by Deborah Conn

From the end of World War I through today’s conflicts in Iraq and Afghanistan, orthotics and prosthetics have been crucial to treating—and healing—thousands of returning soldiers and veterans. Aiding these battlefield casualties has led to important advances in devices, technologies, and treatments that, in turn, find their way to the civilian O&P community. 

Whether to improve treatment for military personnel, research new technologies and components to speed recovery, or develop state-of-the-art rehabilitation facilities, government-funded progress in O&P is not only noteworthy, it also is prescient: What’s happening today in military research may well foretell some of what’s ahead for the O&P industry in the coming years. 

O&P’s Military Service 
The O&P industry and the military joined ranks after World War I when the Council of National Defense met with artificial limb and brace manufacturers to prepare for the expected demand for orthotic and prosthetic services for returning wounded soldiers. AOPA’s forerunner, the Artificial Limb Manufacturers and Brace Association (ALMBA), was formed as a result. 

After World War II, the National Academy of Sciences created the Committee on Prosthetic Research and Development (CPRD), which coordinated federal efforts and developed research programs at universities and industrial laboratories to create improved upper- and lower-extremity prostheses. Resulting developments included the Bowden Cable System, still used today for upper-extremity prostheses, and the PTB, the patella tendon-bearing below-knee prosthesis, which continues to serve as the basis for all below-knee prostheses today. 

Today’s conflicts, Operation Enduring Freedom in Afghanistan and Operation Iraqi Freedom, have brought about even greater advances in O&P technology and quality of care. Unfortunately, troop injury statistics also are more dramatic: The global war on terrorism has resulted in the highest percentage of major amputations per battle injuries than for any of America’s previous wars, except the Civil War and Vietnam. As of August 2008, 841 soldiers have experienced major limb amputations, 192 of them involving multiple limbs. 

Ironically, improved safety precautions and on-site battlefield care, which increase combatants’ chances of survival, are the reason for the higher incidence of amputations. “All personnel are required to wear body armor, which helps protect vital internal organs from blast injuries,” explains Joseph Miller, CPO, chief, Orthotics and Prosthetics Service for the integrated Department of Orthopedics and Rehabilitation at Walter Reed Army Medical Center and National Naval Medical Center in Bethesda, Maryland. He also reports that basic combat medics are better qualified, and all soldiers are trained and equipped to be combat lifesavers. Moreover, the military can transport severely injured patients to treatment facilities in the United States in a few days, a significant improvement over past conflicts. 

Technology Mimics Biology 
When soldiers return to the United States, their treatment options continue to improve as the result of the military’s pioneering efforts. According to Miller, the focus of military-funded research runs the gamut from far-forward surgical procedures to new rehabilitation techniques, prosthetic and orthotic components, and psycho-social studies. 

The Defense Advanced Research Projects Agency (DARPA), responsible for the development of new technology for the military, launched the Revolutionizing Prosthetics Initiative in 2005 (O&P Almanac, December 2007). The goal is to produce within four years a prosthetic arm that will mimic the properties and sensory perception of a biological arm. 

The second phase of the initiative began in March 2008 and runs through March 2010, when the research team expects to deliver the final limb system. “We are presently in the preliminary design stage for the mechanical hardware and the control interface,” says Dr. Richard Weir, director of the Biomechatronics Development Laboratory at the Rehabilitation Institute of Chicago. “We expect to have initial prototypes of the final limb system by the end of the first quarter of 2009.” 

Another agency involved in O&P research is the Telemedicine and Advanced Technology Research Center (TATRC), located at Fort Detrick in Frederick, Maryland. TATRC is the U.S. Army Medical Research and Materiel Command’s central laboratory for advanced technology research. It collaborates with government, academia, and industry in seven major areas, including advanced prosthetics and human performance. 

TATRC’s projects include powered and regenerative kinetics prostheses, advanced socket design, a comfortable and dynamic sensing socket, osseointegration infection prevention, an over-ground body-weight support gait-training system, limb trauma outcomes, quality-of-life surveys, and orthotic and prosthetic education. 

Improved Amputee Treatment 
Along with the military’s focus on technology is a strong commitment to amputee care. Military health care is funded by two federal entities, the Department of Defense (DOD) for active duty soldiers, and the Department of Veterans Affairs (VA), which funds treatment for retired personnel and their families, and provides care for them and for active duty military personnel. 

