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Objective: Aim: The aim of the study was to determine the needs for long-term rehabilitation of persons with damage as a result of a mine-explosive trauma and the availability of rehabilitation for these persons in the territorial community., Patients and Methods: Materials and Methods: Research materials included domestic and foreign scientific sources and normative legal acts on the topic. Research methods included the content analysis, bibliosemantic, data summarization, medical and statistical., Results: Results: The needs for long-term rehabilitation are determined by combined damage, among which damage to the limbs (34.78%-65.22%) [10], craniocerebral injuries (7.9%-12.7%) [11], the acoustic system (40.5%) [16], injuries of bones and soft tissues of the face (10.85%) [18]. Іn 2018, for the first time, 1.2 per 10,000 adult population of participants of the Anti-Terrorist Operation/Joint Forces Operation were recognized as persons with disabilities [7]. Permanent limitations of life activities were caused mainly by brain and limb injuries. In general, long-term rehabilitation is available to persons with injuries in the territorial community in accordance with European approaches. At the same time, the participation of the general practitioner-family doctor is limited by regulatory requirements only to refer the patient to rehabilitation specialists and other specialists., Conclusion: Conclusions: High needs for long-term rehabilitation of persons brain and limb injuries as a result of mine-explosive trauma have been established. There is a need to expand the participation of general practitioners-family doctor in the organization and implementation of rehabilitation as a full-fledged member of a multidisciplinary rehabilitation team, which requires making appropriate changes to regulatory acts.

Heterotrophic ossification (HO) is a well-described phenomenon in patients with spinal cord injury, head injury, burns, hip replacement, and general trauma. However, it has also been described through a relative paucity of case reports that repeated microtrauma from the use of weight-bearing leg prostheses is an additional possible cause of HO. In our case, we examine a patient who developed an extreme case of HO after he began an exercise regimen with assistance from a running limb. This abnormal formation was actually advantageous because it created a more snug fit of the prosthetic device and improved the patient's ability to run.

Purpose: Music therapy has a long history of treating the physiological, psychological, and neurological injuries of war. Recently, there has been an increase in the use of music therapy and other creative arts therapies in the care of combat injured service members returning to the United States from Iraq and Afghanistan, especially those with complex blast-related injuries. This case report describes the role of music therapy in the interdisciplinary rehabilitation of a severely injured service member. Methods: Music therapy was provided as stand-alone treatment and in co-treatment with speech language pathology, physical therapy, and occupational therapy. The report is based on clinical notes, self-reports by the patient and his wife, and interviews with rehabilitation team members. Results: In collaboration with other treatment disciplines, music therapy contributed to improvements in range of motion, functional use of bilateral upper extremities, strength endurance, breath support, articulation, task-attention, compensatory strategies, social integration, quality of life, and overall motivation in the recovery process. The inclusion of music therapy in rehabilitation was highly valued by the patient, his family, and the treatment team. Conclusions: Music therapy has optimized the rehabilitation of a service member through assisting the recovery process on a continuum from clinic to community. Implications for Rehabilitation Music therapy in stand-alone sessions and in co-treatment with traditional disciplines can enhance treatment outcomes in functional domains of motor, speech, cognition, social integration, and quality of life for military populations. Music therapists can help ease discomfort and difficulty associated with rehabilitation activities, thereby enhancing patient motivation and participation in interdisciplinary care. Music therapy assists treatment processes from clinic to community, making it highly valued by the patient, family, and interdisciplinary team members in military healthcare. Music therapy provides a platform to prevent social isolation by promoting community integration through music performance.

Objective: The purpose of this study is to utilize a natural history approach to describe and understand symptom recovery in personnel diagnosed with a blast-related mild traumatic brain injury (mTBI) resulting from an improvised explosive device blast., Participants and Design: The population included military personnel who experienced a blast mTBI while mounted (vehicle; n = 176) or dismounted (on foot; n = 37) (N = 213). Patients had no co-morbid psychiatric or muscle-skeletal issues and were treated within 72 h of injury. Prevalence and duration of self-reported symptoms were separately analyzed by injury context (mounted vs dismounted)., Results: Headache was prominently reported in both mounted (85%) and dismounted (75%) populations. The mean time from injury to return to full duty was between 7.8 d (mounted) and 8.5 d (dismounted). The dismounted population reported visual changes that lasted 0.74 d longer., Conclusion: Our analysis implicates that headache is a common and acutely persistent symptom in mTBI regardless of injury context. Additionally, patients in mounted vs dismounted injury did not report significant differences in symptom prevalence. Although knowing the injury context (i.e., dismounted vs mounted) may be beneficial for providers to understand symptom presentations and deliver accurate anticipatory guidance for patients with blast-related mTBI, no significant differences were observed in this population. This may be due to the population characteristic as the trajectory of recovery may vary for patients who were not able to return to full duty within 30 d or required higher levels of care.

