Page 15 - Journal of Special Operations Medicine - Spring 2015

however, “self­efficacy”—confidence in one’s capacity to pathway, has shown promising results. This protocol
perform specific tasks—was predictive of a positive out­ focuses on training the patient in the ability to use a
come. 8,9 As demonstrated in this case presentation, one rigid carbon orthosis similar to an amputee learning to
could argue that a highly trained and highly motivated use a prosthetic.
Soldier has “self­efficacy” and, as a result, may be more
likely to have a better outcome. Self­efficacy may be en­ Furthermore, specific movements, loads, and challeng­
10
hanced by returning wounded warriors home to a sup­ ing terrains are subsequently introduced. This allows a
portive unit and command climate with a well­trained and thorough test of the durability of the IDEO while the
integrated performance staff such as in this case, though patient is at the CFI and allows the prosthetist to make
there is no literature currently available on this topic. appropriate changes to the device. Strength, running,
plyometrics, power, and agility training are all incorpo­
In a subgroup analysis of the LEAP cohort, Ellington rated into the program, aimed at accommodating the
et al. recently demonstrated that patients treated with patient’s ability to run at a sustained pace and perform
ankle fusion actually had worse sickness impact profile activities that require explosive power and agility. Patz­
12
outcomes, which is a validated patient­reported outcome kowski et al. through an assessment of physical testing
measure, compared with those treated with below knee parameters and patient­derived satisfaction question­
amputation with typical skin flap design closure. These naires, demonstrated that this device may accommodate
11
data illustrate two important points. First, the ability to superior functional performance when compared to sev­
salvage an injured extremity does not necessarily predict eral commercially available orthoses. 14
a more favorable clinical outcome. Second, the overall
success of a particular treatment approach may be best The use of the IDEO alone, however, does not necessar­
assessed not by the need for revision surgeries or the num­ ily predict favorable outcomes. Blair et al. have shown
ber of postoperative complications but rather by patient­ that use of the IDEO in concert with the RTR clinical
derived measures of their physical and emotional health. pathway dramatically increased the likelihood of Ser­
vicemembers being able to RTD. Those patients whose
Several unique modalities have been used at the CFI rehabilitation integrated both the IDEO and RTR
to address these complex issues. The IDEO (Figure had an RTD rate of 54.8%, compared with an RTD
8) is a custom carbon fiber energy storage and return rate of 32.3% among those with the IDEO alone (p =
ankle­foot orthosis designed at the CFI. The IDEO .0001, odds ratio 7.96, 95% confidence interval 2.20 to
works by storing energy within the brace as the tibia 28.83). 15
translates forward and the ankle dorsiflexes during the
mid and terminal stance phases. As the limb is subse­ Conclusion
quently unloaded, the brace returns the stored energy
to the patient by powering ankle plantarflexion as the This case illustrates the promise of a sophisticated, mul­
limb is unloaded. 12,13 The integration of the IDEO with tidisciplinary approach to the care and rehabilitation of
a specialized rehabilitation program, the RTR clinical those patients with seemingly devastating lower extrem­
ity injuries. Further research is needed to determine if
Figure 8 Intrepid Dynamic Exoskeletal Orthosis. the success seen in this case, demonstrating the success­
ful integration of human performance programs at unit
level such as the THOR program and the CFI’s IDEO
3
and RTR program, can be applied more broadly to fur­
ther enhance functional outcomes of our combat­injured
patients and return more patients back to active duty.

Disclaimer

The opinions or assertions contained herein are the pri­
vate views of the authors and are not to be construed as
official or reflecting the views of the Department of the
Army, Department of Defense or the US Government.
This work was prepared as part of their official duties,
and as such, there is no copyright to be transferred.

Disclosures
Source: Blair et al. Return to duty after the integrated orthotic and
rehabilitation initiative. J Orthop Trauma. 2014;28:e70–e74. The authors have nothing to disclose.

Case Report: Return to Duty After Severe Bilateral Lower Extremity Trauma 5