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Justin Z. Laferrier, MSPT, OCS, SCS, CSCS, ATP; - page 9 / 12

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LAFERRIER et al. Mobility and AT in servicemembers with major traumatic limb loss

DISCUSSION

Our survey shows different use of prosthetic devices, wheelchairs, and other ATs in two distinct groups of vet- erans and servicemembers with combat-associated lower- limb loss. The Vietnam group’s use of these devices was related to available technology at the time, attitudes about disability, and processes associated with aging. The OIF/ OEF group’s use of these devices may have correlated with their younger ages, improvements in rehabilitation care and policies, shifts in attitudes about returning to Active Duty and more intense activities, availability of more technologically advanced devices, and their stages in the rehabilitation process.

Use of prosthetic devices, wheelchairs, and some assistive devices were significantly more common in the OIF/OEF group than in the Vietnam group. This finding is surprising, because one might expect more use of mobility ATs in older populations with more comorbidity and disability, such as Vietnam war veterans with lower- limb loss. Mobility ATs may improve an individual’s quality of life through increased functional capacity, independence, and participation in society. While mobility ATs successfully serve these purposes to varying degrees, some users are dissatisfied with their prostheses or assis- tive devices and, consequently, underuse or abandon them. In the Vietnam group, those with unilateral lower- limb loss used their prosthetic devices for a sustained period of time before discontinuing them. Reasons for abandonment in this group were typically associated with the process of aging (device too heavy, comorbid condi- tions, vascular conditions) rather than dissatisfaction with the device itself. In contrast, those with unilateral lower- limb loss in the OIF/OEF group, who were followed for an average of 3 years, discarded prosthetic devices within the first year because of dissatisfaction with the device or because of the combat injuries to the other leg. As this group ages, more abandonment may occur because of age-related conditions similar to the Vietnam group. The clinical literature is sparse on reasons for abandonment of prosthetic devices in combat-associated lower-limb loss. Additional research is needed on better prosthetic device fit, methods to decrease pain, and attention to innovations to increase satisfaction (decrease weight of the device or design more comfortable harnesses) with the devices to conserve prosthetic device use, thereby enhancing physi- cal function as these servicemembers and veterans age.

Our study found that, while many rely on prostheses, wheelchair use is a frequent aid for mobility, especially for those with bilateral lower- or multiple-limb loss. The availability of a wheelchair for prosthetic device users is paramount, because the wheelchairs are often necessary to use as a backup when prostheses are repaired or replaced and during times when the residual limb cannot support the prostheses because of infections, soft-tissue injury, weight change, or poor socket fit. In addition, many of the survey participants reported that evening use of a wheelchair helps the residual limb rest after a day of using a prosthetic device use. This shift in acceptance of the wheelchair as an important mobility AT to a supple- ment for primary prosthetic use could explain the higher levels of supplementary wheelchair use among OIF/OEF servicemembers and veterans when compared with Viet- nam war veterans. Nearly all wounded servicemembers with lower-limb loss were trained on the use of prosthe- ses, but not as many received training on the other forms of mobility AT. A recent study from the University of Pittsburgh reported only 18 percent of wounded service- members reported receiving formal wheelchair training as part of their rehabilitation [21]. One possible explana- tion for this preference for prosthetic training over wheel- chair training is the patient’s desire to return to ambulation. Many people in the early months after a trau- matic disability resist wheelchairs because they insist they will walk again. Other studies have found that train- ing is paramount, because choosing the type of wheel- chairs and assessing functional ability need individual attention to increase mobility safely [22–28]. Thus, we recommend that wounded servicemembers with lower- limb loss be offered wheelchair training early in their rehabilitation process, regardless of their perceived future needs for a wheelchair or assistive device.

In our study, several factors are associated with wheel- chair use: bilateral lower- or multiple-limb loss, cumula- tive trauma disorder, comorbidities, combat injuries, and a low ambulatory functional level. As wounded service- members and veterans age (as in the Vietnam group), the presence of decreased physical conditioning and chronic conditions such as diabetes and vascular diseases may increase the likelihood of wheelchair use. For the OIF/OEF participant, bilateral lower- and multiple-limb losses are associated with wheelchair use, but cumulative trauma dis- order also significantly predicts wheelchair use. Because of improvements in combat-injury care and widespread use of body armor, more injured OIF/OEF servicemembers

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