Introduction: Since the onset of the Global War on Terror close to 50,000 United States service members have been injured in combat, many of these injuries would have previously been fatal. Among these injuries, open acetabular fractures are at an increased number due to the high percentage of penetrating injuries such as high velocity gunshot wounds and blast injuries. These injuries lead to a greater degree of contamination, and more severe associated injuries. There is a significantly smaller proportion of the classic blunt trauma mechanism typically seen in civilian trauma., Methods: We performed a retrospective review of the Department of Defense Trauma Registry into which all US combat-injured patients are enrolled, as well as reviewed local patient medical records, and radiologic studies from March 2003 to April 2012. Eighty seven (87) acetabular fractures were identified with 32 classified as open fractures. Information regarding mechanism of injury, fracture pattern, transfusion requirements, Injury Severity Score (ISS), and presence of lower extremity amputations was analyzed., Results: The mechanism of injury was an explosive device in 59% (n=19) of patients with an open acetabular fracture; the remaining 40% (n=13) were secondary to ballistic injury. In contrast, in the closed acetabular fracture cohort 38% (21/55) of fractures were due to explosive devices, and all remaining (n=34) were secondary to blunt trauma such as falls, motor vehicle collisions, or aircraft crashes. Patients with open acetabular fractures required a median of 17units of PRBC within the first 24h after injury. The mean ISS was 32 in the open group compared with 22 in the closed group (p=0.003). In the open fracture group nine patients (28%) sustained bilateral lower extremity amputations, and 10 patients (31%) ultimately underwent a hip disarticulation or hemi-pelvectomy as their final amputation level., Discussion: Open acetabular fractures represent a significant challenge in the management of combat-related injuries. High ISS and massive transfusion requirements are common in these injuries. This is one of the largest series reported of open acetabular fractures. Open acetabular fractures require immediate damage control surgery and resuscitation as well as prolonged rehabilitation due to their severity. The dramatic number of open acetabular fractures (37%) in this review highlights the challenge in treatment of combat related acetabular fractures., (Published by Elsevier Ltd.)

Veterans with blast-related mild traumatic brain injury (mTBI) report difficulty engaging in life roles, also referred to as participation. Current measures are either global or lack comprehensive coverage of life roles and have not been validated in Veterans with mTBI. The Community Reintegration of Service-members instrument (CRIS) is a promising measure that was specifically developed for Veterans using a well-formulated conceptual framework and Rasch analysis. However, the CRIS has not been validated in Veterans with mTBI. Two data sets were combined for 191 Veterans with blast-related mTBI to conduct a confirmatory factor analysis of the CRIS. High residual and low loading items (33) were removed to improve the model fit. The remaining items demonstrated high correlation (0.87-0.89) between subscales and high test re-test (0.85 to 0.95). Mean scores were better for Veterans without Post Traumatic Stress Disorder (PTSD) or depression compared to Veterans with PTSD or depression. The refined CRIS offers a valid comprehensive measure of participation for Veterans with blast-related mTBI. Future directions include examining aspects of participation that may not be covered by the CRIS for Veterans with mTBI..

