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Center for the Intrepid offers state-of-the-art healing

By Carolyn Rogers

Rehabilitation center rebuilds wounded warriors

Since 2001, nearly 28,500 U.S. troops have been wounded in combat in Afghanistan and Iraq. Of those, more than 24,600 have survived their injuries (86.3 percent)—the highest survival rate of any war in U.S. history.

Advances in body armor, battlefield medicine, and aeromedical evacuation have all contributed to the decline in the mortality rate, but the downside is that a greater percentage of troops are returning home with grievous injuries such as burns, traumatic brain injuries, blindness, spinal cord injuries, and multiple amputations. Since 2001, nearly 700 U.S. service members have lost at least one limb.

To meet the growing and urgent need for rehabilitation services, in 2005 a group of philanthropists, physicians, and researchers resolved to create the world’s most technologically advanced physical rehabilitation and research facility to care for wounded military personnel.

The symbol of a broken ring, cracked but still intact, marks the entrance to the Center for the Intrepid, a 65,000 square-foot rehabilitation center next to Brooke Army Medical Center in San Antonio, Texas.

Cutting-edge facility built from private funds
The $50 million “Center for the Intrepid” (CFI)—located next to Brooke Army Medical Center (BAMC) at Fort Sam Houston in San Antonio, Texas—opened its doors to patients in February 2007.

The sleek 65,000 square-foot facility was built entirely from private funds donated by more than 600,000 Americans. The Intrepid Fallen Heroes Fund—which provides assistance to the nation’s wounded soldiers and their families—spearheaded the 16-month fundraising effort.

Designed to help wounded service members with severe extremity injuries, burns, and amputations maximize their ability to live and work productively, the new center is “a dream come true,” says Col. Mark Bagg, MD, director of CFI and chief of orthopaedics and rehabilitation at BAMC.

Already a world-renowned burn-treatment center, BAMC became the second military hospital to offer specialized amputee care in January 2005. Walter Reed Army Medical Center in Washington, D.C., established the first military amputee care center in 2004, and San Diego Navy Medical Center opened its center in 2006.

More than 400 troops are expected to undergo a demanding rehabilitation process at the Center for the Intrepid each year. While carrying out this patient-care mission, CFI’s 100-member staff also conducts leading-edge research in the fields of orthopaedics, prosthetics, and physical/occupational rehabilitation.

Technology “without parallel”
“The equipment and technology in this facility are without parallel anywhere in the world,” says Dr. Bagg.

CFI is equipped with an indoor running track, a firing range, a natatorium, a two-story climbing wall, a prosthetic fabrication lab, and a military performance lab.

Outpatient services include behavioral medicine, individual case management, occupational and physical therapy, physical medicine and orthopaedics, prosthetics, and community reintegration programming.

The goal of the center’s military performance lab is to analyze human motion, with particular emphasis on amputee gait. Information collected in the lab is ultimately used to help physicians, physical therapists, and prosthetists adjust treatment plans and to help patients improve function. Capturing this data allows for more focused and faster rehabilitation for soldiers, Dr. Bagg says.

The military performance lab is comprised of two functional areas—the gait lab and the computer-assisted rehabilitation environment known as CAREN.

Meet CAREN
“CAREN is a 3-D rehabilitation simulator,” Dr. Bagg says. “It’s the first of its kind in the world.”

The simulator consists of a 21-foot dome with a 300-degree screen upon which a variety of “virtual realities” can be displayed. CAREN immerses patients in a fully reactive virtual and physical environment through the use of sensors placed on the body,

high-speed infrared cameras, a surround-sound system, and a movable platform with a treadmill and force plates that measure the pressure placed on the ground.

CAREN’s elevated platform rocks and sways as the computer-driven scenario changes. For example, the platform may sway like a speed boat on a choppy ocean or the incline might shift as a patient takes a simulated hike through the woods. City street simulations help patients transition to the hustle of everyday life.

“The capabilities of the CAREN will be central to the research mission of the center as investigators study vestibular disturbances, balance dysfunction, and responses to varying levels of stress in patients with post-traumatic stress disorder,” Dr. Bagg says.

High-tech gait lab
In the gait and motion analysis lab, physical therapists and biomedical engineers use 26 infrared cameras to analyze human motion. Force plates in the floor, parallel bars, and treadmills measure ground reaction forces in three directions to determine the torque produced by muscles or prosthetic components. Electromyography is used to assess electrical activity during muscular contraction, and can detect both the timing and intensity of muscle contractions.

“All of this information is used to assess patient progress,” Dr. Bagg says. “It also serves to validate new treatment protocols and prosthetic components.”

Regaining independence, confidence
CFI’s occupational therapy (OT) clinic focuses on restoring soldiers’ health and day-to-day function. Occupational therapists work with patients to regain range of motion, increase muscle strength, and decrease pain.

One way the OT staff encourages independence is through the use of its “activities of daily living” (ADL) apartment. The clinic houses a fully-functional ADL apartment designed to help patients relearn all aspects of independent living with their prosthetic devices. To better simulate most homes, the apartment is purposely not handicapped accessible.

Furnished with a computer workstation with state-of-the-art voice recognition technologies, a fully equipped kitchen, laundry, bath, and a comfortable living room, the apartment takes the patient completely out of the hospital environment.

Firearms training, driving simulators
In addition to the traditional OT modalities, two high-tech simulation systems are available to CFI patients.

The firearms training simulator helps patients with prosthetic devices attain basic marksmanship skills by simulating military and recreational target activities, such as skeet shooting. Patients learn to use a variety of Bluetooth-enabled weapons that are of a similar size, shape, weight and recoil as actual weapons. They can practice different firing techniques and experience everything from basic scenarios through very complex scenes requiring identification of friend or foe.

