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Comprehensive Rehabilitation Following Combat Extremity Trauma: Evolution and Its Impact on Outcomes

Rivera, Jessica C. MD; Pasquina, Paul F. MD

Journal of Orthopaedic Trauma: October 2016 - Volume 30 - Issue - p S31–S33
doi: 10.1097/BOT.0000000000000672
Supplement Article

Summary: Recent military combat operations have resulted in a high burden of extremity-related long-term disability due to limb amputation and persistent deficits despite limb reconstruction. The US Army amputee care programs, established at focused centers with interdisciplinary care teams, have redefined the standard of how rehabilitation following limb loss is undertaken as the limb reconstruction is just one part of the entire patient's restoration of wellness and reintegration. Inspired by this approached, comprehensive rehabilitation programs designed for patients with limb reconstruction have also excelled rehabilitation following a spectrum of severe limb trauma. These programs, which include advances in orthotics and orthosis training, have improved function and military retention among the limb salvage patient population. Lessons learned from comprehensive rehabilitation efforts emphasize the value of highly skilled, interprofessional care teams and the overall wellness of the patients. Although this approach is resource intensive and not available in all health care systems, civilian trauma counterparts can learn from the example of holistic attention to the patient's recovery.

*US Army Institute of Surgical Research and San Antonio Military Medical Center, Department of Orthopaedics Surgery, Fort Sam Houston, TX; and

Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences, Bethesda, MD.

Reprints: Jessica C. Rivera, MD, USA ISR ETRM, 3698 Chambers Pass, JBSA Fort Sam Houston, TX 78234 (e-mail:

The authors report no conflict of interest.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.

Accepted July 19, 2016

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Since military operations began in Afghanistan and Iraq, more than 52,000 US servicemembers have been wounded in action.1 Numerous reports describe the complexity of these wounds often resulting from high-energy, explosion mechanisms.2–4 More than 1650 servicemembers have sustained 1 or more traumatic limb amputations and numerous others with multiple extremity open fractures, extensive soft tissue loss, and frequently accompanied physical, cognitive, and mood disorders.5,6 These complex injury patterns have typified the challenges facing military orthopaedic surgeons and rehabilitation professionals in support of Operations Iraqi and Enduring Freedom.

Severe extremity injury results in a heavy burden of musculoskeletal-related disability and a detriment to remaining in active duty service.7–11 As such, one cannot overlook the impact that rehabilitation services have on restoring functional independence, dignity, and quality of life. A combination of improved interdisciplinary care, coupled with advanced technology and improved access to holistic care services has greatly benefited individuals with limb loss and individuals undergoing limb reconstruction.12 The purpose of this article was to review how comprehensive extremity rehabilitation contributes to optimizing posttraumatic outcomes.

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The Department of Defense established mission- and vision-driven amputee patient care programs in strategic geographical sites within the United States: Walter Reed National Medical Center, San Antonio Military Medical Center, and Naval Medical Center in San Diego. These Centers share the mission of providing highest quality of care for wounded servicemembers and the vision of collaborative, interdisciplinary care including physical and occupational therapists, speech and language pathologists, prosthetists and orthotists, assistive technology specialists, vocational and driving rehabilitation professionals, physicians, nurses, psychologists, and social workers cumulatively skilled in addressing physical impairments, cognitive and communication deficits, complex pain syndromes, and secondary psychologic trauma.13 Contributing to the success of these Centers is also their ability to leverage advances in technology, family and peer support, and coordinated sports, creative arts, and recreational programs to inspire successful recovery and community reintegration.14

Effective rehabilitative care begins with early engagement of the rehabilitative team for input on optimal residual limb length, wound, and pain management, the prevention of secondary complications, and promotion of maximal independence with activities of daily living and mobility.15 Before socket fitting, work begins on proper residual limb care, prosthetic component selection, and preprosthetic training. The choice of prosthetic components has greatly expanded over the past decade to include microprocessor-controlled variable dampening knees, externally powered knees and ankles, and multiaxial and energy storing and energy releasing feet. Considerable debate remains as to which prosthetic components perform best considering the significant heterogeneity among patients' injuries and individual goals.16 When beginning prosthetic training, initial attention is focused on designing and fabricating a well-fitting socket and properly aligning the prosthetic components, followed by ambulation training. As the patient demonstrates appropriate balance, ability to recover from falls and improved gait, they are then advanced to stairs, ramps, obstacles, and eventually taught how to return to running or other higher level activities.14,16