“The mantra for DOD is ‘return to active duty,’” says Dennis Clark, CPO, president of Clark & Associates Prosthetics and Orthotics, based in Waterloo, Iowa. Clark and his colleagues helped manage prosthetic care at Walter Reed from 2003 to 2005, flying back and forth from Iowa on a weekly basis. 

“A significant percentage of wounded soldiers are staying in the military, and the DOD has a whole new mindset that focuses on the rapid fitting of prostheses and physical therapy. These folks are receiving world-class care, and they’re moving back to maximum function at an extraordinary rate,” he says. 

State-of-the-art rehabilitation centers are the centerpiece of the military’s treatment of amputees. The Center for the Intrepid, located next to the Brooke Army Medical Center at Fort Sam Houston in San Antonio, Texas, opened its doors in January 2007. More than 600,000 Americans donated $50 million to build the 65,000-square-foot facility, which focuses on treating amputees and burn victims from the wars in Afghanistan and Iraq. 

The Military Advanced Training Center (MATC) at Walter Reed opened in September 2007. Both MATC and the Center for the Intrepid use highly advanced technology, including the Computer Assisted Rehab Environment, which allows for a total body movement analysis in a virtual environment. 

The Comprehensive Combat and Casualty Care Complex at the Naval Medical Center San Diego underwent a recent renovation to provide an advanced setting for prosthetic and rehabilitation services, with an outside multi-terrain obstacle course, gait lab, and an apartment for daily-life training.

Nearly all amputees have been fit with at least one prosthesis, according to Walter Reed’s Joseph Miller. In some cases, other injuries, such as head trauma, postpone or preclude the use of a prosthesis. 

Miller says the general military policy for lower extremity amputees is to provide a conventional prosthetic system, a sport-use device, and a running prosthesis. Upper-extremity patients are fit with externally powered systems, such as a myoelectric limb, in addition to conventional and cosmetic limbs. 

In addition, the VA has 23 polytrauma facilities across the country that treat both veterans and returning service members who have injuries to more than one physical region or organ system. Polytrauma can include traumatic brain injury, hearing loss, amputations, fractures, burns, and visual impairment. 

“The VA is the largest health-care provider in the world,” says Clark, adding that it includes a “tremendous amount of O&P care. Much of the care is provided by VA prosthetists and orthotists, but the VA also has more than 600 individual contracts with qualified providers across the United States.” 

Hometown Care 
After returning service members are treated at a military hospital or rehab center, they normally return to a military base or to their hometown, where they receive follow-up care from local prosthetists. 

Many prosthetists who work with veterans bid on contracts with VA facilities. Gerald Deason, CPO, of Birmingham Limb and Brace in Birmingham, Alabama, successfully bid on a contract that allows him to attend twice-monthly clinics at the VA hospital in Birmingham. 

“At each clinic, patients choose from a list of five different providers,” he explains. “After that, they come to our office and we work with them. When we’ve completed services, they have a follow-up at the VA.” 

Roger Howard, CPO, has a practice in Watertown, New York, located near Fort Drum, home of the Army’s 10th Mountain Division. “The army will fly active duty soldiers back to Walter Reed for care,” he says, “but folks in my area have opted to come to my office, 20 minutes down the street, to get cutting-edge, personalized service with a focus on patient results.” 

Howard says military insurance offers more leeway than most other carriers regarding the components he can use. In fact, “a lot of new products are coming into the mainstream because the government has recognized them as viable options,” he says. “When the government starts to recognize technologically advanced components, other insurance companies generally follow suit, so it’s a win-win situation for everybody involved.” 

According to Howard, active duty service members are ideal patients for most practitioners. “They are young, often healthy, and extremely motivated,” he says. “They have can-do attitudes, as opposed to ‘why did this happen to me?’” 

This attitude also impresses Jason McNaughton, CPO, of Total Rehab Orthotics and Prosthetics in Fayetteville, North Carolina. His patients include paratroopers with the 82nd Airborne Division and the Golden Knights, members of the U.S. Army Parachute Team, which performs throughout the country at air shows and recruitment events. 

Such active patients provide valuable feedback to manufacturers seeking to make their products more durable. McNaughton also welcomes the responses he receives from military amputees. “Before they were injured, they were so fit, so they are able to get the full benefit of the product,” he says. “They can give me so much feedback, it helps hone my skills as a prosthetist.”

Deborah Conn is a contributing writer for O&P Almanac. Reach her at debconn@cox.net.