RAISING THE BAR: EXTREMITY TRAUMA CARE
Fred A. Cecere, MD
Steven J. Stanhope, PhD
Kenton R. Kaufman, PhD
Bill W. Oldham, MBA
COL John C. Shero, MS USA (Ret)
COL James A. Mundy, MS USA (Ret)
SPECIAL ISSUE – Supplement to Military Medicine, Volume 181, Number 11/12
Fred A. Cecere, Bill W. Oldham
Christopher A. Rábago, Mary Clouser, Christopher L. Dearth, Shawn Farrokhi, Michael R. Galarneau,
M. Jason Highsmith, Jason M. Wilken, Marilynn P. Wyatt, Owen T. Hill
The Bridging Advanced Developments for Exceptional Rehabilitation (BADER) Consortium:
Reaching in Partnership for Optimal Orthopaedic Rehabilitation Outcomes
Steven J. Stanhope, Jason M. Wilken, Alison L. Pruziner, Christopher L. Dearth, Marilynn Wyatt, Gregg W. Ziemke,
Rachel Strickland, Suzanne A. Milbourne, Kenton R. Kaufman
The Center for Rehabilitation Sciences Research: Advancing the Rehabilitative Care for
Service Members With Complex Trauma
Brad M. Isaacson, Brad D. Hendershot, Seth D. Messinger, Jason M. Wilken, Christopher A. Rábago,
Elizabeth Russell Esposito, Erik Wolf, Alison L. Pruziner, Christopher L. Dearth, Marilynn Wyatt, Steven P. Cohen,
Jack W. Tsao, Paul F. Pasquina
Daniel J. Stinner
Christopher A. Rábago, Jason M. Wilken
Shawn Farrokhi, Brittney Mazzone, Adam Yoder, Kristina Grant, Marilynn Wyatt
M. Jason Highsmith, Jason T. Kahle, Rebecca M. Miro, Derek J. Lura, Stephanie L. Carey, Matthew M. Wernke,
Seok Hun Kim, William S. Quillen
Functional Outcomes of Service Members With Bilateral Transfemoral and Knee
Disarticulation Amputations Resulting From Trauma
Barri L. Schnall, Yin-Ting Chen, Elizabeth M. Bell, Erik J. Wolf, Jason M. Wilken
Anne M. Andrews, Christina Deehl, Reva L. Rogers, Alison L. Pruziner
Billie J. Randolph, Leif M. Nelson, M. Jason Highsmith
M. Jason Highsmith, Leif M. Nelson, Neil T. Carbone, Tyler D. Klenow, Jason T. Kahle, Owen T. Hill, SP USA,
Jason T. Maikos, Mike S. Kartel, Billie J. Randolph
Descriptive Characteristics and Amputation Rates With Use of Intrepid Dynamic Exoskeleton
Owen Hill, Lakmini Bulathsinhala, Susan L. Eskridge, Kimberly Quinn, Daniel J. Stinner
AMSUS - The Society of Federal Health Professionals should not be held responsible for statements made in its publication by contributors or advertisers.
Therefore, the articles reported in this supplement to MILITARY MEDICINE do not necessarily reﬂ ect the endorsement, ofﬁ cial attitude, or position of AMSUS or
the Editorial Board.
Elizabeth Russell Esposito
Michelle Mattera Keon
Christopher A. Rabago
Rachel A. Strickland
“Raising the Bar” in Extremity Trauma Care:
A Story of Collaboration and Innovation
Fred A. Cecere, MD; Bill W. Oldham, MBA
’s military health system is working in remarkable
injured service members reach their highest level of function.
