Defence Codex - The journal for defence engineering & science

Small steps forward on the road to recovery

The air is fresh and the sun is rising over the English countryside. Leaving the busy main road that skirts round the nearby towns and villages, it is a tranquil drive along a winding tree-lined road towards the Defence Medical Rehabilitation Centre (DMRC) at Headley Court, Surrey. But this is no easy path to convalescence and those that approach the Edwardian building with its 85 acres of grounds will experience the dedication, skill and commitment of the multi-disciplined teams that will guide them through their rehabilitation. Codex Assistant Editor, Wendy Jacob visited the centre to find out more about their work.

Car bombs, machine gunfire and Improvised Explosive Devices (IEDs) rip through human flesh and tear away limbs. Glass, rusty nails, sand and grit savage and penetrate the mind and body – shattering bone, invading tissue and creating devastating physical and emotional damage. Success in saving patients that previously would have died on the battlefield has led to an increase in loss of limbs and internal system damage. In a recent statement Surgeon General, Lieutenant General Louis Lillywhite, recognised the role that medical science plays in addressing current challenges in rehabilitation and that there is now a greater need to focus on longer term care of wounded personnel: "Success in saving patients that previously would have died has resulted in the survival of individuals with complex injuries. We know that these will have needs that will be very different from those from previous conflicts."

DMRC at Headley Court is receiving an influx of patients from recent operations in Afghanistan and is expanding staff and facilities so that each patient will continue to receive the very best in quality and quantity of care that will maximise their chances of returning to service, or minimise disability on discharge. Although advances in body protection and trauma care are saving lives, an increasing number of British troops survive with injuries that require dedicated rehabilitation programmes. All military personnel who are injured on combat operations pass through Headley Court to be assessed and however slight or serious, their injuries will be given a programme aimed at maximising their recovery.

Lt Col Rhodri Phillip, a Consultant in Rheumatology and Rehabilitation Medicine has been at Headley Court for the last year and explains that as the number of trauma cases has increased, they have changed their practice to accommodate their needs: "In the past, the majority of patients came from road traffic accidents or training injuries. Over the last four years there has been an increase in casualties from IEDs and gun shot wounds. In 2006 we created a Complex Trauma Team which improved management in this area by creating dedicated teams rather than the traditional musculoskeletal groups."

One of the most life changing injuries is loss of limb and in current and recent conflicts there has been an increase in multiple amputations and other traumatic, complex injuries. Phillip explains that the same principles of care apply, but there has been a difference in the scale of injuries that they are receiving: "The nature of IED injuries is such that patients often have multiple injuries which can include brain injuries, loss of sight or hearing, as well as loss of limbs."

Phillip says that although amputations are often the most visible signs of injury, there are other injuries that are equally devastating and require long-term rehabilitation: "Protective armour can reduce the need for amputation but we are getting more smashed feet as a result of blast contacting with the vehicle's metal base. This transfers force through the feet and ankles causing compression fractures. We have head injuries from being thrown in the air, multiple digit loss, and recently we have seen an increase in eye and facial injuries. Some of the hardest cases are from feet and ankles and those who require elective amputations at a later date."

The courage and determination of the patient is matched by the commitment and skills of the multi-disciplinary team that deliver the rehabilitation programme. Using a bio-psychosocial model of rehabilitation that combines physical training, mental health, occupational therapy and social work, they work with the patient to maximise their physical ability and psychological health with the unified aim – getting patients back to their units and a normal life. This has led to an urgent requirement for improved prosthetics and Phillip is keen to emphasise the importance of developments in this area: "Achieving a good fit can be a problem as stumps may be irregular with skin and muscle wounds. The surgeon tries to maintain as much limb length as possible without compromising the patient. They try to keep as much healthy tissue as they can, but in a blast injury fabric and dirt are forced into tissues which will come out with time."

Technical improvements in prosthetics, dedicated rehabilitation programmes, psychological support, as well as individual aspirations influence long-term outcome and an increasing number of personnel are returning to their units ready and willing to carry on the fight. Historically, around 95% of patients have returned to military duty but recently this has fallen to 85–90% due to the number of serious injuries [figures from NHS/Defence Medicine 23.3.09].