Introduction: Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals., Objective: The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being., Methods: Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care.", Results: 42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work., Conclusion: The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Introduction: The use of improvised explosive devices is a frequent method of insurgents to inflict harm on deployed military personnel. Consequently, lower extremity injuries make up the majority of combat related trauma. The wounding pattern of an explosion is not often encountered in a civilian population and can lead to substantial disability. It is therefore important to study the impact of these lower extremity injuries and their treatment (limb salvage versus amputation) on functional outcome and quality of life., Patients and Methods: All Dutch repatriated service members receiving treatment for wounds on the lower extremity sustained in the Afghan theater between august 2005 and August 2014, were invited to participate in this observational cohort study. We conducted a survey regarding their physical and mental health using the Short Form health survey 36, EuroQoL 6 dimensions and Lower Extremity Functional Scale questionnaires. Results were collated in a specifically designed electronic database combined with epidemiology and hospital statistics gathered from the archive of the Central Military Hospital. Statistical analyses were performed to identify differences between combat and non-combat related injuries and between limb salvage treatment and amputation., Results: In comparison with non-battle injury patients, battle casualties were significantly younger of age, sustained more severe injuries, needed more frequent operations and clinical rehabilitation. Their long-term outcome scores in areas concerning well-being, social and cognitive functioning, were significantly lower. Regarding treatment, amputees experienced higher physical well-being and less pain compared to those treated with limb salvage surgery., Conclusion: Sustaining a combat injury to the lower extremity can lead to partial or permanent dysfunction. However, wounded service members, amputees included, are able to achieve high levels of activity and participation in society, proving a remarkable resilience. These long-term results demonstrate that amputation is not a failure for casualty and surgeon, and strengthen a life before limb (damage control surgery) mindset in the initial phase. For future research, we recommend the use of adequate coding and injury scoring systems to predict outcome and give insight in the attributes that are supportive for the resilience that is needed to cope with a serious battle injury., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Introduction: The recent Afghanistan conflict caused a higher proportion of casualties with facial injuries due to both the increasing effectiveness of combat body armour and the insurgent use of the improvised explosive device (IED). The aim of this study was to describe all injuries to the face sustained by UK service personnel from blast or gunshot wounds during the highest intensity period of combat operations in Afghanistan., Methods: Hospital records and Joint Theatre Trauma Registry data were collected for all UK service personnel killed or wounded by blast and gunshot wounds in Afghanistan between 01 April 2006 and 01 March 2013., Results: 566 casualties were identified, 504 from blast and 52 from gunshot injuries. 75% of blast injury casualties survived and the IED was the most common mechanism of injury with the mid-face the most commonly affected facial region. In blast injuries a facial fracture was a significant marker for increased total injury severity score. A facial gunshot wound was fatal in 53% of cases. The majority of survivors required a single surgical procedure for the facial injury but further reconstruction was required in 156 of the 375 of survivors aero medically evacuated to the UK., Conclusions: The presence and pattern of facial fractures was significantly different in survivors and fatalities, which may reflect the power of the blast that these cohorts were exposed to. The Anatomical Injury Scoring of the Injury Severity Scale was inadequate for determining the extent of soft tissue facial injuries and did not predict morbidity of the injury., (Copyright © 2016. Published by Elsevier Ltd.)

As longitudinal studies for those with bilateral transfemoral amputation (BTFA) or knee disarticulation (KD) are lacking, it is important to quantify performance measures during rehabilitation in an effort to determine reasonable expectations and trends that may influence the rehabilitation process. At initial evaluation (date of first independent ambulation) and follow up (median 135 [range = 47-300] days later), 10 participants with BTFA/KD completed 6 minute walk testing and Activity Specific Balance Confidence and Lower Extremity Functional Scale questionnaires. Of these, six participants also completed stair ambulation; ascent time and stair assessment index (SAI) scores were calculated. Patients utilized their prescribed prostheses at each visit. Participants were able to cover a significantly greater distance (135.3 [70.1] m) in 6 minutes at the follow-up visit (*p = 0.005). The change in SAI scores for stair ascent and descent was not statistically significant (p = 0.247). Stair ambulation confidence scores were significantly greater at the final visit (*p = 0.034). Stair negotiation appears to plateau early; however, confidence builds despite absence of functional gains over time. Service members with BTFAs/KDs are able to achieve functional community ambulation skills. Thus, this investigation suggests that clinicians can realign rehabilitation paradigms to shift focus towards community distance ambulation once safe stair ascent and descent is achieved., (Reprint & Copyright © 2016 Association of Military Surgeons of the U.S.)