The difference in outcomes as a result is staggering. In the
1980s, only 2% of soldiers remained on active duty following
limb loss, despite relatively minor injuries such as a partial
By 2010, 19% of service members
major extremity trauma. About 25% of this group actually
returned to theater, even though their injuries were much
more devastating than those suffered during previous con
Wounded soldiers now have access to cutting-edge tech-
at realizing optimal outcomes for a population already used
to performing at high levels. The approach is holistic and
family centered, focusing more on the patient
’s ability than
disability. Best of all, advances in the care of these patients
ﬁts to other injured service members as well as the
This work is possible because of the synergies that exist
between programs operating through the Department of
Defense (DoD) and the U.S. Department of Veterans Affairs
(VA) across the patient care spectrum. The result is comple-
mentary rather than competing care that begins at the point
of injury and continues for the rest of a patient
pedic rehabilitation care have been bolstered by three sepa-
rate but interconnected programs that have identi
that translate research advances into clinical care for patients
with traumatic extremity injuries.
The Extremity Trauma and Amputation Center of Excel-
lence (EACE) was created by Congressional mandate as a
joint enterprise between the DoD and the VA to develop a
comprehensive strategy to help service members with trau-
matic injuries optimize their quality of life.
The Center for Rehabilitation Sciences Research (CRSR)
was established to advance the rehabilitative care for service
members with combat-related injuries while also educating
the next generation of military medicine professionals.
The Bridging Advanced Developments for Exceptional
Rehabilitation (BADER) Consortium was developed as
a research capacity building program to further establish
research infrastructures and investigators at DoD and VA sites
and to launch a series of multiteam clinical research initiatives.
These programs operate independently, but they are
designed to be interdisciplinary and collaborative in nature.
This complementary approach is re
ﬂective of the efforts by
the DoD to address the complex health needs of the combat
wounded before they reach the VA, which has already had
an established amputee and rehabilitation science program.
Together, they provide a unique opportunity to strengthen
DoD/VA research programs and in
ﬂuence the long-term
direction of care for this unique patient population.
It is an approach that is working, as evidenced by a 2015
report by the Defense Health Board on the sustainment and
advancement of amputee care.
It found that the DoD is
amputee science and care through its infrastructure, systems
” That same report also reiterated the need
for collaborations between institutions, practitioners, and
researchers across disciplines and organizations in order to
sustain these advancements.
Whether it is team members from the EACE and the
BADER Consortium embedding at military treatment facilities
(MTFs) to help answer clinically relevant questions and support
research in high-priority areas or CRSR staff working to
ﬁne and validate rehabilitation strategies for injured service
wounded warriors get back to the life they were living
before their traumatic injuries.
By working collaboratively, researchers do not have to
give up their autonomy. Indeed, each domain of rehabilita-
tion care can and should be able to work independently.
The resultant creativity and energy is evidenced by the
myriad of research projects already underway at MTFs and
VA centers around the country. These researchers are not
constrained by working toward the same goal
patients regain their highest functional levels
they are empowered to meet those goals in different ways.
One project funded by the Defense Medical Research and
Development Program and supported by the EACE and
BADER focused on preventing falls in service members
with amputations through the use of advanced rehabilitation
At CRSR, they are
management strategies that can improve the quality of life
for patients with severe combat injuries. The BADER Con-
sortium supports the goal of optimal outcomes by providing
needed administrative assistance and infrastructure support
to help address important gaps in clinical orthopedic rehabil-
itation research and patient care.
Thought Leadership and Innovation Foundation, 16775 Whirlaway
Court, Leesburg, VA 20176.
MILITARY MEDICINE, Vol. 181, November/December Supplement 2016
undertake this mission of restoring function. The networks
that already exist at these facilities enable the orderly adop-
tion of cutting-edge technological devices and associated
rehabilitation techniques to enhance patient function.
These advances are being developed, tested, and evalu-
ated by the same high-performing, motivated population
most likely to bene
ﬁt from them. In this capacity, the MTFs
and VA medical centers can serve as the nation
translational and clinical trial network for traumatic amputee
rehabilitation, offering possibilities for personalized care and
optimal function of these devices.
