Table 3

Summary of similarities/differences in rehabilitation

UKUSA and/or Canada
HOLate excision after 18 months from injury (modified to US protocol after 2010)Early excision after minimum 6 months since injury
Tc-99m isotope bone scan used to gauge if ‘cold’ and inactive (modified to US protocol after 2010)CT used to gauge maturity by looking for cortication of HO
No standard recurrence prevention protocolRecurrence postoperative prevented by use of 6 week celecoxib course and/or 700cGy radiotherapy
CT CAD/CAM modelNo model made. (Since 2010) 3D reconstruction generated on PACSPlastic model generated by CAD/CAM machine from CT data to help plan socket modification/surgical resection
Upper limb prostheticsMyoelectric hand issued to selected patients. Majority happy to use mechanically operated prostheticsMyoelectric hand issued with training provided by occupational therapists
Lower limb prostheticsUse of PPAM Aid to allow early mobilisation before stump has healedPPAM Aid not used. Therapists unaware of device and benefits
For above knee amputees, C-leg (Otto Bock) is standard issueAbove knee amputees—same in USA and Canada
Salvaged limbs/late amputationRetaining patient motivation to persist with limb reconstruction difficult: some seek elective amputationSimilar issues noted with US patients
Rehab strategies in TSF include fully weightbearing protocols, that is, using isokinetic dynamometer, squats
Energy-storing ankle foot orthosisNo equivalent orthosis for lower leg reconstruction patientsIDEO trialled at BAMC in lower leg reconstruction patients: initial results very promising
Scar managementConservative treatments include myofascial release, soft tissue massage, silicone and pressure garmentsSame in US patients
Delivery of exercise programmeMilitary exercise rehabilitation instructors (ERI) (from Physical Training Corps). Some civilian ERIs at DMRCCivilian physical therapy assistants
Exercises delivered in group therapy settingExercises delivered on individual basis
Further rehabilitation equipmentIndoor rock climbing wall (off site)Indoor rock climbing wall (on site)
Outdoor athletics track (off site)Indoor athletics track with overhead harness (on site)
Swimming and hydrotherapy pools (on site)Swimming and hydrotherapy pools (on site)
FlowRider wave machine for indoor surfing (on site)
CAREN (on site)*
Gait Lab (on site)†Gait Lab (on site)†
  • Rock climbing wall, athletics track and surfing on FlowRider (Wave Loch, Inc., LA Jolla, California, USA). These aim to make rehabilitation more demanding and also more fun and recreational.3 ,4

  • *CAREN: Used at the US E5 and Glenrose Hospitals, the Computer Assisted Rehabilitation Environments or CAREN (MOTEK Medical BV, Amsterdam, The Netherlands) is a simulator which allows subjects to stand while supported in a harness in a virtual reality 3D world with moving and tilting terrain. It is used for gait education, proprioception and balance retraining in walking and running as well as post traumatic stress disorder desensitisation.29

  • †Gait Lab: Gait rehabilitation aims to restore normal gait as much as possible, and with amputees this is important to minimise unnecessary energy expenditure in ambulation. The gait laboratory allows objective analysis by computer using ground force/vector plates embedded in the floor as well as cameras tracking markers on the subject with motion analysis software to reconstruct the patient's movement. The information gained through motion analysis helps modify prosthetic devices and individualise physical therapy treatment to improve walking, running and jumping.4

  • BAMC, Brooke Army Medical Center; CAD/CAM, computer aided design/computer aided manufacturing; DMRC, Defence Medical Rehabilitation Centre; HO, heterotopic ossification; IDEO, Intrepid dynamic exoskeletal orthosis; PACS, Picture Archiving and Communications System; PPAM, pneumatic postamputation mobility.