For service members who wish to remain on active duty, this realistic training allows them to re-qualify with the weapon systems common to all branches of the military.

A driving simulator is also on-site for patient use. This system gives patients the opportunity to train with adaptive devices and develop new driving skills in preparation for on-the-road training provided by the Veterans Administration (VA).

“Therapy disguised as fun”
For amputee and burn patients, the physical therapy (PT) team uses multiple interventions that focus on patients’ abilities and interests—not their disabilities. The PT staff makes extensive use of the center’s rehabilitation training and exercise center. This two-story, light-filled space, located at the heart of the complex, features a cantilevered running track, a treadwall, and a climbing tower with auto-belay to promote strengthening, agility, and aerobic capacity.

The center’s natatorium houses a six-lane pool and a FlowRider®—a unique indoor wave machine used to improve balance, coordination, strength, motivation, and confidence conditioning.

To accomplish “total rehabilitation,” the PT team coordinates an extensive adaptive sports program while also providing the full spectrum of PT modalities—including amputation awareness, residual limb care, wheelchair mobility, crutch training, and more.

Prosthetics: One-stop shopping
When it comes to fitting prosthetics, CFI has a “huge advantage,” Dr. Bagg says. On the facility’s third floor, patients are provided with prosthetic fitting, physical therapy, and a gym—all within the same area.

Prosthetists and technicians employ a team approach to provide state-of-the-art, on-site fabrication of artificial limbs. Computer-assisted technology is used to design, mill, produce, and fit prosthetic devices—including unique specialty limbs for sports and other activities. The proximity of the prosthetic fabrication factory enhances interaction between the lead prosthetist and technicians, and patients are able to be immediately fitted—and tested—in the devices.

Looking ahead
The Center for the Intrepid represents a tremendous advance in the quality of facilities available for military and VA patients and providers, Dr. Bagg says.

“Much of the cutting-edge technology available at CFI is integrated into the transitional military amputee training center recently opened at Walter Reed Army Medical Center,” he adds.

For now, CFI caters solely to amputees and burn patients injured in Iraq or Afghanistan. Eventually, its mission will expand to encompass retirees, family members, and veterans.

“If this war goes away, the plan is to involve the VA and provide the veterans with some of the services we’re currently offering,” Dr. Bagg says. “That’s the long-range vision.”

Carolyn Rogers is a staff writer for AAOS Now. She can be reached at rogers@aaos.org

Intrepid: The namesake
The U.S.S. Intrepid, the legendary aircraft carrier that sparked this country’s spirits following the devastation of the attacks on Pearl Harbor, is now the namesake of the world’s most technologically advanced rehabilitation center for amputees and burn victims.

During CFI’s emotional dedication ceremony on January 29, 2007, Sen. Hillary Clinton summed up the significance of the name “Intrepid,” how it resonates and applies to our wounded warriors of today, much as the U.S.S. Intrepid inspired and healed Americans more than 65 years ago.

“The keel of the Intrepid was laid one week after Pearl Harbor—an attack that devastated our Navy and shocked our country,” Sen. Clinton said. “The Intrepid was our first answer—to show the enemy that they have damaged our ships, but not our spirits. We are here today to celebrate that spirit once again.”

Can amputees return to active duty?
The primary focus of the Center for the Intrepid is the acute rehabilitation of the war-wounded, with the hope of bringing those patients to a physical level where they can return to active duty if they choose.

“Our feeling is that we’ve invested so much time in their training, if a soldier wants to stay on active duty, we should do what we can to give them that ability,” Dr. Bagg says.

Whether patients desire to return to active duty or not, staff at CFI staff work with them to help each reach his or her personal goals.

“Everyone stays until they’ve reached the maximum potential that we can achieve,” Dr. Bagg says. “They have to stay until they get their final prosthesis, and that usually takes several months. Some go earlier, some go later.”

Soldiers are fitted with three separate prostheses: a myoelectric device, a body-powered one, and one or more passive devices that can be sports-specific or cosmetic.

Returning to combat
Only 47 people—a small percentage of those who have lost a limb—have remained in active service, military officials report. Most are assigned to instructor or desk jobs away from combat.

Just a few—the Army doesn’t keep track of exactly how many—have returned to the war zone, and only at their own insistence. To do so, they just prove they can do the job without putting themselves or others at risk.

Army Maj. David Rozelle is one of those “insisters.” After losing his right foot in a June 2003 land mine explosion in Iraq, Maj. Rozelle underwent extensive rehabilitation stateside. In early 2005, he retuned to combat—making him the first amputee to return to the same battlefield on which he was injured since the Civil War.

When he returned to Iraq, Maj. Rozelle commanded a cavalry troop and conducted reconnaissance operations, just as he had before the blast. Other amputees who have returned to combat have reportedly conducted door-to-door searches, convoy operations and other missions in the field. Maj. Rozelle’s second tour lasted four months.

As fate would have it, later that year Maj. Rozelle returned to the very medical center that gave him back his Army career and, for the most part, his life as he enjoyed it before his injury.

Maj. Rozelle was handpicked to serve as deputy to the program manager for amputee care at Walter Reed Army Medical Center. In that role, Maj. Rozelle was put in charge of construction of its new amputee care center—the Military Advanced Training Center for Soldier Amputees. (See “Walter Reed keeps pace” sidebar.) His charge was to build the center, help develop the center’s policy and programs, and act as a mentor for injured soldiers.

December 2007 AAOS Now
http://www.aaos.org/news/bulletin/dec07/research4.asp