The field of rehabilitation is deeply rooted in military medicine, especially in promoting the restoration of function and community reintegration of injured service members returning from war. Since military operations began in Iraq and Afghanistan over a decade ago, rehabilitative care programs have been integral in supporting the Military Healthcare System in providing high quality comprehensive care for combat casualties and their families, particularly those with complex blast injuries resulting in conditions such as amputation and other limb dysfunction, traumatic brain injury, and spinal cord injury. Fundamental to a successful rehabilitation program is the coordination of interdisciplinary care that not only crosses multiple medical specialties and disciplines, but also promotes ongoing education, research, quality improvement and readiness. This brief article is intended to highlight some of the most important lessons learned from current and past conflicts in delivering the highest quality rehabilitative care to our nation's heroes.

This clinical report describes the outpatient rehabilitation program for patients with multiple limb amputations enrolled in the Comprehensive Combat and Complex Casualty Care facility at the Naval Medical Center San Diego. Injury-specific data for 29 of these patients wounded by blast weaponry in Afghanistan in 2010 or 2011 were captured by the Expeditionary Medical Encounter Database at the Naval Health Research Center and were reviewed for this report. Their median Injury Severity Score was 27 (N = 29; range, 11-54). Patients averaged seven moderate to serious injuries (Abbreviated Injury Scale scores ≥2), including multiple injuries to lower limbs and injuries to the torso and/or upper limbs. All patients received care from numerous clinics, particularly physical therapy during the first 6 mo postinjury. Clinic use generally declined after the first 6 mo with the exception of prosthetic devices and repairs. The clinical team implemented the Mayo-Portland Adaptability Inventory, 4th Revision (MPAI-4) to assess functioning at outpatient program initiation and discharge (n = 23). At program discharge, most patients had improved scores for the MPAI-4 items assessing mobility, pain, and transportation, but not employment. Case reports described rehabilitation for two patients with triple amputations and illustrated multispecialty care and contrasting solutions for limb prostheses.

Returning to active military duty and to recreational activities has been difficult for service members sustaining combat-related high-energy lower extremity trauma (HELET). The Return to Run (RTR) clinical pathway was introduced in 2009 with favorable results in returning active duty service members to running, sports participation, active duty, and deployments. The RTR pathway was introduced at a second institution in 2011 to determine if the pathway could be reproduced at a different institution. In this study, a series of patients is presented who underwent limb salvage procedures after sustaining HELET at an outside military treatment facility and subsequently participated in the authors' RTR protocol. They received a novel orthotic device from the San Antonio Military Medical Center and returned to their home institution for rehabilitation. In this cohort, an improvement in functional capability was obtained in nearly all patients. In conclusion, successful translation of the integrated orthotic and rehabilitation initiative to outside institutions is possible.

A digitally captured, designed, and fabricated facial prosthesis is presented as an alternative to customary maxillofacial prosthodontics fabrication techniques, where a facial moulage and patient cooperation may be difficult., (Copyright © 2015 Editorial Council for the Journal of Prosthetic Dentistry. Published by Elsevier Inc. All rights reserved.)

Unlabelled: Vast numbers of blast-injured Operation Iraqi Freedom/Operation Enduring Freedom/Operation New Dawn personnel report postconcussive symptoms that include headache, dizziness, poor memory, and difficulty concentrating. In addition, many report hearing problems, such as difficulty understanding speech in noise, yet have no measureable peripheral auditory deficits. In this article, self-report and performance-based measures were used to assess 99 blast-exposed Veterans. All participants reported auditory problems in difficult listening situations but had clinically normal hearing. Participants' scores on self-report questionnaires of auditory difficulties were more similar to scores of older individuals with hearing impairment than to those of younger individuals with normal hearing. Participants showed deficits relative to published normative data on a number of performance-based tests that have demonstrated sensitivity to auditory processing deficits. There were several measures on which more than the expected number of participants (15.9%) performed one or more standard deviations below the mean. These were assessments of speech understanding in noise, binaural processing, temporal resolution, and speech segregation. Performance was not universally poor, with approximately 53% of participants performing abnormally on between 3 and 6 of the 10 measures. We concluded that participants exhibited task-specific deficits that add to the evidence suggesting that blast injury results in damage to the central auditory system., Clinical Trials Registration: ClinicalTrials.gov; Approaches to Auditory Rehabilitation for Mild Traumatic Brain Injury (mTBI); NCT00930774; https://clinicaltrials.gov/ct2/show/NCT00930774?term=NCT00930774&rank=1.

