Friday, Nov. 11, 2011

Rehabilitating Wounded Warriors

Sergeant Sebastian Gallegos is standing in the middle of the kitchen, staring at a carton of eggs on the counter. "You can do this," his occupational therapist, Lisa Smurr, tells him. "It's too easy." He exhales and reaches toward the carton with his robotic right arm, which beeps three times before the pincer at the end of it closes around an egg. As he carries the egg toward a mixing bowl, the pincer tightens, cracking the shell. Gallegos's sense of humor, however, is still intact. "At least I didn't get my hands dirty," he says.

On the second try, the broad-shouldered Marine picks up an egg with his prosthetic and breaks it cleanly into the bowl. After whisking it, he slowly, but flawlessly, cooks it in a pan. The exercise is part confidence builder, part rehabilitation, as Gallegos learns to use the complicated prosthetic he received only two weeks before.

The kitchen sits on the top floor of the Center for the Intrepid, a state-of-the-art, $50 million rehabilitation facility for amputees and patients with salvaged limbs, at Brooke Army Medical Center (BAMC) outside San Antonio. For wounded soldiers like Gallegos, who had his arm blown off by a roadside bomb in Sanguin, Afghanistan, making eggs counts as one of the many small victories being won as they return to America and fight a third war, which is likely to last longer and cost as much as the conflicts in Iraq and Afghanistan. Treating the troops who were injured there is expected to cost as much as $867 billion in the coming decades as the focus shifts from critical injuries to long-term treatment for traumatic brain injury and post traumatic stress disorder. Seriously injured troops, including those with severe burns and mangled limbs, are coming to bases like this one where teams of doctors, physical therapists and prosthetic engineers push the warriors, as they call them, to be as active as they were before their injuries. Many of the patients with missing limbs are training for triathlons; others work out on climbing walls and in an indoor surfing tank. They spur each other on during training sessions and engage in a makeshift form of group therapy as they go about putting their lives back together.

Behind the security walls separating the post from San Antonio, BAMC (pronounced bam-see) looks like a college campus. Palm trees line walkways through the green spaces, and the barracks even look a bit like freshman dorms. But stand in one place and you'll see young men — there are very few female patients here — walk or jog by with metal devices where one or both legs should be. Some push themselves in wheel chairs; others have braces on their lower legs. At any given time, there are about 600 wounded warriors at various levels of treatment, and many of them are headed to the Center for the Intrepid for an appointment or a grueling therapy session.

The center, which opened in 2007, is a one-stop shop for amputees, who start rebuilding their strength before their surgical incisions have fully healed. A team of on-site prosthetists makes everything from simple carbon fiber arms and legs to complex robotic devices like the one Gallegos is trying to master. Physical therapists use infrared sensors to evaluate how patients are walking on their new legs, then adjust the prosthetics accordingly. Amputees also get on boogie boards in the Flow Rider, an indoor surfing tank like the kind found on cruise ships, to help learn to balance and work on core strength.

The fourth-floor therapy apartment where Gallegos is scrambling eggs looks like a page from an Ikea catalogue. There's a bedroom, living room, kitchen and washer and dryer, and occupational therapists use everyday chores — like cooking or making a bed — to teach wounded troops to use their prosthetic limbs. For Gallegos, learning to make a simple meal has a special significance. "My wife does a lot for me, so I tried to make eggs for her," he says of a breakfast he attempted before he got his fancy new prosthetic. "I tried to scramble them in the pan and I couldn't hold it, so I got eggs all over the kitchen. I got shells in the eggs and I was trying to pick them out, but they were already cooking." After being fitted with the robotic arm, he decided to try again.

Gallegos' prosthetic is controlled by sensors on what's left of the bicep and triceps on his right arm. These muscles essentially act as a gearshift; flexing them in different sequences switches the prosthetic's mode from elbow to wrist to pincer. "He has to do mental gymnastics to move," Smurr explains. "It's frustrating because it's easier just to use your left hand. But you can overuse your other hand and get other injuries. The more we can teach someone to try and integrate and use two hands to do a task, the better off they are in the long run."

As impressive as BAMC's work is with amputees, the base may become more widely known for its innovation with limb-salvage patients. For every amputee in the Iraq and Afghanistan Wars, there are an estimated five or six patients with severely damaged limbs that doctors were able to save. Like amputees, these patients require extensive rehabilitation to learn to walk or use their arms again. And the pain and loss of function led dozens of limb-salvage patients at BAMC to request what's called a "late amputation," i.e., having a limb cut off months or even years after an injury. It was a startling trend with an equally surprising solution. "The reason why we had all these guys who wanted their legs cut off was that they wanted to run," explains Johnny Owens, a physical therapist and director of limb-salvage rehabilitation at BAMC. For high performing troops, running separates those who can do their jobs from those who can't. And amputation was sometimes requested by troops who wanted to get a prosthetic nicknamed a "cheetah leg," a curved, carbon fiber blade used by runners like South Africa's Oscar Pistorius, a double amputee who may be fast enough to compete in next year's Olympics.

Owens and his colleagues at BAMC noticed that the limb-salvage patients requesting amputations had fused ankles, severe nerve and muscle damage and could not generate enough power from their legs to jog, let alone run. So Ryan Blanck, a prosthetist at the Center for the Intrepid, designed a device called the IDEO, short for Intrepid Dynamic Exoskeletal Orthosis, that fits into the patient's shoe and runs two carbon fiber struts up the back of the calf to a cuff that attaches just below the knee. With the orthotic in place, Owens put the warriors through intense physical rehab based on sports medicine and taught them to run by landing midfoot instead of on their heels. The result: patients who could barely walk ten feet because they were in such pain were, within a week of special training, running, sprinting and jumping. The BAMC team developed a program called the Return to Run Clinical Pathway. More than 160 troops have gone through it since 2009; of those, more than 50 — including Navy SEALs, Rangers and Special Forces troops — have returned to active duty where they are jumping out of airplanes and fast-roping out of helicopters.

"It's not all about getting back to the military," Blanck says. "It's about getting back to life. Playing softball. Just being a coach for their kid's soccer or t-ball team. It's amazing how demoralizing that can be if you can't do that."

Blanck's team, which has published papers on the orthotic and has applied for grants to fund larger studies, wants to replicate the training program at other military bases and eventually create a version that can be used in the civilian world to help, say, a car crash victim walk again or get an injured construction worker back on the job. "This is a major game-changer for the military," Owens says. "Every conflict, something comes out of it — the M*A*S*H units in Korea, the nurses of the Crimean War. This could be the significant advancement to come out of this decade-long conflict."

But as cool as the physical rehabilitation is at BAMC, much of the emphasis here is on healing warriors' minds. This takes place in formal group therapy sessions, but also in informal ones that happen while watching football or playing video games. "This is an Army facility, but it's a gathering place," says Judith Markelz, who runs BAMC's Warrior and Family Support Center, a one-story building that looks like a giant version of a suburban home. Over meals, the troops and their families talk about how to deal with a new reality they never bargained for. "Plan A was to get married, have kids and see the world," Markelz says of many young military families she's been helping at BAMC. "We're on plan B."