Microprocessor-controlled prosthetic knees offer tangible
examples of how injured service members are getting access
to cutting-edge care, but it is providing these devices with a
well-designed rehabilitation program that truly offers the
opportunity for patients to return to their busy lives and
work, thereby making the goal of optimizing outcomes a
reality. The Return-to-Run program pioneered at the Center
for the Intrepid is one example of coupling high-tech with
rehabilitation, resulting in long-term improvements in physi-
cal performance, pain- and patient-reported outcomes.
In the same vein, research has found that the body, mind,
and spirit should be jointly considered following traumatic
injuries. The Military Extremity Trauma Amputation/Limb
showed that service members who underwent
and had a lower likelihood of post-traumatic stress disorder.
There was a time when simply helping a patient regain
some aspect of mobility was considered a success. But this
generation of injured service members has more demanding
medical and interpersonal needs than previous cohorts.
These young men and women typically lived highly active
and athletic lifestyles before their injuries. They want to
return to their busy lives, whether it is through the use of
prosthetic and orthotic devices that help them regain their
mobility or specialized rehabilitation training that helps them
adapt to changing terrains.
The needs of this unique population have spurred many
stunning advancements in patient care over the past 15 years.
It is why programs like the EACE, CRSR, and BADER have
been able to thrive in a relatively short amount of time.
Much is still not known about the challenges injured ser-
vice members will face in the future. Many of these patients
are young, but so are the programs providing the resources
to support these critical research efforts. These heroes, who
face lifelong adaptations to the rigors of the world, need
continued and dedicated teams of specialists trained in their
unique challenges. As the research into these areas faces
greater challenges, it is important for the centers and the col-
laborations to be allowed to grow and mature.
In the coming years, there needs to be an increased effort
to develop research enterprises that will wield the greatest
impact on current and future limb loss partners. Great
research advances have been made during the recent 15 years
Vagaries of combat
number of patients with traumatic extremity injuries who
—present funding and stafﬁng challenges that
could threaten medical advancements and treatment break-
throughs in the future. Only when clinicians and researchers
—along with the DoD and VA leadership—to
develop programs and research capabilities with the greatest
potential for impacting our wounded will these challenges
It is through this larger coordination of effort we can
ensure military health professionals will continue to raise the
bar in the development and implementation of a new normal
where service members who have experienced all kinds of
extremity trauma can achieve their highest level of function
and enjoy a better quality of life.
This work was funded by Congressionally Directed Medical Research Pro-
grams (CDMRPs), Peer Reviewed Orthopaedic Research Program (PRORP)
via award number W81XWH-11-2-0222; the NIH-NIGMS (P20 GM103446);
the NIH-NICHD through a collaboration agreement; and the University of
Delaware, College of Health Sciences.
1. Kishbaugh D, Dillingham TR, Howard RS, Sinnott MW, Belandres PV:
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tee soldiers in the current con
ﬂicts in Afghanistan and Iraq. J Trauma
2010; 68(6): 1476
3. Defense Health Board Reports. Sustainment and advancement of ampu-
—April 8, 2015. Available at http://www.health.mil/About-
August 19, 2016.
