Major David Rozelle
Chairman Michaud, Congressman Miller, and distinguished Members of the subcommittee, thank you for inviting me to participate in this hearing alongside my colleagues from the Department of Veterans Affairs (VA). I am Major David Rozelle, an Armor Officer and Administrative Officer of the Military Advanced Training Center at Walter Reed Army Medical Center. I am excited to talk with you today about the use of advanced technology at the MATC and at the Center For the Intrepid (CFI) at Brooke Army Medical Center in San Antonio, Texas. The openings of the CFI on the 29th of January 2007 and the MATC on September 13, 2007, were noteworthy events that demonstrated the tremendous support of the American people for our wounded warriors. These facilities are also representative of the significant advances that are being made in the care provided to our courageous service members. Although the two centers mirror each other in capabilities, the CFI is monumental in appearance while the MATC is strictly utilitarian. The MATC, however, will eventually move its capabilities to a more permanent home once Walter Reed closes.
One patient recently described the interior of the MATC as “where the magic happens.” It is a mix of technology and philosophy that allows our warriors to return to a lifetime of the highest physical, psychological and emotional function. Each service member is treated as a “tactical athlete”—the MATC brings the latest advances in sports medicine to bear on their treatment. Within the walls of the MATC there is a multidisciplinary health professional team that works together to seamlessly bring the patient from recently wounded status to a return to warrior status. This team includes representatives from the Veterans Benefits Administration, VA Social Workers, and VA Vocation Education and Rehabilitation counselors. While the team includes those thought to be part of the traditional rehabilitation team--the physical therapists, occupational therapists, physiatrists, and nurse case managers--it also includes psychological liaison providers, biomechanists, the patients, the patients’ Family members, and others.
The facilities boast many “state-of-the-world” or “state-of-the-art” capabilities:
- The fire arms training simulation room utilizes blue tooth technology to replicate the weight, feel and response of actual weapons, the M16 and M14 rifles and the 9mm pistol. This allows the service member to regain confidence in their ability to carry out the roles of a combat Soldier. It is also utilized to clear individuals prior to their participation in some of the outdoor recreational activities like skeet shooting and hunting.
- The gait labs are among the largest and most sophisticated in the world. With a 23 camera capture system, a dual force plate treadmill, and force plates of different sizes arranged in an array in the floor, the gait lab is able to analyze the gait patterns of our clients while they utilize a variety of prosthetic components and apply the results to both prosthetic adjustments and to physical therapy and occupational therapy treatment plans.
- The Computer Assisted Rehabilitation Environment or CAREN System is another “state-of-the-art” technology that provides tremendous potential for our clients. Imagine a helicopter simulator and replace the helicopter with a platform and an imbedded treadmill with dual force plates under the treadmill. Now link this through a computer system to a screen that projects an image which is linked to your actions as you move on the platform. We can have you walking up and down a hilly trail with the platform shifting to mirror the changes on the screen, if you speed up the system detects it and speeds up both the projection and the treadmill, if you slow down the system responds accordingly. It can generate a city street scenario, beginning with walking down a quiet street, then adding in stressors, additional people, cars backfiring, trash on the side of the road, pedestrian tunnels, and allow our psych staff to work with you as you approach these stressors. This is a new and exciting technology that is applicable not only to our patients with limb loss, but also those with traumatic brain injury or combat stress.
- The facility offers a variety of opportunities to work on advanced skills that are applicable to both leisure activity and military skills. This includes both a climbing wall and a treadwall--the climbing wall adds the challenge of functioning at height while the treadwall challenges the patient cardiovascularly.
- The SoloStep is an overhead support system that permits the patients to be supported as they progress from walking to running. The MATC offers the only Solostep system in the world that goes in a continual loop. Rather than a 20 foot straight run where the patient has to continually stop and turn around, ours goes around the entire length of our track. This support system frees the therapist from having to hold the patient as they ambulate and allows the therapist to watch the patient and make immediate corrections to their gait.
- Elevating parallel bars were developed specifically for the military amputee patient population. The Army Medical Department has the only three sets in the world. This allows the patients to train for community obstacles which they will frequently encounter such as sloping streets, sidewalks, or ramps. These also will play a significant role in research efforts to provide our warriors with more functional prosthetic devices.
- A vehicle simulator is available to provide the initial training with hand controls. We collaborate with the VA, who will provide the follow-on training out on the street in actual vehicles. One of our staff members, a VA employee, has developed software programs for the simulator to specifically address driving issues related to deployment. Known as combat driving, it includes such practices as rolling stops and wide lane changes to avoid obstacles in the road. While these are potentially life saving measures in theater, they may be extremely dangerous if practiced stateside. By working on modifying these behaviors on the simulator we are able to better prepare our patients for a return to driving.
A very active community reintegration program has been developed which includes a variety of activities from field trips to a museum or a mall or a wide range of sports activities to include skiing, kayaking, scuba, cycling, mountain climbing, and surfing. This was a lesson learned during the Viet Nam war as the military worked to help patients return to the civilian community. The success of that program has kept it an integral part of the military amputee rehabilitation process. Another program that has been very successful is our running program, training our clients for a range of distance races, biathlons, and triathlons.
