Page 14 - Journal of Special Operations Medicine - Spring 2015

a 4­week, intensive physical therapy regimen adapted After a 2­week deload period, the upper body program
with the intention to increase the functional capacity of was switched to an undulating classic periodization
patients fitted with these orthoses. He completed his fo­ model, while the linear progression was maintained for
cused therapy program 4 weeks later (week 8). the lower body primary lifts throughout the adaptation
phase. Weighted explosive movements were also added
The patient returned to his home unit, the 5th SFG(A), during the adaptation phase, such as classic clean pulls,
where he continued the intense, self­directed continu­ which had to be modified to clean pulls with hex bar
ation of the therapy he underwent at the CFI, and he to accommodate for the devices. Dumbbell and barbell
underwent a reevaluation with his new orthoses by the squat jumps were also introduced. The programming
THOR staff, resulting in modified training guidelines layout for the conditioning for the adaptation phase re­
3
and goals. In addition to his strength and conditioning, mained the same. Work capacity circuits remained the
he received physical therapy care consisting of soft tis­ main form of aerobic work he was getting. He was able
sue mobilization, manual therapy, and dry needling to to work up to 45 minutes of steady state cardiovascular
facilitate his participation in conditioning. He also re­ training on the Alter G treadmill toward the end of this
ceived consultation and nutrition recommendations by phase.
the staff sports dietician. His strength and conditioning
program was divided into three phases—introduction, Four months following completion of the RT clinical
adaptation, and execution—each designed to be of 3 pathway, he was seen for a repeat evaluation, where he
months’ duration. demonstrated the ability to perform sprint drills, lunges,
and box jumps. On completion of the adaptation, he
The initial challenge was to determine what he could was reevaluated by THOR staff and an orthopedic sur­
3
and could not do based on the limitations of his devices. geon at Blanchfield Army Community Hospital in Fort
Therefore, after the RTR clinical pathway participation Campbell, Kentucky, and cleared to attempt to return to
at the CFI, the goals of the introduction phase was to full duty. He has since been cleared to return to duty and
outline exactly what limitations the braces would cause participate in unrestricted airborne operations by his
and to reintroduce weightlifting and conditioning with chain of command and has been assigned as the opera­
more job specificity for his lower body. There were no tions sergeant “Team Sergeant” for an Operational De­
upper body adaptations necessary, and a traditional lin­ tachment Alpha. The execution phase began with him
ear periodization model for his main upper body lifts being deployed. Due to the nature of his deployment he
was followed. For the lower body, however, it quickly was able to continue to train, so his weekly layout was
became evident that adaptation would have to be made. transmitted via secure email by the performance staff.
All squatting exercises were very difficult due to the re­
strictive range of motion caused by the braces. In deep Discussion
knee and hip flexion, his knees were unable to move in
front of his toes, causing him to have to reach very far This case demonstrates several salient features common
back with his hips to squat, thus causing him to be off in the care of Servicemembers involved in high­energy
balance. It was quickly discovered that he was able to extremity trauma. In a large series of combat­wounded
leg press and deadlift with a hex bar, which then served subjects, 77.1% of injured extremities involved intra­
as his primary lower body lifts. Unilateral lower body articular fractures, and it has been estimated that the in­
exercises were incorporated to help offset differences in cidence of post­traumatic osteoarthritis (PTOA) related
leg strength he had acquired. to tibial plafond fractures approaches 74%. This case
6,7
clearly demonstrates the development of debilitating
Since the device was new to the staff, conditioning dur­ PTOA of the ankle as a direct consequence of complex,
ing the introduction period was used to determine what intra­articular distal tibia fractures.
limitations the braces caused with movement and to re­
introduce his body to aerobic exercise. The latter part of The great deal of data recently published comparing
this period was used to introduce explosive movements, outcomes between those patients treated with either
particularly those involving direction­change. Since primary amputation or limb salvage underscores the
the amount conditioning that could be done with the challenges of treating patients with severe lower extrem­
braces was limiting, work capacity circuits were incor­ ity trauma. The Lower Extremity Assessment Project
porated. The main goal of the adaptation phase was to (LEAP) study group has characterized civilian patients
increase general strength and aerobic endurance, as well sustaining high­energy extremity trauma through the
as slowly increase explosive capabilities. The weekly comparison between those treated with either ampu­
layout of the plan remained the same throughout the tation or limb salvage. No significant differences in
adaptation phase. Linear periodization was continued outcomes were demonstrated, and both groups were
for both upper and lower body. considered to be significantly disabled. One domain,

4 Journal of Special Operations Medicine Volume 15, Edition 1/Spring 2015