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Fig. 1 The customized IDEO orthosis stores energy and provides power during push-off.
Courtesy of MAJ Daniel J. Stinner, MD

AAOS Now

Published 11/1/2015
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Andrew J. Sheean, MD

Making an Intrepid Move

Rehabilitation center expands focus to meet changing needs

"Wounded warriors" is a phrase often applied to service members who return to the United States after serving in battle zones such as Iraq and Afghanistan. Many come home with devastating injuries, including major extremity trauma and amputated limbs. To meet their needs for rehabilitative services, the Center for the Intrepid (CFI) opened its doors in 2007. (See "Center for the Intrepid Offers State-of-the-Art Healing," AAOS Now, December 2007.)

But as combat operations scaled down, the mission of the CFI evolved. Today, it remains a leader in the fields of orthotics and prosthetics, rehabilitation, and human performance-related research. The CFI, however, has become increasingly focused on serving those recovering from non–combat-related conditions.

"Amputee and limb-salvage care will always remain priorities at the CFI, even though the numbers of patients requiring acute rehabilitation has decreased in recent years. To ensure that our staff remains at the tip of the spear and is always well prepared for the next amputee or limb-salvage patient, we have to be creative with our patient population," said MAJ Daniel J. Stinner, MD, recently named CFI Medical Director.

A look inside the CFI
As part of the Department of Orthopaedics & Rehabilitation at the San Antonio Military Medical Center (SAMMC), the CFI is a 65,000 sq. ft. Advanced Rehabilitation Center. It is located with the United States Army Institute of Surgical Research on Joint Base San Antonio–Ft. Sam Houston and houses an impressive array of technologies.

An indoor running track, fire arms training simulator, indoor pool, two-story climbing wall, and fully equipped prosthetics labs are just part of the story. The CFI is also a fertile ground for cutting-edge, patient-centered, multidisciplinary collaborations, such as the Return-to-Run (RTR) clinical pathway. This interdisciplinary rehabilitation initiative combines sports medicine principles and physical therapy techniques with specialized orthoses. Several clinical investigations have demonstrated promising short-term results of the RTR clinical pathway, and it has played a pivotal role in returning a cohort of service members to their pre-injury functional levels.

The physical therapy component involves intensive, sports-specific physical therapy that focuses on strength training, agility drills, and conditioning necessary to foster each patient's ability to run—and ultimately to return to duty. A key component of the RTR pathway is the Intrepid Dynamic Exoskeletal Orthosis (IDEO).

The IDEO is a customized orthosis that stores energy within the brace as the leg moves forward and the ankle dorsiflexes during the mid- and terminal stance phases (Fig. 1). As the limb is subsequently unloaded, the brace returns the stored energy to the patient, providing ankle push-off power.

Another key component is the Military Performance Lab (MPL), where both cutting-edge interventions and ongoing research contribute to improvements in rehabilitation. The MPL's Computerized Assisted Rehabilitation Environment (CAREN) (Motek Medical, Amsterdam, Netherlands) immerses patients in a variety of realistic virtual reality environments, projected onto a screen that is 21 feet in diameter and has a 300 degree arc that nearly surrounds the patient (Fig. 2). Its movable platform with embedded treadmill and force plates can simulate uneven and challenging terrains.

In this setting, patients are able to interact with environments ranging from quiet forested paths to busy U.S. city scenes or combat missions in the mountains of Afghanistan. The state-of-the-art gait-and-motion analysis lab within the MPL provides therapists and researchers with the opportunity to objectively assess patient progress, test commercial and prototype prosthetic and orthotic devices, and explore new means for understanding the biomechanical aspects of injury and recovery.

Fig. 1 The customized IDEO orthosis stores energy and provides power during push-off.
Courtesy of MAJ Daniel J. Stinner, MD
Fig. 2 A recovering soldier, wearing the IDEO orthosis, maneuvers through a virtual reality environment in the Military Performance Lab at the Center for the Intrepid. Department of Defense photo by Glenn Fawcett
The Center for the Intrepid, a part of the department of orthopaedics & rehabilitation at the San Antonio Military Medical Center on Joint Base San Antonio-Ft. Sam Houston.
Courtesy of MAJ Daniel J. Stinner, MD

These technologies are invaluable in the rehabilitation and reintegration of the service members recovering from combat-related trauma. But they also contribute to the body of literature on human performance optimization, gait analysis, and prosthetics design.

An expanding mission
In addition to providing amputee care, prosthetic fittings, and specialized rehabilitation services, the CFI is increasingly focusing on how to address the expected morbidity and deconditioning following planned surgical interventions to optimize performance and recovery.

The patient population has expanded to include military healthcare beneficiaries who require therapy and may benefit from an advanced rehabilitation program. One example is blood-flow restriction therapy after procedures such as anterior cruciate ligament reconstruction.

Select civilian patients may also be authorized to receive up to 6 months of physical and occupational therapy. These patients have traumatic injuries that require them to be treated at SAMMC, the Department of Defense's (DoD) only Level 1 trauma center. This authorization allows for better continuity of care for patients and enriches the training experience of DoD healthcare personnel, ensuring that they are well prepared to care for combat casualties.

Another example of the CFI's commitment to advanced rehabilitation through a novel, interdisciplinary approach is the Performance Optimization Warrior Enhanced Rehabilitation (POWER) program. The POWER program is focused around three tenets of sports medicine and performance optimization: physical activity, nutrition, and health psychology. The integration of well-established physical therapy services with dieticians and sports psychologists is geared to helping patients mitigate both the physical and the emotional consequences of injury. Each patient's program is individualized to address the specific deficits related to his or her injuries or condition.

According to LTC Kathleen E. Yancosek, PhD, director of the CFI, "The POWER program seeks to address the age-old question: 'Why is it that, regardless of similarity in injury and treatment, some patients just have better outcomes?' The implied answer seems to lie in behavioral issues such as resilience, learned optimism, stress and pain tolerance, goal setting/seeking, and self-efficacy.

"The POWER program is a direct, multimodal approach to influence behavioral components believed to affect patient outcomes," she continued. "POWER is a framework for all services at the CFI, and researchers are working with providers to systematically evaluate POWER."

Patients who have sustained multiple traumatic injuries spend 4 to 6 hours per day with physical and occupational therapists. Patients recovering from isolated orthopaedic conditions receive 60 to 90 minutes of focused therapy up to five times per week. As patients progress through the POWER program, validated outcome measures—such as the Short Form Musculoskeletal Function and Veterans Rand 12-Item Health Survey—are collected to assess the progress of individuals and to better characterize the overall impact of this program on functional outcomes.

Over the past 8 years, the CFI has provided a platform for specialists from a variety of disciplines to bring their collective expertise to bear in meeting the needs of a truly unique patient population.

"As we enter a period between active conflicts, the goal of military medicine is to retain the critical skills and lessons learned since 9/11. The CFI is well poised not only to meet this goal but also to apply these techniques for the benefit of current beneficiaries and to continue to refine them for the betterment of future wounded," said LTC Anthony E. Johnson, MD, chair of the department of orthopaedics and rehabilitation at SAMMC. Conceived from an intrepid spirit of innovation, the CFI will continue to provide indispensable resources to its patients.

Andrew J. Sheean, MD, is a member of the AAOS Now editorial board.