Military Medicine International Journal of amsus raising the bar: extremity trauma care guest editors
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MILITARY MEDICINE, 181, 11/12:20, 2016 The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for Service Members With Complex Trauma Brad M. Isaacson, PhD, MBA, MSF*†; Brad D. Hendershot, PhD, CRSR‡§; Seth D. Messinger, PhD*†; Jason M. Wilken, PT, PhD†∥; Christopher A. Rábago, PT, PhD†§∥; Elizabeth Russell Esposito, PhD†§∥; Erik Wolf, PhD**; Alison L. Pruziner, DPT†‡§; Christopher L. Dearth, PhD†‡§; Marilynn Wyatt, PT, MA†¶; COL Steven P. Cohen, MC USA (Ret.)††‡‡; CAPT Jack W. Tsao, MC USNR§§∥∥; COL Paul F. Pasquina, MC USA (Ret.)†‡ ABSTRACT The Center for Rehabilitation Sciences Research (CRSR) was established to advance the rehabilitative care for service members with combat-related injuries, particularly those with orthopedic, cognitive, and neurological complica- tions. The center supports comprehensive research projects to optimize treatment strategies and promote the successful return to duty and community reintegration of injured service members. The center also provides a unique platform for fostering innovative research and incorporating clinical/technical advances in the rehabilitative care for service members. CRSR is composed of four research focus areas: (1) identifying barriers to successful rehabilitation and reintegration, (2) improving pain management strategies to promote full participation in rehabilitation programs, (3) applying novel technologies to advance rehabilitation methods and enhance outcome assessments, and (4) transferring new technology to improve functional capacity, independence, and quality of life. Each of these research focus areas works synergistically to in fluence the quality of life for injured service members. The purpose of this overview is to highlight the clinical research efforts of CRSR, namely how this organization engages a broad group of interdisciplinary investigators from medicine, biology, engineering, anthro- pology, and physiology to help solve clinically relevant problems for our service members, veterans, and their families. OVERVIEW
Between 2001 and 2015, there have been approximately 327,000 cases of traumatic brain injury (TBI), 138,000 incidents of post- traumatic stress disorder (PTSD), and 1,645 service members who have sustained one or more major extremity amputations while serving in Operations Iraqi Freedom, Enduring Freedom, and New Dawn.
1 The majority of these severe injuries occurred from the effects of blasts, 2 most commonly the result of improvised explo- sive devices and rocket-propelled grenades. 3 Improved trauma care on the battle field and throughout the military health care system (MHS) has resulted in historic survival rates, 3 with service members now surviving injuries that in previous wars would have been fatal. Because of the complexity of these wounds and the fre- quency of multiple, coexisting injuries and impairments, greater challenges now exist for rehabilitation practices. 3 –6
field survival is only the first step to recovery after a war injury. It is the responsibility of the MHS, the Department of Veterans Affairs (VA), and —arguably—the entire nation to help service members not only survive after injury but thrive as well. Recovery from complex wounds is extremely challenging for patients and families alike. Rehabilitation practices focus on goal setting and improving function through retraining, adaptive strategies, or utilizing novel equipment and assistive technology. The clinics emphasize restoring basic mobility for activities of daily living (e.g., dressing, bathing, and feeding); encompass cog- nitive training in order to restore speech and communication; focus on return to recreational and sports activities; and provide tools for emotionally reconnecting to one ’s family, friends, and community. Given the uniqueness of war-related trauma and the desire to see patients thrive after injury, new rehabilitative methods and tech- nology that focus on the military population must be explored. Wounded service members represent a patient cohort that is relatively young, had high fitness levels before injury, 2 and is highly motivated to return to high-demanding activities. 6 Careful thought and consideration must be given to mitigate the long- term risks of living with a disability for this population, given their relatively young age at time of injury. For example, the incidence rates of diabetes, heart disease, arthritis, and chronic pain are signi ficantly higher in veterans with limb loss than in *Department of Physical Medicine and Rehabilitation, The Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. †The Henry M. Jackson Foundation for the Advancement of Military Medicine, 6720A Rockledge Drive, no. 100, Bethesda, MD 20817. ‡Department of Rehabilitation, Research and Development Section, Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda, MD 20889. §Extremity Trauma and Amputation Center of Excellence, 2748 Worth Road, Suite 29, Joint Base San Antonio Fort Sam Houston, TX 78234. ∥Center for the Intrepid, Department of Rehabilitation Medicine, Brooke Army Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio, Fort Sam Houston, TX 78234. ¶Naval Medical Center San Diego’s Gait Analysis Laboratory, 34800 Bob Wilson Drive, San Diego, CA 92134. **U.S. Army Medical Research and Materiel Command Clinical and Rehabilitative Medicine Research Program, 810 Schreider Street, Fort Detrick, MD 21702. ††Departments of Anesthesiology and Critical Care Medicine, The Johns Hopkins School of Medicine, 600 North Wolfe Street, Baltimore, MD 21205. ‡‡Departments of Anesthesiology and Physical Medicine & Rehabilita- tion, Uniformed Services University of theHealth Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. §§Department of Neurology, University of Tennessee Health Science Center, 855 Monroe Avenue, Suite 415, Memphis, TN 38163. ∥∥Memphis Veterans Administration Medical Center, 1030 Jefferson Avenue, Memphis, TN 38104. doi: 10.7205/MILMED-D-15-00548 MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 20
