The Role of Physical Therapy for Military Amputees

Their stories – those of the more than 1,600 military veterans who have fought in the recent wars in Iraq and Afghanistan and lost one or more limbs as a result of injuries sustained on the battlefield – are as tragic as they are inspirational.Welcome_to_soldier_ride_Heath_Calhoun

Tragic in the sense that losing a limb is not something anyone plans for. It’s a life changer. A game changer. It’s painful, requires reshaping the way you think about life and working hard to continue living it the way you want to.

That’s where the inspiration comes in. Inspiration in the sense that thanks to a strong will, dedication and a team of medical professionals that won’t let them give up, they get back to living in ways that many of us can’t even imagine.

Here’s how.

“GAME OVER”

Meet Retired Army Staff Sgt. Brendan Ferreira. In 2010, while serving in Afghanistan, a suicide bomber ran up to Brendan and detonated a homemade explosive.

“That was game over for my left arm,” Brendan told a reporter during a fitness competition in 2014.

In fact, it was almost game over for Brendan, he said. Doctors told him that he would never be able to do what he once could. He believed them because, as he said, they are doctors.

Complications from the attack and his recovery nearly caused him to lose both of his legs. He started drinking. Abusing pain meds. Smoking. Eating terrible foods.

He, in his words, “blew up to 260 pounds” and nearly missed the first steps of his daughter because he was feeling sorry for himself and his new life.

At that time, people kept telling him what an inspiration he was. For a while he wanted nothing more than for them to stop saying that. He wasn’t, he said.

Then one day something clicked. Instead of shying away from his new life, he embraced it.

If people were going to call him an inspiration, he was going to earn it.

So despite a serious loss of vision, nearly deaf, one arm and legs still recovering from nearly needing to be amputated, Brendan started working out.

And in November 2014, he earned that inspiration at the Working Wounded Games near Washington DC – an annual fitness competition for adaptive athletes where he earned the top overall prize.

This wasn’t just any fitness competition. It was a sand bag throwing, rowing, deadlifting, weighted sled pulling kind of competition.

He overcame. He adapted. He became the inspiration. How did he do it? Here’s one of the pieces.

PHYSICAL THERAPY, MENTAL THERAPY

The steps to recovery—the hours of physical rehabilitation, the grueling sessions spent getting used to a prosthetic—are often looked over, although they are arguably the most important aspect of an amputee’s journey to finding normalcy once again in their new physical state.

According to the Amputee Coalition of America, “right after an amputation, most people aren’t dreaming about breaking world records or accomplishing great feats. They probably will, however, at some point, get tired of ‘being taken care of’ and want to reclaim their independence. This is where physical therapy and occupational therapy come in.”

The coalition tells veterans and amputees to remember first and foremost that every individual is different when it comes to rehabilitation and physical therapy after an amputation of a limb.

It depends on the severity of the injury, prior function level and how well the patient complies with the treatment program prescribed.

What is largely the same, the coalition says, is the four main phases amputees undergo when learning to live active lives again in their new bodies.

The ultimate goal of physical therapists working with amputees is to see them getting back to participating in their life, said Adele Levine – a physical therapist who spent nine years at Walter Reed’s amputee clinic — in an interview with Mimi Geerges.

“You have to do your homework, you have to do your physical therapy,” she said. “You want to walk well, you have to do the work, it’s not just going to happen.”

At the hospital’s Military Advanced Training Center, amputees work with physical therapists on strength, balance, stability and conditioning — much like athletes around the world who are getting stronger in college training rooms and world-class gyms.

LIGHT EXERCISE, BIG GOALS

In Phase 1, often immediately after surgery, physical therapists help educate patients on what to expect during their rehabilitation.

The patient and the physical therapist create a list of short-term goals — such as being able to move from the bed to the wheelchair or improving the range of motion in a limb – and long term goals, such as being able to move around obstacles such as stairs and curbs and completing daily functions solo.

Light exercise is often used to keep the rest of the body moving well and to help prevent tight joints from forming as the body heals.

In most patient cases, physical therapy and rehabilitation begins a few weeks after the surgery. The physical therapist will go over a strength and conditioning plan that is sustainable and doable, and then the hard work begins.

“Your physical therapist will instruct you in the correct way to move in bed and to transfer out of your bed using proper body mechanics while protecting the surgical site from injury,” the coalition writes on its web site.

GET MOVING

A patient’s early recovery plan usually includes deciding whether to use a prosthetic limb, an option generally available to most patients. With recent technological advancements, more patients recovering from amputation are candidates for prosthetic limbs than ever before.

And they typically don’t have to wait long to get one. Patients, who are eligible for a prosthetic limb, typically receive a “preparatory prosthesis” three to six weeks after surgery.

“As soon as the incision is healed, we put you in a prosthesis,” said John Robb, owner and president of Reach Orthotic & Prosthetic Services.

Patients continue rehabilitation with a preparatory device for anywhere from three to nine months, before receiving a “definitive” or long-term prosthetic. That’s because during recovery, a patient’s residual limb will change as it heals. And what a patient needs from a device may change as he or she gets stronger.

During that time, communication between a prosthetist orthotist and physical therapist is critical to ensuring a patient’s recovery progresses smoothly. The physical therapist plays an important role in teaching the patient how to put the leg on and take it off correctly, managing the fit of the device and transitioning a patient from walking on parallel bars to a can to walking with no assistance.

“That is a significant time of change for the patients, and we have to adjust the prosthesis so it can adjust to those changes appropriately,” said Robb, who is a certified prosthetist orthotist. “I always preach we all need to be talking the same language.”

STRENGTH AND ENDURANCE

Throughout the second phase of rehab, physical therapists continue a patient’s rehabilitation through targeted exercises and therapy programs designed to build strength and endurance in ways that are completely new for the patient’s body.

Therapists will also work to help control swelling and the possible development of lymphedema during this time. For patients who have lost a lower extremity, gait training may start at this point.

But it’s in phase three that the coalition tells patients to expect to learn more about how to live with a prosthetic device. Strength training and gait training become more intense and balance and fall prevention techniques are refined.

“It is tremendously important in this phase that you listen to your therapist and do not try to progress too quickly,” the coalition writes. “Doing too much too soon may lead to… the development of abnormal gait patterns. This can be frustrating at first, but your therapist will push you as hard as you can safely tolerate.”

From there, the improvements continue bit by bit. The plan is to empower a patient to get back to living their life.

“They’re generally going to be very, very active on their prosthetic device,” Robb said.

BACK TO LIFE

At the Walter Reed National Military Center in Washington DC, Levine said the service members typically stay between six months and four years, working on strength and rehabilitation.

Once an amputee learns to walk with a prosthetic, they can learn to run. Once a patient can learn to lift increasingly heavier objects with a prosthetic arm, they can start to see how they can do most things in life they enjoyed pre-injury.

Occupational therapy is often also used during the rehabilitation period as the main goal of any kind of therapy is to help patients get and remain as independent and active in life as possible.

“Never let anyone tell you, ‘It can not be done,’” the coalition advises. “It may not be easy, but you’ve made it this far, and the only thing that can stop you is your imagination.”

And that’s key, according to Robb. Progress doesn’t stop once a patient gets back on their feet. They may return to physical therapy a year or two later to refine their use of a prosthetic or to learn how to use a new one. Or they may decide to they want to do more and tackle a new activity.

“Our goal is to get them back to being as normal as possible – to participating in an as many activities as they used to participate in or that they want to participate in, whether it’s getting back to riding a bicycle, aquatic sports, running or taking care of their families,” Robb said.