by Rebecca St. Andrie

If you were reading the papers recently, you probably saw a striking picture: two recently-wounded veterans from Iraq and Afghanistan, running on their state-of-the-art prosthetic legs with the president.

But as anyone in O&P knows, a lot of work had to happen before that picture could be taken.

“I got hurt when I was 22,” says retired Army Sgt. Neil Duncan, one of the soldiers in the picture. “[I went] from a very fit, very healthy and strong 22 to a feeble, disabled 22. [But] that didn’t last very long.”

Duncan’s story—and that of his prosthetist, Mike Corcoran—shows what progress is being made in helping severely wounded soldiers become active, healthy and independent. The growing number of casualties creates a painful situation. But the soldiers’ drive, the prosthetists’ hard work and manufacturers’ advancements are pushing the field of O&P forward.

Pressure on the practitioners
Corcoran, a CPO who helps run Medical Center Orthotics & Prosthetics in Silver Spring, Md., fit both Duncan and Army Spc. Max Ramsey, the two soldiers who recently ran with President Bush. He and his team of five prosthetists and two technicians are responsible for about 80 percent of the lower-limb cases coming into Walter Reed. Last year, that amounted to fitting 600 legs in a year—each one often done within 24 hours.
Corcoran notes that the cases can often be very challenging.

“Most of the cases you see in the civilian world [are] very clean surger[ies],” he says. 

“These [soldiers’] amputations have lots of skin grafts, because they’re trying to save as long a limb as possible. We’ve got guys with residual limbs of maybe two or three inches…it’s not easy prosthetics.”

Doing better, faster
Fitting legs within one to two days means that Corcoran and his co-workers have put in a lot of long days.
“They’re just amazing guys,” says Duncan. When a change in his residual limbs meant that one of his prostheses’ sockets didn’t fit anymore, the prosthetists at Walter Reed put in extra hours to finish a new one in time for Duncan’s upcoming race.

“I worked with them seven hours a day, every day. They constantly amaze me by the amount of stuff they go out of their way to do for me. They take it on a personal level rather than on a business level,” he says.

Corcoran says that the pressure has forced him and his company to be more efficient. “When we’re doing it in a day turnaround, it’s not like we’re going through a bunch of check sockets. We’ve got to get it right the first go-round,” he says. 

“The positive effect is that it’s made us better practitioners. Our productivity is faster and our outcomes are way more successful. It doesn’t take five check sockets to get a good-fitting prosthesis; we get it right the first time.”

He feels that his experience at Walter Reed will definitely bring improvements in his civilian practice.

“Because of the complexity [at Walter Reed], [I’m convinced that] there’s nothing in the civilian world that cannot be successfully managed. I haven’t seen anything that I couldn’t fit.”
 
Manufacturer advances
Anyone in O&P knows that practitioners need support to succeed. Suppliers have been very willing to get Corcoran whatever he needs. Ossur and Otto Bock, two of Corcoran’s main suppliers, have worked to get him materials within a one-day turnaround, and have been working to develop new products to meet the challenges presented by these severely wounded soldiers.

For instance, “ninety percent of our patients experience a phenomenon called heterotropic ossification (HO), where the residual limb starts to grow bone erratically, like tree roots. The socket has to fit really, really well, or else [you] cannot walk…it’s like someone’s stabbing you with needles,” explains Corcoran.

Corcoran and a patient flew to Iceland recently to help Ossur develop a liner that would help patients with HO have a better-fitting socket. This new liner has five rings to help patients achieve suction instead of one at the end of the residual limb, where HO most often occurs.

Soldiers’ desire for high levels of activity also pushes the limits of current technology. For instance, Ramsey, the other patient of Corcoran’s who ran with the president, is back on active duty.

“He’s assigned to the Black Knights, the parachuting team; he’s jumped a few times now since he’s left Walter Reed,” says Corcoran. “He’s broken quite a few knees. Hopefully, Otto Bock’s new C-Leg, their hardened C-Leg, will hold up to the rigors that he wants to put it through.”

What wider approval will do
The willingness of the military to pay for the latest technology has certainly spurred some of this progress. Each soldier who needs a lower-limb prosthesis gets not only gets the latest-technology walking leg, but a running and a swimming leg as well.

“At Walter Reed, when a patient comes in with a prescription, you know you’re going to make it and you know you’re going to get paid. [That] allows us to focus our energies on providing a top-notch prosthesis and not have to be on the phone arguing with the insurance companies,” says Corcoran.

That means that suppliers have had more opportunity for their new products to be adopted quickly. For example, Corcoran and Duncan are both enthusiastic about Ossur’s Power Knee. Corcoran, especially, loves the chance to use the newest technology.

“I wish [civilian] insurance [companies] would pay for devices like this quicker,” he says. “They still don’t want to pay for C-Legs or Rheo Knees, they still want to say they’re experimental when these devices have been out for years. There’s nothing really experimental going on [with] the soldiers. [They’re just] the newest, latest products.”

Walter Reed’s willingness for soldiers to spend longer in rehabilitation also makes a difference. Corcoran cites the example of a triple-amputee soldier who recently walked, and argues that in the civilian world, the amputee would have just been put in a wheelchair.

The soldiers’ drive
The stories coming out of Walter Reed confirm that a patient’s drive, combined with proper technology, training and fit, can achieve great results. Duncan confirms his rehabilitation experience was fairly normal—his main challenge was to build up stamina.

“That was really the hardest part, I think—just trying to develop that stamina and strength. Not so much for running, but just for daily life. Now I can walk around the house, but before I’d stand up and take a few steps and I’d be sweating and in pain,” he says.

He also confirmed that proper training was key.

“The therapists I had would say, ‘Well, we want you to run, but we want you to be able to do this task first.’ [They also told me that] a lot of people jump into [running], but they’re very sloppy and they rely on the prosthesis more than they do their own strength, and so they never develop.”

Will the progress spread?
So, will the civilian O&P world start seeing these stories happen?

There are some encouraging signs. Interest and understanding of O&P in the general public is higher as a result of the wars in Iraq and Afghanistan.

In the past, individual practices have been able to use that positive publicity to argue on behalf of their patients. (See “Paving the Way,” March 2005 O&P Almanac.) AOPA certainly intends to use this growing understanding to push for a better situation for O&P, and is looking to help its members do so, too. (See sidebar “O&P Goes Mainstream.”)

In the meantime, those in O&P can know that progress is happening. And the pressure is on to give amputee soldiers the best care possible.

The recent report from the President’s Commission on Care for America’s Returning Wounded Warriors stated that better medical care means more soldiers are surviving the conflicts in Iraq and Afghanistan with severe injuries. It’s a hard situation, but stories like Duncan’s show that those involved with O&P have always been in the business of transforming hard situations and restoring people’s hope.

Rebecca St. Andrie is managing editor of the O&P Almanac.