age-matched population controls. 7,8
Thus, research strategies must focus on both the immediate and long-term impacts of wellness and quality of life to mitigate these increased risks. The Center for Rehabilitation Sciences Research (CRSR) was developed in 2011 to facilitate innovative research projects that promote service member recovery and rehabilitation (Fig. 1). CRSR provides ef ficient dissemination of research knowledge gained from supported projects to military treatment facilities (MTFs) and the Department of Defense (DoD) Centers of Excel- lence (CoE). Headquartered at the Uniformed Services University (USU), CRSR has succeeded in developing a well-coordinated interdisciplinary team, primarily forged through partnerships between Walter Reed National Military Medical Center (WRNMMC), Brooke Army Medical Center, the Center for the Intrepid (CFI), Naval Medical Center Portsmouth, and Naval Medical Center San Diego (NMCSD) (Fig. 2). These sites have been the principal MTFs caring for the majority of injured service members returning from combat operations overseas. In addition, CRSR is well positioned, together with the Extremity Trauma and Amputee Center of Excellence (EACE) and other DoD CoEs, to fill the critical gaps in military relevant rehabilitative research identi fied by the Defense Health Agency and the U.S. Army Med- ical Research and Materiel Command (USAMRMC). As new discoveries are made, CRSR has the ability to in fluence the educa- tion and training of future health care providers and offer guid- ance for rehabilitating injured service members and their families. CRSR is directed by U.S. Army Colonel (Ret.) Paul Pasquina, who served as the Chief of the Integrated Department of Orthopae- dics and Rehabilitation at both Walter Reed Army Medical Center and the Naval Medical Center in Bethesda, Maryland, before and during their merger to become WRNMMC. Dr. Pasquina is cur- rently serving as the Chief of Rehabilitation for WRNMMC and the inaugural Chairman of the Department of Physical Medicine & Rehabilitation at USU, which serves as the medical academic institution of the MHS. This new USU department promotes the academic growth of all rehabilitation professionals within the MHS and ensures that the knowledge gained through CRSR and other rehabilitative research centers directly in fluences resilience and recovery planning. Although a thorough description and detailed report about CRSR-sponsored projects and its investigators is beyond the scope of this overview, a summary of noteworthy scienti fic con- tributions has been included from each of the four research focus areas. This article will highlight CRSR clinical research efforts and how this organization engages a broad group of interdisci- plinary investigators and connects them directly with clinicians, patients, and families to help solve clinically relevant problems. RESEARCH FOCUS AREA 1: IDENTIFYING BARRIERS TO SUCCESSFUL INTEGRATION This research area, led by Dr. Seth Messinger, focuses on the use of ethnographic interviewing to identify the current barriers to social reintegration for war fighters with neurological and orthopedic- related trauma. One of the paradoxical challenges facing military clinicians who work in outpatient rehabilitation programs is assess- ing the quality and effectiveness of intervention strategies. Recent research conducted in the U.S. Armed Forces Amputee Care Pro- gram has explored the ways in which the duration of rehabilitation, sense of patient and family autonomy, and locus of control in fluence the rehabilitative trajectory of severely injured service members. One study compared two patients with similar upper extremity amputations, ages, branch of service, and regional origins. Although both patients excelled at achieving functional goals in rehabilita- tion, only one had enduring success with his prosthesis; 9 the other abandoned his device. The differing outcomes were attributed to the sense of autonomy/control experienced by the more success- ful patient in contrast to the less successful one. A follow-on study investigated lengths of stay and expectation concurrences between patients and clinicians and the in fluence on outcomes. 10 Dr. Messinger identi fied a critical point beyond which protracted outpatient care may be disruptive as patient concerns shift to other issues and no longer align with those of the therapists. Although these studies are limited in sample size, the depth of ethnographic and qualitative interviewing allows clinical researchers to explore factors that would not otherwise be apparent to the clinical staff. 