Rebuilding body and spirit: Center for the Intrepid puts nation's wounded military on the mend

Private donations built a high-tech rehabilitation center in San Antonio for the most severely injured soldiers. The outcomes are better than anyone expected.

By Victoria Stagg Elliott — Posted Aug. 18, 2008

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Army Staff Sgt. Chad Jukes, a 23-year-old from Logan, Utah, talks about his prosthetic legs the way some men talk about the cars they drive or dream of owning.

He has one model for walking. It features a foot very similar to the one he lost as a soldier in Iraq. Another, designed for hiking, has a flexible black rubber disc on the end. A third ends in a foot that looks like it should belong to a small child. That variation gives him the rigidity he needs for rock-climbing.

"The most basic feet are specialized for walking," he said. "Anything else I do can be done better with something designed for that sport. I no longer have the ability to curl my toes or adjust the angle of my foot, so I need feet that will compensate for that."

He is at the Center for the Intrepid in San Antonio to talk with experts about how the socket of his artificial leg can better fit what is left of his limb. Elsewhere on the third floor of this four-story, 65,000-square-foot building dedicated to the rehabilitation of the most injured soldiers, a patient who also lost a leg zips up and down a corridor testing a running prosthetic. During this exercise, he passes another patient, a double amputee. Sweat is beading on this young man's forehead as he struggles to stay atop a pair of stubbies -- the nickname for short prosthetics made without knees and with feet positioned backward. These are used almost like training wheels by patients who are relearning to walk with their altered limbs.

Learning to run is what most patients here expect at the end of months or years of rehab. Learning to move with prosthetics is the beginning.

From the moment one enters the Center for the Intrepid, it's clear that this is not a typical rehabilitation facility. The building was constructed by the Intrepid Fallen Heroes Fund, which raised $40 million from private donors. The group handed the facility over to the Dept. of Defense, which funds it as an outpatient clinic of the Brooke Army Medical Center. It opened Jan. 29, 2007, and serves an average of 145 injured soldiers a week.

Stars and stripes along with red, white and blue hues are subtly integrated in the décor, and the patients are decades younger than the average amputee. Elsewhere, 65 is the mean age of those who receive a lower-extremity amputation, and diabetes is the most common cause, according to the Agency for Healthcare Research and Quality.

At the center, some patients are missing as many as three limbs and are barely old enough to drink alcohol legally. They also have far greater ambitions. These patients expect to run and to resume other activities they did before being injured.

"Running is never considered a goal for outpatient rehab, but it is a goal for our patients," said Col. Jennifer Menetrez, MD, the center's director. "I don't know how we can deny them that opportunity and that training."

Advances in technology and battlefield medicine are part of what is driving the work of the center. Many of these injured soldiers have survived wounds that would have proven fatal in previous wars.

According to a study in the Dec. 9, 2004, New England Journal of Medicine, in World War II 30% of those who were injured died, compared with 10% of those hurt in the wars in Iraq and Afghanistan. More recent statistics from the Dept. of Defense suggest that the number is hovering at 13%. As of May 1, 748 of those injured had lost at least one limb. Burns, vision loss and damaged hearing also are prevalent. Traumatic brain injuries mean that some need to relearn how to read and write.

"These are complicated patients who are going through a lot. We're here to provide them the best care and motivate them," Dr. Menetrez said.

The Center for the Intrepid is part of a movement to help injured soldiers either return to duty or get the most out of civilian life. The President's Commission on Care for America's Returning Wounded Warriors was formed by executive order March 6, 2007, and issued its recommendations in the report "Serve, Support, Simplify" July 31 that same year. These findings were endorsed by the American Medical Association at its Annual Meeting in June. The organization also agreed to advocate for improved access to care in the civilian sector for veterans who live in areas where Defense Dept. or Dept. of Veterans Affairs resources are not available.

For the most injured members of this population, this center provides rehabilitation opportunities that appeal to their military experience as well as the challenges involved in being injured so severely at such a young age. The technology is top of the line and innovative.

"We encourage amputees, burn patients and limb-salvage patients to be as active as they can. That's going to make them healthier in the long run," said retired Army Col. Rebecca S. Hooper, PhD, center program manager.

Some technology exists in some form at other rehab facilities, albeit rarely all together, and some parts of the rehab result from creative applications of apparatus more often found in other settings. For example, a pool that creates powerful waves and simulates surfing is more often a feature in a water park, but here it is used to help build balance and endurance. The gym has the newest equipment, with a two-story climbing wall as its centerpiece. Firearms training and driving simulators enhance skills patients can use if they return to the military or head for civilian life. To practice daily living skills, these soldiers can spend time in an apartment not designed for people with disabilities.

The Center for the Intrepid "is a blessing for anybody in my situation. If you look at the old amputee clinics and you look at this one, this is so much more of an upgrade," said Army Spc. Frank Fields, a 23-year-old double amputee from Tyler, Texas.

Regular outings for horseback riding, paint ball, archery and golf aim to integrate patients more fully into the outside world. Job fairs and support groups are held for both patients and their relatives.

"We're really trying to meet their needs at every level," said Army Lt. Col. Shaun Scott, one of the center's physical therapists.

One-stop rehab

Prosthetics are manufactured on-site in a second-floor laboratory which looks, in many ways, like a mechanic's workshop. The walls are covered with racks of screwdrivers, wood files and pliers. The shelves are packed with plastic bins labeled with patient names and filled with artificial limbs.