Early rehabilitative intervention is also imperative for the care of individuals with upper limb loss. In addition to promoting residual limb wound care and maturation, special attention is focused on activities of daily living training and adapting to change in hand dominance, when needed.17 Evidence suggests that early prosthetic fitting and training may enhance the incorporation of prosthetic use to promote bimanual task and reduce prosthetic abandonment. Early myoelectric control training can begin before wound closure, as occupational therapists and prosthetists are able to identify sites of strong residual limb muscle contraction amenable to a surface electrode. Myoelectric control and reduction in neuroma pain may be enhanced by advanced surgical techniques, such as targeted muscle reinnervation.18,19

Numerous other supportive programs are incorporated into the comprehensive rehabilitation of injured servicemembers. Military-specific training, such as that afforded by simulating tactical environments using a Computer-Assisted Rehabilitation Environment or virtual reality simulated firearm training is valuable for integrating a familiar role into the holistic rehabilitation effort (Table 1).20–22 Acute and Chronic Pain specialists who practice multimodal pharmacological, nonpharmacological, and procedural approaches to pain management have been successful in caring for complex pain syndromes.23 Adaptive Sports and Recreational Programs, established through partnerships with many federal and non-for-profit organizations have demonstrated their positive effect on outcomes.24 Peer support counseling and family participation in the rehabilitation team is a significant promotor of recovery.14 Driving and vocational rehabilitation are important programs to encourage independence and successful community reintegration, especially for those with comorbid Traumatic Brain Injury and Psychological Health Disorders.25–27 Sexual and reproductive health services are also available to servicemembers with genitourinary trauma often associated with dismounted explosions and high lower-extremity amputations.28



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Synonymous to the high-intensity rehabilitation following prosthetic fitting, the Return to Run (RTR) clinical pathway and Intrepid Dynamic Exoskeletal Orthosis (IDEO), a carbon fiber, energy storing orthosis, was introduced in 2009 to treat patients with severe limb injury reconstruction.29,30 In a prospective, observational cohort of RTR participants, 8 weeks of IDEO-specific rehabilitation resulted in improvements in physical performance measurements, pain, and self-reported outcomes.29 Approximately 82% of participants who desired a late amputation before the RTR clinical pathway due to pain and/or function limitations favored limb retention after the rehabilitation pathway. The RTR clinical pathway has also helped participants with running and others, a return to desired recreational activities.31

The success of the RTR clinical pathway hinges on rehabilitation. Return to duty rates have been found to be significantly lower for patients only fitted for the IDEO compared with patients who also participated in the RTR clinical pathway.32 Participants in the RTR have a 19.5% chance of redeployment following return to duty, frequency unmatched in the amputee population, and before the pathway's availability.33 The RTR clinical pathway has been reproduced at the other advanced rehabilitation centers, successfully resulting in improvements in functional outcomes for participating patients.34

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Comprehensive rehabilitation is costly and requires the expertise of many different disciplines. This can be difficult to accomplish in some health care settings. However, these comprehensive models can still inform practice where focused centers, such as those in the Department of Defense, are not available in that regardless of what resources are available the whole person must be acknowledged and considered throughout the entirety of care. One-third of trauma patients report an unmet psychosocial or vocational need after trauma.35 Low-self efficacy is a known patient characteristic that hinders optimal outcomes.36 One's perception of “wholeness” as a person following injury, especially limb loss, can affect reintegration.37 Although many factors influencing outcomes cannot be controlled for by treating providers, providers should engage patients openly about possible barriers to function and strive to provide as many services as possible to fill holistic needs.

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combat injury; trauma rehabilitation; comprehensive rehabilitation; multidisciplinary; functional outcomes

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