Combat physical therapy: Operation Iraqi Freedom: physical therapy in a combat zone presents some unusual challenges.

The Army has a long history of commissioning physical therapists as officers and providing physical therapy services to soldiers, especially those recovering from wartime injuries. Often, our service was offered away from the combat zone and required that the soldiers be evacuated and separated from their units. With Operation Iraqi Freedom, the battlefield is much different. There are no front lines. Evacuating soldiers to the rear means flying them to Germany or the United States, which still is necessary for those seriously injured or wounded. However, by putting physical therapy close to the troops, acute and chronic musculoskeletal injuries can be expertly assessed and properly treated, preserving our military combat readiness.

In addition to serving as rehabilitation professionals, our role in a combat zone is physician extender and musculoskeletal screener. This allows us to order roentgenograms, make preliminary diagnoses, and prescribe certain medications that help in the management of musculoskeletal injuries. The coordination among medical services is outstanding, partly because we are a small team, living and working together 24/7. We work closely with the orthopedic and emergency medicine doctors in managing orthopedic and musculoskeletal injuries, providing care for patients from all branches of service.

Physical therapy services are divided between the inpatient and outpatient sections, both located within the main hospital. Additionally, direct access physical therapy is provided during sick call at the Troop Medical Clinic, located approximately 1 1/2 miles from the main hospital.

Outpatient Clinics

The most common injuries treated in the outpatient clinics really are no different than those being seen in a comparable patient population in the United States. The top three outpatient injuries are: knee injuries (27%), low back pain (19%), and ankle injuries (17%). However, the mechanisms of injury are quite different. For example, FOOSH (fall on an outstretched hand) injuries occur while diving from rocket propelled grenades. Whiplash injuries result from convoys being ambushed. Ankle fractures occur while chasing insurgents. Nor does non-specific low back pain take a rest during war. It is the second most treated condition in our facility.

Combat Support Hospitals

The primary mission of our 84-bed combat support hospital (CSH) is to surgically or medically stabilize American soldiers and either return them to duty or evacuate them to the rear. Typically, injured American soldiers do not stay in the CSH more than 24-48 hours. Physical therapy interventions rarely are required or appropriate during that time.

A secondary mission of the CSH is to care for injured Iraqi soldiers and detainees. For these patients, there is no "rear" to evacuate them to. The majority stay at the CSH until they are medically stable, able to care for themselves, and walk. Caring for these patients was not something we were anticipating, but the challenges proved rewarding.

As physical therapists, we work closely with the orthopedic surgeons, making rounds each morning to discuss each patient's care and change dressings. The physical therapy interventions are conducted primarily on the wards and are kept basic: ROM, therapeutic exercise, bed mobility, and crutch/ambulation training.

Unusual Challenges

Practicing physical therapy in a combat zone offers some unique challenges. Physical therapy requires space, and space in fixed buildings in Iraq is very limited. One of our clinics is placed between two outside walls of a building with a plywood roof constructed above. The main clinic, however, is located within the combat support hospital, consisting of a series of tents connected by tent foyers. Neither of these spaces offers much protection from the mortar and rocket attacks that occur up to several times daily. During these attacks, evaluations and interventions are halted immediately. Patients are instructed to don their protective gear and wait inside cement bunkers until the "all clear" siren is sounded.

Sometimes, just getting to see physical therapists is a challenge. A few elite units have PTs directly assigned to them. But the majority of soldiers whose units ore located throughout Iraq must convoy for hours to Balad, Mosul, Tikrit, or Baghdad. It's not uncommon far patients to arrive with their convoy having had delays due to ambushes or improvised explosive devices along their routes. This also presents a dilemma to the PT. Back home, we farm our treatment plan knowing we will be following the patient's progress. In Iraq, we try to minimize the number of times a soldier must convoy while still achieving the best possible outcome.

Unusual injuries and limited supplies also present challenges. We learned to construct makeshift ankle foot orthoses (AFOs), socket attachments for crutches (for crutch ambulators who had upper extremity amputations), and even traction devices that the orthopedist used far lower extremity fractures. It is educational and rewarding coming up with creative ways to solve problems.

Working in Iraq has been trying at times, but ultimately rewarding. Like every other soldier in Iraq, we find ourselves in a combat zone where conditions are never ideal. But our service members have benefited by having physical therapy available to them, enabling them to recover quickly from injuries and return to duty. Our Iraqi patients are getting a service that would not even be offered to them anywhere else in Iraq. These thoughts make us proud to be representing the profession of physical therapy during Operation Iraqi Freedom and extremely proud to be wearing the uniform of the United States Army.

Maj Sue Davis, PT, MPT, OCS, end Cpt Chad Rodarmer, PT, MPT, wrote this article while serving with the 31st Combat Support Hospital in Balad, Iraq, in the heart of the Sunni Triangle.