Background: Data from the World Health Organization estimates the global incidence of traumatic brain injury resulting in hospitalization or mortality to be close to 10 million people each year. People who sustain a blast-related TBI are more likely to sustain visual impairment than people injured by other means. There is a lack of published literature regarding the most effective means to assist a patient's recovery from TBI with new vision loss. The aim of this report is to describe the physical therapy management of a person regaining functional mobility when newly blind following a blast-related TBI., Method: This case report describes the inpatient rehabilitation physical therapy (PT) services provided for a single subject who experienced a blast-related TBI with complete vision loss., Outcomes: The subject spent 3.5 weeks in IPR and participated in 21 PT sessions before being discharged home. Improvements in cognition, transfers and functional mobility with adaptations for vision loss were achieved, as well as caregiver training, to provide 24-hour supervision in the home., Discussion: Collaborating with a blind specialist teacher assisted the rehabilitation of this subject. Further research is needed regarding the effective interventions for those with TBI and vision loss.

Fifteen years after the Ottawa Mine Ban Treaty, landmines continue to negatively impact global public health. Recent estimates attribute 11-12 daily casualties to landmines and explosive remnants of war. The majority of these casualties are civilians. Children are disproportionately affected by landmine injuries. In this report, we examine the case and recovery of a child severely injured in a 1982 Golan Heights landmine accident, illustrating the danger landmines pose to civilians and their long-term health implications., (2014 BMJ Publishing Group Ltd.)

Veterans with blast-related mild traumatic brain injury (TBI) experience cognitive deficits that interfere with functional activities. Goal Management Training (GMT), which is a metacognitive intervention, offers an executive function rehabilitation approach that draws upon theories concerning goal processing and sustained attention. GMT has received empirical support in studies of patients with TBI but has not been tested in Veterans with blast-related mild TBI. GMT was modified from 7 weekly to 10 biweekly sessions. Participants included six combat Veterans that reported multiple blast exposures resulting in symptoms consistent with mild TBI. Group analysis showed a significant improvement in measures of executive function derived from performance on the computerized Tower of London. There were no significant changes on self/informant questionnaires of executive function, indicating a lack of generalization of improvement from the clinic to everyday activities. Overall, while the data indicate efficacy of GMT in the rehabilitation of combat Veterans with executive function deficits because of blast-related mild TBI, enhancement of generalization is needed.

Objective: Report the prevalence of lifetime and military-related traumatic brain injuries (TBIs) in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans and validate the Boston Assessment of TBI-Lifetime (BAT-L)., Setting: The BAT-L is the first validated, postcombat, semistructured clinical interview to characterize head injuries and diagnose TBIs throughout the life span., Participants: Community-dwelling convenience sample of 131 OEF/OIF veterans., Design: TBI criteria (alteration of mental status, posttraumatic amnesia, and loss of consciousness) were evaluated for all possible TBIs, including a novel evaluation of blast exposure., Main Measures: BAT-L, Ohio State University TBI Identification Method (OSU-TBI-ID)., Results: About 67% of veterans incurred a TBI in their lifetime. Almost 35% of veterans experienced at least 1 military-related TBI; all were mild in severity, 40% of them were due to blast, 50% were due to some other (ie, blunt) mechanism, and 10% were due to both types of injuries. Predeployment TBIs were frequent (45% of veterans). There was strong correspondence between the BAT-L and the OSU-TBI-ID (Cohen κ = 0.89; Kendall τ-b = 0.95). Interrater reliability of the BAT-L was strong (κs >0.80)., Conclusions: The BAT-L is a valid instrument with which to assess TBI across a service member's lifetime and captures the varied and complex nature of brain injuries across OEF/OIF veterans' life span.