After a prosthetic is fitted, improving how it works involves some of the center's most futuristic technology. A patient can be sent to the first floor gait lab where as many as 26 infrared cameras will track special reflective markers as he or she walks or runs on flat surfaces, gravel, grass or stairs. Plates in the floor measure force applied by each leg. Electromyography detects the timing and intensity of muscle contractions.

"It's very accurate data that we can feed back to prosthetics or other physicians," said Jason Wilken, PhD, lab director. "We can look at muscle activation. We can do metabolic testing. How much energy are they using?"

Or a patient can take advantage of a computer-assisted rehabilitation environment, called CAREN. Patients are put in the middle of a dome-like contraption that is 21 feet at its peak. A 300-degree image is projected onto the dome and surrounds patients as they walk or run on an embedded treadmill. In addition to improving balance, CAREN can be used to address posttraumatic stress disorder.

"We're barely scratching the surface of what we can do with that," Dr. Menetrez said.

Collaboration is constant among patients, physicians and other caregivers. Each new arrival is introduced to a fellow patient who has similar injuries but is further along in recovery. It's not unusual to see a patient with one leg pushing a wheelchair carrying someone who has none. Aerobics and strength classes are often taught by patients.

"The camaraderie within the rehab environment is critical to the improvement of our patients," Dr. Menetrez said.

Staff gather for weekly meetings that are surprisingly free-form for a military facility. Patient names are read, and attendees yell out what other care personnel need to know. Who needs to be taken on informational interviews at local companies to convince them they are still employable? Who is well enough to be moved out of disabled housing because demand far exceeds supply? Who needs to be asked why they are not showing up for appointments? Who needs their car windows tinted because they have burns that can't be exposed to sunlight?

This session is followed by a medical clinic that allows patients to see not only physicians but social workers, VA representatives, physical therapists, occupational therapists and prosthetists. This event is held in a large room segmented into smaller exam areas by curtains. The patients stay put as professionals move, periodically meeting in the middle to work out various strategies.

"We try to make it easier on the patients here by bringing all the different specialties that take care of them together at one time so that they don't have to go to different clinics and different appointments," said Maj. Richard Ursone, MD, staff orthopedic surgeon. "It also makes their attendance much better. ... It makes everybody's job easier. And then we can also talk to each other."

Every Friday, the patients, many of whom are missing at least one limb, play dodge ball against the staff who, for the most part, are able-bodied.

The patients usually win.

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Details on the center

Location: San Antonio

Size: 65,000 square feet

History: Built by the Intrepid Fallen Heroes Fund at a cost of $40 million. Funds were raised through private donations. Ground was broken Sept. 22, 2005. The Center opened Jan. 29, 2007, and is run by the Brooke Army Medical Center.

Who it serves: Military personnel severely injured in Iraq or Afghanistan who have lost limbs, are attempting to maximize the function of injured ones or have severe burns.

Treatment volume: 145 patients a week, who attend 500 appointments with a range of health professionals.

Available resources: Firearms and driving simulators, a wave pool for surfing, computer-assisted rehabilitation environment, gait lab, occupational therapy, activities of daily living apartment, physical therapy, climbing wall, six-lane swimming pool, mental health services, prosthetics, indoor running track, teleconference room to link long distance with health care professionals or family members.

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More survivors, more needs

Soldiers injured in Afghanistan or Iraq are more likely to survive than those hurt in previous conflicts.

Wounded or killed Killed Percent of injured who die
Revolutionary War (1775-83) 10,623 4,435 42%
War of 1812 (1812-15) 6,765 2,260 33%
Mexican War (1846-48) 5,885 1,733 29%
Civil War, Union side (1861-65) 422,295 140,414 33%
Spanish-American War (1898) 2,047 385 19%
World War I (1917-18) 257,404 53,402 21%
World War II (1941-45) 963,403 291,557 30%
Korean War (1950-53) 137,025 33,741 25%
Vietnam War (1961-73) 200,727 47,424 24%
Persian Gulf War (1990-91) 614 147 24%
War in Iraq and Afghanistan (2001-present) 37,441 4,686 13%

Source: "Casualties of War -- Military Care for the Wounded from Iraq and Afghanistan," New England Journal of Medicine, Dec. 9, 2004, based on Dept. of Defense data; Numbers related to Iraq and Afghanistan from the Dept. of Defense, Aug. 4

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Pushing the limits of rehabilitation

The Center for the Intrepid in San Antonio uses cutting-edge technology and adapts not-necessarily-medical devices to help soldiers severely injured in Iraq or Afghanistan achieve their full potential. It's unclear whether these efforts will pay off or if any will translate to other settings of care, but researchers are watching.

"We'll be tasked, I'm sure, to prove that these things are valuable in functional progression, but that's OK. We're up for that challenge," said Col. Jennifer Menetrez, MD, the center's director.

Investigators at the center want to identify the most critical elements of various interventions to help ease implementation at facilities with fewer resources. Rehab medicine experts also are hopeful the science will trickle down to improve care for civilian amputees.

"It's an incredible facility," said Stuart Glassman, MD, chair of the work group on returning soldier care at the American Academy of Physical Medicine and Rehabilitation and a physician with Granite Physiatry in Concord, N.H. "I would hope that it would be able to bring out research to help civilian amputees improve function and quality of life."

The Center for the Intrepid plans to expand its services when possible to soldiers injured in other conflicts, and to provide educational opportunities for doctors working in the community. Meanwhile, researchers have started preparing papers for presentation at scientific meetings and publication in peer-reviewed journals.

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External links

Intrepid Fallen Heroes Fund (link)

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