9 Limited evidence also is available to understand how the brain is cognitively and psychologically altered after experiencing severe trauma, particularly for those who have sustained both FIGURE 1. The CRSR logo highlights the organization ’s focus on ortho- pedic, neurologic, and cognitive injuries in service members. FIGURE 2. A schematic demonstrating the primary research focus areas of CRSR and the primary sites where research is conducted. The center is headquartered at the Uniformed Services University of the Health Sciences. MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 21 Advancing the Rehabilitative Care for Service Members With Complex Trauma limb damage and TBI. This gap has been bridged by investigating the nexus of psychiatry and biomedicine as well as their in fluence on patient participation and success with rehabilitation. To date, 40 patients with both mild TBI and PTSD have been enrolled with unexpected findings discovered. Many subjects self-report that their symptoms of PTSD (e.g., hyper vigilance) could be viewed positively and assist some patients with their transition back into the civilian community. 11 Finally, ongoing research is focused on understanding the aspects of rehabilitative care that help injured service members develop resil- ience as they subsequently leave the rehabilitation program and return to duty or their communities. Early results indicate that the relationships these patients form with their providers and peer- visitors have long-lasting effects as they encounter adversities and challenges once resuming life after injury. Their sense of accom- plishment during rehabilitation, which they attribute to the knowl- edge, skills, and motivation given to them by their providers and peers, continues to be a source of inner strength. In addition, patients note that their access to high technology, particularly in prosthetics, not only improves functional abilities but also provides a sense of symbolic commitment that the military and their nation support their recovery. Although many patients report being less physically active in the years after leaving a rehabilitation pro- gram, they still greatly applaud the robust clinical focus on sports and athleticism that the rehabilitation program provided. Indi- viduals note that this focus on high levels of performance adds tremendously to their successful community reintegration. 12 RESEARCH FOCUS AREA 2: IMPROVEMENTS TO PAIN MANAGEMENT STRATEGIES This research area focuses on pain management strategies criti- cal to recovery and quality of life after severe combat injuries. Drs. Steven Cohen, Jack Tsao and Brad Isaacson lead this area to assist wounded service members with orthopedic and neuro- logical pain relief. For the past several years, research efforts have concentrated on main complications: (1) axial spine pain (2) phantom limb pain (PLP). Axial Spine Pain: Lower Back and Neck Pain Debilitating conditions such as neck and back pain occur more frequently in individuals with limb amputation and trauma and have a more pronounced negative impact on an individual ’s mobility and quality of life. Low back pain (LBP), in particular, remains a signi ficant challenge to treat in clinical practice. Several studies have demonstrated that LBP is the leading cause of injury in active duty service members and one of the most common rea- sons for disability worldwide in people under the age of 45. 13,14
By some estimates, the economic costs of treating LBP approach $100 billion per year in the United States. 15 Similarly, chronic neck pain is a major cause of disability in the world, 16 with a 12-month prevalence rate between 30 and 50%. 16 –18 Injured ser- vice members also suffer from these conditions at high rates and currently there is no “gold standard” for the treatment of neck pain and LBP. To address this lack of standardization and potentially reduce the economic burden of neck pain and LBP for the DoD and VA, Dr. Cohen has led several double-blinded studies to determine the ef ficacy of the current standards of care for LBP. The purpose of one study was to evaluate the best approach for treating patients with lumbosacral and cervical radicular pain. Considerable debate exists as to the bene fits of epidural steroid injection (ESI) verses gabapentin prescription. 19 To address these con flicting opinions, Dr. Cohen led a multisite prospective- blinded study to assess whether ESI, conservative treatment, or combination treatment provided the highest patient satisfac- tion for treating cervical radicular pain. Data from 169 patients suggested no signi ficant differences between these treatment options, but combination therapy improved outcomes compared to stand-alone methods. 20 Dr. Cohen ’s findings highlight the importance of an interdisciplinary approach to management of pain. These outcomes have implications for treating both injured service members and the general population. Phantom Limb Pain Almost immediately after the loss of a limb, 90 to 95% of all patients with major limb amputations experience a vivid phantom limb sen- sation such as warmth, cold, itching, pressure, or sense of position. 21 When the sensations become intense enough to be de fined as painful, they are referred to as PLP. PLP occurs in 80 to 90% of individuals with limb amputation and usually appears immediately following awakening from anesthesia, though pain onset may be delayed for up to a few days or weeks in 25% of patients. The presence of PLP does not seem to correlate with the cause or location of amputation. 22 In most cases, PLP gradually fades with time, particularly with pros- thetic use; however, a signi ficant percentage of patients (30–70%) report having pain that persists for years or decades. Since evidence indicates that pain continuing for longer than 6 months is the most dif ficult to treat, 22,23 better evidence is needed to identify effective treatment strategies. The causes of PLP and nonpainful phantom sensation are not known; however, both peripheral and central processes are impli- cated.