Background: The high incidence of persistent postconcussion symptoms in service members with combat-related mild traumatic brain injury has prompted research in the use of hyperbaric oxygen (HBO2) for management., Objective: The effects of HBO2 on persistent postconcussion symptoms in 60 military service members with at least 1 combat-related mild traumatic brain injury were examined in a single-center, double-blind, randomized, sham-controlled, prospective trial at the Naval Medicine Operational Training Center at Naval Air Station Pensacola., Methods: Over a 10-week period, subjects received a series of 40, once-daily, hyperbaric chamber compressions at 2.0 atmospheres absolute (ATA). During each session, subjects breathed 1 of 3 preassigned oxygen fractions (10.5%, 75%, or 100%) for 60 minutes, resulting in an oxygen exposure equivalent to breathing surface air, 100% oxygen at 1.5 ATA, or 100% oxygen at 2.0 ATA, respectively. Individual, subscale and total item responses on the Rivermead Postconcussion Symptom Questionnaire and individual and total Posttraumatic Disorder Checklist-Military Version were measured just prior to intervention and immediately postintervention., Results: Between-group testing of pre- and postintervention means revealed no significant differences on individual or total scores on the Posttraumatic Disorder Checklist-Military Version or Rivermead Postconcussion Symptom Questionnaire, demonstrating a successful randomization and no significant main effect for HBO2 at 1.5 or 2.0 ATA equivalent compared with the sham compression. Within-group testing of pre- and postintervention means revealed significant differences on several individual items for each group and difference in the Posttraumatic Disorder Checklist-Military Version total score for the 2.0 ATA HBO2 group., Discussion: The primary analyses of between group differences found no evidence of efficacy for HBO2. The scattered within group differences are threatened by Type 2 errors and could be explained by nonspecific effects., Conclusion: This study demonstrated that HBO2 at either 1.5 or 2.0 ATA equivalent had no effect on postconcussion symptoms after mild traumatic brain injury when compared with sham compression.

Objective: Best practice guidelines outline ways in which mild traumatic brain injury (mTBI) and persistent post-concussive symptoms (PPCS) should be managed. In line with the existing evidence base, DMRC Headley Court established a treatment programme for UK servicemen and women with mTBI. This study explored the experiences of a sample of UK military personnel living with PPCS, who also received psycho-educational intervention (Phase 2) at this unit., Setting: DMRC Headley Court, Southeast England., Participants: Sixteen service personnel who had completed the intervention within 24 months prior to interview., Design: Semi-structured qualitative interview study, with purposive sampling and thematic analysis., Results: Participants described their mTBI in terms of: (1) onset; (2) subsequent symptom experience; (3) recovery; and (4) acceptance. All participants reported a significant degree of confusion and chaos in the aftermath of their traumatic event. These themes highlighted how, following enrolment onto the Phase 2 intervention at DMRC Headley Court, participants reported being (largely) able to manage PPCS. Further, many reported acceptance of their condition and described how they had managed to re-establish a sense of order., Conclusions: Following a flexible and tailored intervention for PPCS, patients report feeling empowered and describe having a renewed sense of stability.

Background: Landmine injuries cause extensive soft and bony tissue loss of the weight-bearing areas, particularly the heel. Reconstruction of these injuries is challenging, and there are no studies that report long-term functional results., Objective: To determine the quality of life and long-term functionality of patients who had heel reconstruction with free muscle flap after landmine injuries., Design: A case-control study., Participants: Nine male patients who had heel reconstruction with free muscle flap. Ten male volunteers without any gait disorder were included in the study as the control group., Methods and Interventions: Functional ambulation scale, visual analog scale, energy expenditure index, 6-minute walking test, 10-m walking test, and Short Form 36 were performed to determine the quality of life and functionality of the participants., Results: There were no statistically significant differences between the 2 groups in terms of functional ambulation scale, energy expenditure index, 6-minute walking test, and 10-m walking test. Regarding Short Form 36 scores, all subgroup values were lower in the reconstruction group, whereas only those of general health, vitality, and physical-emotional role limitation subgroups showed statistical significance. Mean visual analog scale scores were found to be statistically different between the groups (P < .05). Mean Freiburg Ankle scores showed moderate functionality., Conclusion: Despite the associated physical and emotional trauma, combat-injured veterans with heel reconstruction after landmine injuries had adequate and functional ambulation at long-term follow-up. Early rehabilitation and close cooperation between surgeons and rehabilitation physicians during the care of these patients will enhance patient outcomes., (Copyright © 2013 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Objective: We examined the occupational performance issues facing young U.S. veterans (aged 20-29 yr) who served in Iraq and Afghanistan. Perceived challenges in occupational performance, the most common mental health and brain injuries of war, and motivations for participation in daily occupations upon return to civilian life were identified., Method: Thirty young veterans from Operation Iraqi Freedom and Operation Enduring Freedom were interviewed using the Canadian Occupational Performance Measure (Law et al., 2005). They were also screened for posttraumatic stress disorder, traumatic brain injury, major depression, and alcohol abuse or dependency., Results: The top five occupational performance challenges were engagement in relationships, school, physical health, sleeping, and driving. The health conditions screened positive for 23%-77% of respondents., Conclusion: This study identified challenges faced by today's young veterans when reintegrating into the community and daily life. Strategies for occupational therapy practitioners to aid veterans in community reintegration are discussed., (Copyright © 2013 by the American Occupational Therapy Association, Inc.)

