral stress: animal models. Med Sci Sports Exerc 1997;29:63–74.
KEY INDEXING TERMS: surfing; medicine; surf medicine; surf clinic; balance; vestibular; pain surf; psychological surf; board; wave