24 Memories of the limb ’s posture and form before amputation often survive in the phantom. 25,26 After a period of several weeks, a patient ’s phantom limb may fade from consciousness and/or disap- pear completely. However, PLP is remarkably dif ficult to treat, and there are several reports of failed drug trials in clinical literature. 23,24
Dr. Jack Tsao leads CRSR ’s PLP research using a combination of virtual reality-based training, simulators, biological assays, and advanced neuroimaging to further understand this debilitating condi- tion. He and his team completed the first randomized, sham- controlled prospective trial of mirror therapy for the treatment of PLP. Mirror therapy functions by having the amputee place a mirror between the intact and amputated limbs while simultaneously mov- ing the phantom limb to mimic the movements of the intact limb viewed in the mirror. Dr. Tsao ’s team is currently performing a func- tional magnetic resonance imagining study to determine activation patterns in the brain before and following mirror therapy. This team has also extended the theory that visual observation is the key to mirror therapy by demonstrating that bilateral amputees with PLP may experience pain relief by observing someone else ’s limbs moving. In a study of 20 bilateral lower limb amputees with PLP, direct visual observation signi ficantly reduced PLP in both limbs, whereas mental visualization methods were not signi ficant.
27 This inexpensive technique may assist service members with limb loss reduce their pain thresholds and positively in fluence their ability MILITARY MEDICINE, Vol. 181, November/December Supplement 2016 22 Advancing the Rehabilitative Care for Service Members With Complex Trauma to participate in rehabilitation regimens. Additional work is being conducted by Dr. Tsao ’s team to determine if genetic factors influ- ence PLP since some individuals do not develop this debilitating condition following limb amputation, whereas others are severely affected. Lastly, studies are being conducted to determine how many sessions of mirror therapy are needed for pain relief and whether existing neuropathic pain models are applicable for treating PLP. Heterotopic Ossification Heterotopic ossi fication (HO) is a pathologic process characterized by ectopic osseous growth in muscle and/or periarticular regions. 28 Although HO may develop from rare genetic disorders, abnormal bone growth has been most frequently reported following trauma, arthroplasty, burns, spinal cord injury, and traumatic brain injury. 28 While, most cases of HO in the general population are clinically asymptomatic, and do not require surgical intervention, military ser- vice members injured by blasts in Afghanistan and Iraq, have much different prognosis. 29,30
Armaments such as improvised explosive devices (IEDs) and rocket propelled grenades (RPGs) generate exten- sive polytrauma, and approximately 63% of war fighters with limb loss have developed post-traumatic HO (with 20% to 40% requiring surgical excision). 31,32 Symptomatic HO is problematic for service members since it delays rehabilitation regimens, causes pain, limits range of motion, and requires modi fications of prosthetic limbs. 32,33
The CRSR is committed to understanding the etiology of these ectopic osseous masses and improving surgical planning for servicemen and women. Dr. Brad Isaacson is the lead investigator and received two Congressionally Directed Medical Research Programs (CDMRP) grants (W81XWH-12-2-0017 and W81XWH-16-2-0037) and private donations from the Wounded Warrior Amputee Softball Team to advance this field of orthopedics/ rehabilitation. Data from his laboratory has demonstrated a link between bench top research and bedside care, with the mineral apposition rate (MAR), a hallmark for bone growth, computed to be 1.7 times faster in trauma-induced HO compared to non- Yüklə 2,47 Mb. Dostları ilə paylaş:
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