Totally committed, both on the technical as well as the relational level, hospital nursing teams draw on complementary skills when working with wounded soldiers and their families, throughout the treatment pathway and through to the complete rehabilitation of the patient. Humanising the treatment takes on added meaning in intensive care, as a team from the Percy military teaching hospital in Clamart can testify.

Introduction: Explosions have caused a greater percentage of injuries in Iraq and Afghanistan than in any other large-scale conflict. Improvements in body armour and field medical care have improved survival and changed the injury profile of service personnel. This study's objective was to determine the nature, body region, and severity of injuries caused by an explosion episode in male service personnel., Materials and Methods: A descriptive analysis was conducted of 4623 combat explosion episodes in Iraq between March 2004 and December 2007. The Barell matrix was used to describe the nature and body regions of injuries due to a combat explosion., Results: A total of 17,637 International Classification of Diseases, Ninth Revision (ICD-9) codes were assigned to the 4623 explosion episodes, with an average of 3.8 ICD-9 codes per episode. The most frequent single injury type was a mild traumatic brain injury (TBI; 10.8%). Other frequent injuries were open wounds in the lower extremity (8.8%) and open wounds of the face (8.2%), which includes tympanic membrane rupture. The extremities were the body regions most often injured (41.3%), followed by head and neck (37.4%) and torso (8.8%)., Conclusion: The results of this study support previous observations of TBI as a pre-eminent injury of the wars in Iraq and Afghanistan, with mild TBI as the most common single injury in this large cohort of explosion episodes. The extremities had the highest frequency of injuries for any one body region. The majority of the explosion episodes resulted in more than one injury, and the variety of injuries across nearly every body region and injury type suggests a complex nature of explosion injuries. Understanding the constellation of injuries commonly caused by explosions will assist in the mitigation, treatment, and rehabilitation of the effects of these injuries., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The purpose of this exploratory study is to pilot a biopsychosocial instrument called the Perceived Impact of Problem Profile (PIPP) on a cohort of landmine/Unexploded Ordnance (UXO) victims with lower limb disability versus a cohort of persons with similar disability due to other trauma or medical causes. The aim is to provide greater understanding of the psychosocial impact of landmine/UXO injury to inform victim assistance a interventions within Lao PDR., Methods: This study employs a mixed methods design, which involved piloting the PIPP instrument through an interviewer administered questionnaire and demographic questionnaire. Fifty one participants were interviewed in both urban and rural locations within Lao PDR., Results: An analysis of the data reveals significant differences in perceived impact for pain, anxiety and how recently the injury/illness occurred. Both groups complained of high levels of anxiety and depression; landmine/UXO victims who complained of anxiety and depression reported a much greater impact on life satisfaction and mood., Conclusion: The perceived impact of the disability is greatest on psychosocial factors for both cohorts, but especially in landmine/UXO victims emphasising the need to focus on improving psychosocial interventions for landmine/UXO victims within Victim assistance programmes in Lao PDR.

Mild traumatic brain injury (mTBI) has been described as the most common form of traumatic brain injury within military populations; however, few epidemiologic studies have examined incidence rates for mTBI in this population. The objective of this study was to examine trends in the incidence of mTBI among active-duty U.S. service members between 1997 and 2007. Specifically, we were interested in evaluating trends in the incidence rates in relation to the initiation of combat operations in Iraq and Afghanistan. A retrospective cohort study was conducted utilizing data extracted from the Defense Medical Surveillance System to identify all incident cases of mTBI within the study population. The primary outcome of interest was the incidence rate of mTBI per 1000 person-years. Multivariable Poisson regression was used to analyze the data. There were 98,012 mTBI cases and 14,956,955 person-years of follow-up, for an overall incidence rate of 6.55 (95% CI 6.51,6.59) per 1000 person-years. There was a steady increase in the mTBI rate over time. The average change in the mTBI rate was 8.5% (95% CI 8.2%,8.8%) per year; however, the rate rose dramatically in the last 2 years of the study period. Overall, for 2006-2007 versus 1997-2005, the rate ratio was 1.61 (95% CI 1.58,1.65). The greatest increase in the rate of mTBI was observed among those serving in Iraq, who experienced a 38.4% (95% CI 35.4%,41.1%) annual increase in new cases. The observed increase in the incidence of mTBI in this population has significant policy implications in terms of allocating appropriate health care resources.

