The Wounded Soldier: Rehabilitation and Recovery

Jackie S. Hebert, M.D., FRCPC
Clinical Director, Adult Amputee Program, Glenrose Rehabilitation Hospital
Associate Professor, Division of Physical Medicine and Rehabilitation, University of Alberta
Edmonton, AB 

Military patients are unique in the rehabilitation setting. Canadians have been fortunate to have relatively few seriously wounded soldiers as a result of the current conflicts compared to the vast numbers of war wounded in the United States1. However, the soldiers that do return to Canadian soil with severe life-altering impairments such as major limb amputation require a comprehensive integrated approach to their care.

 

An interdisciplinary rehabilitation team focuses on patient-centered care and goals that improve an individual's function, participation, and quality of life. The military patient adds an extra layer of complexity to the already integrated team approach. The injuries sustained are usually multiple, with severe tissue trauma, and have occurred in an "unfavorable" environment. Infections typically require isolation which complicates rehabilitation treatment. The rehabilitation diagnoses are multiple and complex.

There is a higher incidence of pre-existing mental health issues in soldiers; greater in those returning from combat zones2. The rate of traumatic brain injury (TBI) accompanying all injuries is about eight times the rate of amputation, with mild TBI the most predominant1, strongly associated with Post Traumatic Stress Disorder (PTSD) and physical health problems after soldiers return home3. At the time of injury, the seriously wounded soldier is immediately extracted from a war zone, separated from their unit with no decompression and placed under medical and surgical care. The occurrence of stress disorders and other psychological trauma is expected. For this reason, psychology and mental health support needs to be instituted immediately for the wounded soldier; not for diagnosis of PTSD (at this early stage), but for medical management of acute decompression stress and to begin a relationship with a mental health professional who will follow them throughout their recovery and watch for warning signs of mental health deterioration.

The surgical team treating the wounded soldier must understand that precise surgical technique affects outcome. The soldier will push the limits of what is possible throughout their recovery. Less than a perfect adductor and hamstring myodesis in a transfemoral amputee will result in an uncorrectable truncal lurch when walking that is unacceptable to the wounded soldier. They expect not just to regain perfect gait but also to run. Therefore approaching amputation as true "functional reconstruction" with careful balancing of muscle tension and skin closure is essential, and will greatly impact their physical outcome.

Surgical and rehabilitation decisions must involve the wounded soldier. Although soldiers are used to authoritative decisions, they need to be fully informed regarding potential consequences of treatment decisions such as limb reconstruction versus amputation. For example, a major latissimus dorsi flap may be a good choice to preserve femoral length in a unilateral transfemoral amputee, but in a bilateral transfemoral amputee that is expected to use a wheelchair and their upper extremities for transfers and daily mobility, it could be a disaster to lose functional latissimus strength. Individual tolerance to a year of multiple procedures for reconstruction versus immediate amputation and moving on to the recovery phase is highly variable. These are very individual decisions that cannot be made without involving the patient, and ideally a rehabilitation practitioner.

Rehabilitation must be instituted early in acute care. Between surgical procedures, the patient should be started on physical strengthening exercises. Core strengthening, isometrics, and range of motion can prevent complications and prepare the soldier for the hard rehabilitation work ahead. Giving clear guidelines on restrictions and allowed exercise gives the therapists in acute care the permission to start the rehabilitation process, and the soldier the power to start taking control of their recovery. Phases of recovery must be outlined and understood by all military and civilian personnel treating the wounded soldier. (Table 1)

Table 1: Phases of Amputation Rehabilitation for the Wounded Soldier

Phase of Rehabilitation

Essential Tasks

I. Post Surgical

(Pre-prosthetic)

  • Physiotherapy and mobilization, core strengthening
  • Provide guidelines on restrictions and safe exercise
  • Psychological and peer support

II. Prosthetic Training

  • 4 - 6 weeks for initial phase of prosthetic training
  • Advanced skills such as running, high impact activities and full functional prosthetic use take an additional 4 - 6 months and up to a year to reach full potential
  • Sporting events and peer support from more active amputees
  • No back to work while in active rehabilitation

III. Reintegration to normal activities

  • Return to responsibilities of home, family, and community
  • Close monitoring of mental health essential as the soldier is disengaged from the sheltered rehabilitation environment and returns to their life as a changed individual (highest risk time for mental health deterioration)
  • Transitional support needed to prevent feelings of abandonment and isolation
  • Informal interaction with a supportive work environment

IV. Return to productive activities and roles

  • Must find a meaningful purpose in life; vocational or otherwise
  • Address concerns over "not deployable - not employable" standards (acceptance back into the military family through re-employment or assistance with retraining)
  • Community, family and social roles take on increasing importance

In Canada, seriously wounded soldiers are integrated into treatment programs that serve Canadian civilians. In this way, the military patients are fortunate to have the experience of a rehabilitation team that sees a concentrated number of patients with a similar diagnosis. A rehabilitation team encourages a person to set individual and life goals, reassess their priorities, and consider how to get maximal fulfillment from their life. Although this approach can give hope, show options, and help a wounded soldier achieve their potential, it can also make it difficult for a soldier to fit back in to the military structure, where rank plays a major role in a soldier's influence on their organization. There is also often encountered a sense of entitlement, not only from the soldier but also from public expectation stemming from our gratitude for their sacrifice, and eventually a sense of betrayal if those expectations are not met. Prosthetic and rehabilitation technology advancements as a direct result of the current conflicts have made lives for persons with multiple impairments dramatically better, but come with a price tag in some cases too high for government budgets. However, both Canadian soldiers and civilians benefit from the massive amounts of funding being invested into research by the US military. It pushes us to provide higher and better levels of care to our patients as we become aware that better technology is available, and we see the improved results of intensive, prolonged rehabilitation treatment.

Maximizing outcome for a wounded soldier involves a coordinated team approach, setting realistic and appropriate goals, instituting early rehabilitation strategies, and continuing therapy until full functional recovery is attained. The approach must be comprehensive, addressing patient and family psychosocial issues, and coordinated with the military. Physically and functionally, most patients reach their maximum potential at the end of their formal rehabilitation. But recovery is lifelong, with the primary determinant of long-term outcome likely being an individual's mental health and support system. Adjusting to a permanent impairment means finding a meaningful purpose in life and a meaning for their loss, and this is true more so for the wounded soldier than the average civilian.
 

References 

  1. CRS Report for Congress; Order Code RS22452, United States Military Casualty Statistics: Operation Iraqi Freedom and Operation Enduring Freedom. Fischer, Hannah. Updated September 9, 2008
  2. Hoge C.W. et al. Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. NEJM 2004;351:13-22.
  3. Hoge C.W., McGurk D., Thomas J.L., Cox A.L., Engle C.C., Castro C.A. Mild traumatic brain injury in U.S. soldiers returning from Iraq. N Engl J Med 2008;358:453-63.

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