Military amputees are usually fit, young and prior to injury, used to participating in physically demanding professional and recreational activities. Phillip says that this can be a problem for patients who may feel that they are not progressing fast enough. He puts this down to the young and fit being naturally competitive and admits it is sometimes difficult to temper their expectations: "Maintaining motivation and morale when things aren't going quite so well is a challenge. One of the drawbacks of being motivated is that when things aren't going so well, it can be a bigger knock-back than for someone with lesser expectations."

The use of lower limb prosthetics places heavy demands on the body and research shows that walking with a lower limb prosthesis uses 125% more energy than walking with uninjured legs. The energy demands increase with higher amputations so physical fitness and motivation are essential for progress. Another area where this patient group differs from other amputee populations is in reports of phantom limb pain. Military amputees rarely suffer from this which may be down to a number of factors including the youth and fitness of the patient, aggressive use of neuropathic pain modulators and intensive rehabilitation programmes including early mobilisation.

The desire to be up and walking may be delayed by nerve injuries leading to loss of function and pain. These may require direct repair, grafting or waiting for the nerves to repair themselves which can take up to two years. Complications include scarring, tethering of tissue from operations and plastic surgery which can also delay the fitting of prosthetics.

Despite the challenges, developments in prosthetic legs mean that it is now possible for an amputee to walk with a near normal gait and stride. Even a double amputee can adapt and learn to walk, and run again (South African Oscar Leonard Carl Pistorius, known as the 'Blade Runner' – the fastest man on no legs' is a double amputee using artificial limbs that are contoured to bend like a human ankle).

Lighter prosthetics, made from carbon graphite, titanium, silicon and different types of gel, as well as improved methods of attachment using suction or vacuum, instead of buckles and straps not only improve mobility and function, but are more comfortable. The development of prosthetics that have been designed specifically for different uses – from everyday, wearing in the shower and the numerous different sports that amputees participate in – means that it is not unusual for an amputee to have a 'wardrobe' of five or more 'limbs'. The cost of these can be considerable and as Phillip will confirm, the military user will test these to the limit.

Phillip believes that science and technology could make a greater contribution to the rehabilitation and quality of life of his patients and he has recently been involved in an MOD Centre for Defence Enterprise (CDE) initiative seeking proposals and expressions of interest in the areas of prosthetics and rehabilitation. CDE is working jointly with Headley Court to stimulate interest and seek innovative ideas that will insure that injured personnel benefit from current and future research and developments in these areas.

Although Headley Court already has a research programme looking at many aspects of patient care, they are turning to industry and academia to add to their expertise. Broadly, the research requirements fall into two areas: Physiology and Repair Processes and Functional Restoration and Retraining. Phillip has been impressed by the interest he has received and proposals are currently being assessed: "The call is now closed and we have had over 30 high quality proposals and decided to develop seven of these". This commitment to innovation is echoed by Lieutenant General Lillywhite: "I believe that the care of injured soldiers receive in this conflict [Afghanistan] is significantly better than they've received in previous conflicts. But we continue to seek even better outcomes for our service personnel."

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Multi-disciplined teams work closely with patients

Civilian Clinical Specialist and Physiotherapist, Kate Sherman has been at Headley Court for seven years and has seen a change in the injuries and needs of patients: "Generally blast injuries are creating harder demands on rehabilitation programmes due to their complexity. At Headley Court we can meet these challenges and provide the different environments that help patients progress."

Sherman believes that determination and motivation are strong influences in the speed of rehabilitation and pays tribute to the patients who she says are 'hard to hold back'. "This is a very special environment with a positive atmosphere and patients set their own challenges and what they want to achieve – and they do achieve."

She also pays tribute to the multidisciplinary teams that work with patients – from the physios and the prosthetists through to the occupational therapists who visit patients' homes to advise on adaptations and aids that may be required. "We have very supportive teams here and work together with the patients who motivate each other and on occasions, are sometimes hard to stop getting into mischief," jokes Sherman.