Physical therapy at Walter Reed Army Medical Center: veterans who are injured in Iraq often receive physical therapy at Walter Reed.

The Walter Reed Army Medical Center (WRAMC) is the hub of the Walter Reed Health Care System (WRHCS), which includes 10 facilities in three states. At Walter Reed, the physical therapy service addresses all aspects of rehabilitation including neurorehab, pediatrics, orthopedics, amputees, and vestibular. The service is divided into five major sections: inpatient (all inpatients except for orthopedic), orthopedic inpatient, outpatient, amputee, and aquatic therapy.

Clinics and Teams

WRAMC's physical therapy service has eight military physical therapists (PTs) and 11 civilian PTs. It also has seven civilian physical therapy assistants (PTAs) and seven military physical therapy technicians. The physical therapy staff engages in approximately 4,000 patient visits a month, averaging 3.5 visits per patient.

The physical therapy service at WRAMC operates or participates in various clinics. PTs attend balance clinic performing vestibular evaluation and treatment and working with otolaryngologists, audiologists, and neurologists. In the "Golden Years" clinic, patients work with an interdisciplinary team that includes a physical therapist, geriatrician, geriatric psychiatrist, nurse practitioner, occupational therapist, social worker, medical resident, and pharmacist. The physical therapy service also provides COPD pulmonary rehabilitation and gym/sports programs.

In addition, WRAMC's physical therapists provide support to other health care specialties. Ltc Barbara Ashby Springer, PT, PhD, OCS, SCS, says, "We're part of the mastectomy team. We provide preoperative and post-operative care. We also work closely with neurosurgeons and attend their clinics as well. We are involved in many interdisciplinary meetings involving neurology, orthopedics, physical medicine and rehab, general medicine, surgery, cardiothoracic, CCU, and cardiac step-down." Springer is WRAMC's chief of physical therapy service. She also is the physical therapy consultant to the North Atlantic Regional Medical Command (NARMC), which includes 10 clinics in the WRHCS and 15 facilities in the NARMC She recently replaced Col Billie J Mielcarek, who assumed position as Commander, US Army Medical Department Activity, Ft George Meade, Maryland. Col Mielcarek is the first Army PT to command a hospital.

The Focus Shifts

The focus of the physical therapy services provided at WRAMC has shifted during recent years, Springer reports. "We used to see anybody who was a beneficiary. We then were given guidance by the hospital that our priority would be active duty service members coming back from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) and "all other active duty personnel. After those categories comes anyone signed up with TRICARE Prime [the Department of Defenses worldwide health care program for active duty and retired uniformed services members and their families], then those over the age of 65."

Due to the recent guidance and to the continuing overseas military operations, Springer estimates that approximately half the patients now seen by her service are as a result of the war in Iraq, and those numbers are climbing. In January 2004, for example, there were approximately 950 post-deployment physical therapy patient visits. This had risen to 1,430 by March and to approximately 1,827 by June.

The nature of the injuries--and, thus, the type of interventions required--also has shifted as a result of recent military operations. "We've seen at least 242 active-duty personnel with amputations at WRAMC. All but about 20 have been battle injuries; approximately 130 are major amputees--to at least the first major joint or above. Many are caused by improvised explosive devices, rocket propelled grenades, regular grenades, and landmines. Bemuse [the torsos of] our military personnel are protected by Kevlar, their limbs [increasingly] are affected. Because they have such excellent medical care on the field, their lives are being saved. They're seen in Iraq for emergency care. Then they get air-evac'd out, first to Landstuhl, Germany, then to Walter Reed."

Brian Murphy, PT, MPT, agrees that the nature of injuries has shifted. Murphy, president of APTA's Veterans Affairs Section, is clinical manager of rehabilitation and acting director of the George E Wahlen Department of Veterans Affairs Medical Center (VASLC) in Salt Lake City.

Murphy notes that PTs' special services are being called on increasingly as a result of the ongoing war in Iraq. "Because of the improvements in body armor, soldiers are surviving blast injuries that in past conflicts would have killed them, but they are losing limbs," he reports.

Transition of the Patient

Steve Springer, Ltc Springer's husband and a retired Army officer, is nurse case manager at WRAMC's Amputee Center. He says, "I work on the transition of the patient from inpatient to outpatient status, developing a long-term plan of care. It involves coordination with all the specialty areas, with the biggest impact on physical therapy, occupational therapy, and prosthetics. We work very closely to make sure that the clinical criteria are met before we return the patients to their long-term rehabilitation, which is usually near their home of record or another health care facility."

Military personnel with amputations have three options, Springer explains: 1) request to stay on active duty in the same job they held before the injury, 2) stay in the military but request another job that is not as physically demanding, or 3) separate with a medical disability. Most, he says, do separate and are placed in the Veterans Administration system at whichever center is closest to their retirement location. "On a case-by-case basis, we bring them back here for care and research. If the VA hospital doesn't have a required specialty, we get them back here. We work hand-in-hand with the VA," he says.

That was the case with Pfc Jessica Lynch. (See "Jessica Lynch's Story of Recovery an page 36.") Burt Reed, PT, the owner of Mountain River Physical Therapy in Mineral Wells, West Virginia, is the physical therapist who has worked with Lynch since her discharge from Walter Reed. Reed recalls that he initially spoke several times with one of Lynch's PTs on the telephone. "She gave me a very detailed summary of where Jessica started and where she was after 12 weeks at Walter Reed. Then we corresponded; I outlined how we were going to continue the treatment plan. The PTs at Walter Reed see Jessica occasionally, primarily for orthotics."

Steve Springer addresses the provision of prosthetics for those with amputations. He says, "We work with two contracting companies, one for upper extremities, one far lower extremities. They come here weekly, and longer term they coordinate with our patients once they're medically retired. Whatever they need, they receive, plus the physical and occupational therapy support and follow-up." Describing the VA perspective, Murphy says, "Due to the number of these young personnel with amputations coming back from both Iraq and Afghanistan, the VA and the Department of Defense have made meeting their prosthetic needs a high priority."

In remarks made in December 2003 after touring the physical therapy facilities at Walter Reed, President George Bush said, "A grievous injury, such as the loss of a limb, no longer means forced discharge. In other words, the medical care is so good and the recovery process is so technologically advanced that people are no longer forced out of the military. Today, if wounded service members want to remain in uniform and can do the job, the military tries to help them stay."

Murphy says that the patient population served at a VA facility inspires the PTs and other health care practitioners. "It is intrinsically motivating to work with people who have sacrificed so much. As a veteran myself, I understand what it means to serve, and it helps me to communicate to my staff the importance of what they do."

Ltc Springer says, "We're trying to bring everyone who comes through here up to the highest level possible. Service members are conditioned like athletes to begin with, so we're trying to return them to that level--even to active duty, if possible. We use a lot of the same theories as in sports, as far as getting their strength back and their core conditioning. We involve them in different drills and plyometrics, running--if they want to--and arm-crank bicycles. Some even are signed up for the New York City marathon."

"We have so many people who come through here who are so motivated. We all consider it an honor and a privilege," she says.

Walter Reed's Mission

The five-point mission of the Walter Reed Army Medical Center is to:

* Develop leadership in clinical readiness for combat and contingency missions.

* Exploit advances in wellness, prevention, and disease outcomes management for maximum quality of life and health.

* Serve as the Army's center of gravity for complex care, clinical education, and clinical research.

* Become the national leader in outcomes-focused integration of primary and specially care.

* Partner with other services and agencies to promote excellence in military health care with prudent stewardship of resources.

photographer Barry Myers

Donald Tepper is editor of PT Magazine.