As mentioned earlier, much of our success is due not to the technology advances, but to the philosophy and approach to patient care. Again, during the Viet Nam war it was identified that having the patients work in larger cohort groups appeared to have greater benefit than working independently, close to home. Many veterans with limb loss from previous wars have volunteered to be peer visitors for our patients. This ability to see the future, whether it is seeing a recently injured warrior who is one or two months ahead of you, or seeing the more distant future provided by the peer visitors, provides a sense of purpose and focus for our patients to strive towards.
Technology has played a significant role in prosthetic restoration. New methods of measurement have resulted in more efficient methods of measuring the service member’s amputated limb with better precision, efficiency, and quality. These methods include Computer Aided Design Computer Aided Manufacturing (CADCAM), optical digitizing and stereo lithography where CT Scans are digitized and used to print an accurate 3 dimensional model of the residual limb including any existing heterotopic ossification. Additionally, the treatment for service members in the Global War on Terror has resulted in current technology being utilized in new ways. The US Armed Forces Amputee Patient Care Program at WRAMC was the first in the world to utilize the micro- processor prosthetic knee as an early rehabilitation knee unit, providing newly injured service members increased stability, safety and confidence in the use of a prosthetic limb.
The Program pioneered and implemented the use of the Military Ambulatory Diagnostic Prosthesis philosophy for the lower limb amputee. Under this philosophy, the prosthetic sockets are rapidly produced with extremely durable temporary materials and coupled with the most technologically advanced components. The patients receive multiple and frequent sockets to accommodate the volume and shape changes common during the early post-operative phases.
Similarly, with upper extremity limb loss, the concept of Early Post-Operative Prosthesis was resurrected and coupled for the first time with a policy of utilizing external powered prosthetic components. The use of myo-electric prosthetic components instead of body powered components places much less stress on the residual limb and permits the patient to begin to train much earlier in the rehabilitation process. The ability to rapidly manufacture and change sockets to accommodate upper extremity residual limb changes has permitted our patients to continue to use a prosthesis throughout the early stages of rehabilitation and makes them much less likely than their civilian counterparts to reject prosthetic use.
The innovative use of current state of the art technology has attracted many manufacturers to the program. These manufacturers are seeking to provide new technology to the program prior to release to the general population. The early release of this technology allows the military prosthetists to obtain critical knowledge of the technology and provide expert feedback to the manufacturer.
The current emphasis on care of the military amputee patient has stimulated the application of a wide range of advanced technologies into the development of enhanced prostheses, which can much more closely simulate the human body.
Collaboration between the DoD and the VA is ongoing and has already led to several significant successful projects. Among these is the development of the VA/DoD Clinical Practice Guidelines (CPG) for Care of the Amputee. This CPG sets in place the clinical pathway for both pre and post amputation patient care. Additionally, the establishment of a VA/DoD Clinical Rotations Program allows for rehabilitation practitioners (physical therapist, occupational therapist and prosthetist) all from the same Veteran Integrated Service Network (VISN) to train as a team simultaneously with counterparts at MATC and the CFI. This unique program bridges the span between the VA and DoD practitioners and provides an understanding of operations at the varying installations which ultimately leads to better care of the injured service member.
With the financial support of Congress, we have been able to develop a research program that has already provided some exciting developments and, with the advanced care centers, promises to significantly change how we provide warrior care in the future.
Over 82% of amputations in the U.S. occur as the result from complications of diabetes and dysvacular disease, with a greater prevalence rate of individuals over the age of 65. Data obtained from OEF and OIF reveal a much different patient population. As of September 2007, there have been over 700 service members, who have sustained a major limb amputation in support of GWOT. Twenty-three percent (23%) of these individuals have lost an upper limb and over 20% have lost more than one limb. Nearly 90% of these service members have been under the age of 35 and as a result have unique psychosocial needs and generally seek to return to a more active lifestyle than older individuals. Additionally the majority of combat related amputations do not occur in isolation. Over 50% have had a documented traumatic brain injury (TBI), some with vision and/or hearing loss, many have significant remote fractures and significant soft tissue wounds, others with co-morbid paralysis from peripheral nerve injury or central cord injury and nearly all with contaminated wounds requiring frequent surgical washouts and extensive antibiotic use. These complex medical, surgical and rehabilitation challenges require a unique approach to treatment and warrant dedicated research programs to optimize care.
The advanced training centers have proven to be an ideal setting for training in advanced techniques related to amputee care and prosthetics. In addition to the VA/DoD Clinical Rotation Program, we have held a number of courses attended by military therapists and Veterans Affairs therapists and prosthetists from around the country.
The combination of advanced technologies, innovative clinical practices, caring providers and an amazing group of warriors in transition with the strength and courage to seek the high ground and continually move forward has led to revolutionary changes in our understanding of the capabilities of individuals with limb loss.
I thank you for inviting me to talk with you today about the capabilities and the magic of the Military Advanced Training Center at Walter Reed and the Center for the Intrepid in San Antonio. Your continued support for our wounded, ill, and injured is very much appreciated by the Soldiers and staff at Walter Reed and throughout the Army.