4. Kaufman KR, Wyatt MP, Sessoms PH, Grabiner MD: Task-speci
ﬁghters with transtibial amputa-
tions. Clin Orthop Relat Res 2014; 472: 3076
Amputation/Limb Salvage (METALS) study: outcomes of amputation
versus limb salvage following major lower-extremity trauma. J Bone
Joint Surg Am 2013; 95(2): 138
MILITARY MEDICINE, Vol. 181, November/December Supplement 2016
“Raising the Bar” in Extremity Trauma Care
The Extremity Trauma and Amputation Center of Excellence:
Overview of the Research and Surveillance Division
Christopher A. Rábago, PT, PhD*†; Mary Clouser, PhD*‡; Christopher L. Dearth, PhD*§;
Shawn Farrokhi, PT, PhD*∥; Michael R. Galarneau, MS, EMT*‡; CPT M. Jason Highsmith, SP USAR*¶**††;
Jason M. Wilken, PT, PhD*†; Marilynn P. Wyatt, PT, MA∥; LTC Owen T. Hill, SP USA*†
ABSTRACT Congress authorized creation of the Extremity Trauma and Amputation Center of Excellence (EACE)
as part of the 2009 National Defense Authorization Act. The legislation mandated the Department of Defense (DoD)
and Department of Veterans Affairs (VA) to implement a comprehensive plan and strategy for the mitigation, treat-
ment, and rehabilitation of traumatic extremity injuries and amputation. The EACE also was tasked with conducting
clinically relevant research, fostering collaborations, and building partnerships across multidisciplinary international,
federal, and academic networks to optimize the quality of life of service members and veterans who have sustained
extremity trauma or amputations. To ful
ﬁll the mandate to conduct research, the EACE developed a Research and Surveillance
Division that complements and collaborates with outstanding DoD, VA, and academic research programs across
the globe. The EACE researchers have efforts in four key research focus areas relevant to extremity trauma and
amputation: (1) Novel Rehabilitation Interventions, (2) Advanced Prosthetic and Orthotic Technologies, (3) Epidemiology
and Surveillance, and (4) Medical and Surgical Innovations. This overview describes the EACE efforts to innovate,
discover, and translate knowledge gleaned from collaborative research partnerships into clinical practice and policy.
In 2009, Congress legislated the creation of the Extremity
Trauma and Amputation Center of Excellence (EACE) as a
joint enterprise between the Department of Defense (DoD)
and Department of Veterans Affairs (VA) to optimize the
quality of life (QoL) of service members and veterans who
sustain extremity trauma or amputation.
conduct clinically relevant research, foster collaborations, and
build partnerships across multidisciplinary international,
federal, and academic networks. In accordance with this
mandate, the EACE
’s mission is focused on the mitigation,
treatment, and rehabilitation of traumatic extremity injuries and
amputations. The purpose of this editorial is to provide an over-
view of the EACE efforts to innovate, discover, and translate
knowledge gleaned from collaborative research partnerships
across established DoD, VA, and academic research programs.
At the time of the
ﬁrst EACE staff hire in September 2011,
the U.S. military was engaged in nearly 10 years of continu-
ous combat. As of October 1, 2015, data compiled from the
Expeditionary Medical Encounter Database, Naval Health
Research Center, indicate that approximately 26,000 trau-
matic extremity injuries resulted from deployments during
Operations Enduring Freedom (OEF), Iraqi Freedom, (OIF)
and New Dawn (OND). These injuries ranged in severity and
complexity, with nearly 50% involving the lower limbs.
From 2001 to 2015, 1,687 individuals with major limb ampu-
EACE Amputee Registry. Of these individuals, 69% suffered
a single limb loss injury and 31% lost multiple limbs. The over-
all incidence of extremity injuries from these operations is
consistent with previous wars, comprising more than half of
all combat wounds.
With extremity injuries sharply rising early in the con
leadership within the DoD and VA health care systems
realized the need for specialized systems of care that could
deliver concentrated, interdisciplinary health care required by
*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 Health Research Center, 140 Sylvester Road, San Diego,
§Research and Development Section, Department of Rehabilitation,
Walter Reed National Military Medical Center, 8901 Rockville Pike, Bethesda,
∥The Department of Physical and Occupational Therapy, Naval Medical
Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134.
¶James A. Haley Veterans Administration Hospital, Center of Innovation
in Disabilities and Rehabilitation Research, 8900 Grand Oak Circle (151R),
Tampa, FL 33637.
**University of South Florida, Morsani College of Medicine, School of
Physical Therapy & Rehabilitation Sciences. 3515 E. Fletcher Avenue,
Tampa, FL 33612.
††U.S. Department of Veterans Affairs, Rehabilitation and Prosthetics
Services, 810 Vermont Avenue, NW Washington, DC 20420.
The view(s) expressed herein are those of the author(s) and do not
ﬂect the ofﬁcial policy or position of Brooke Army Medical Center,