The number of catastrophic injuries caused by improvised explosive devices in the Afghanistan and Iraq Wars has increased public, legislative, and research attention to upper limb amputation. The Department of Veterans Affairs (VA) has partnered with the Defense Advanced Research Projects Agency and DEKA Integrated Solutions to optimize the function of an advanced prosthetic arm system that will enable greater independence and function. In this special communication, we examine current practices in prosthetic rehabilitation including trends in adoption and use of prosthetic devices, financial considerations, and the role of rehabilitation team members in light of our experiences with a prototype advanced upper limb prosthesis during a VA study to optimize the device. We discuss key challenges in the adoption of advanced prosthetic technology and make recommendations for service provision and use of advanced upper limb prosthetics. Rates of prosthetic rejection are high among upper limb amputees. However, these rates may be reduced with sufficient training by a highly specialized, multidisciplinary team of clinicians, and a focus on patient education and empowerment throughout the rehabilitation process. There are significant challenges emerging that are unique to implementing the use of advanced upper limb prosthetic technology, and a lack of evidence to establish clinical guidelines regarding prosthetic prescription and treatment. Finally, we make recommendations for future research to aid in the identification of best practices and development of policy decisions regarding insurance coverage of prosthetic rehabilitation., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Blast-related traumatic brain injury (bTBI) poses a significant concern for military personnel engaged in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF). Given the highly stressful context in which such injury occurs, psychiatric comorbidities are common. This paper provides an overview of mild bTBI and discusses the cognitive sequelae and course of recovery typical of mild TBI (mTBI). Complicating factors that arise in the context of co-morbid posttraumatic stress disorder (PTSD) are considered with regard to diagnosis and treatment. Relatively few studies have evaluated the efficacy of cognitive rehabilitation in civilian mTBI, but we discuss cognitive training approaches that hold promise for addressing mild impairments in executive function and memory, akin to those seen in OEF/OIF veterans with bTBI and PTSD. Further research is needed to address the patient and environmental characteristics associated with optimal treatment outcome.

Purpose: To report the use of the Boston Ocular Surface Prosthesis (BOSP) in patients with severe periorbital thermal injuries., Design: Retrospective, interventional case series., Participants: Patients with severe periorbital thermal injuries treated with the BOSP., Methods: Chart review of 10 consecutive patients (16 eyes) who sustained severe periorbital thermal injuries during combat missions in Iraq and Afghanistan and were treated for exposure keratopathy with the BOSP, a Food and Drug Administration-approved gas-permeable, scleral contact lens., Main Outcome Measures: Corneal epithelial defect healing, uncorrected and best-corrected visual acuity, and BOSP wear time., Results: Exposure keratopathy occurred after severe periorbital thermal injuries and followed a predictable course of scar contracture. In all patients, vision-threatening ocular surface disease developed as a result of chronic ocular exposure. Rehabilitation of the ocular surface was accomplished using the BOSP, with 10 of the 16 treated eyes achieving a corrected visual acuity of 20/70 or better. Five eyes achieved a best-corrected visual acuity of 20/40 or better. The BOSP also was used as a drug-delivery vehicle to treat corneal ulcers successfully in 6 eyes. The only eye that required penetrating keratoplasty was an early intervention believed to be a direct sequelae of the original thermal burn, rather than a failure of the BOSP regimen. The mean BOSP wear time was 16 hours per day., Conclusions: The BOSP can play an important role in rehabilitation of the ocular surface for patients with severe periorbital thermal injuries and resultant exposure keratopathy. Use of the BOSP should be considered as a treatment option for these difficult cases of severe periorbital thermal injuries., (Copyright © 2012 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Traumatic and trauma-related hemipelvectomies are rare and severe life-threatening injuries. Rapid hemostasis, early aggressive resuscitation, amputation completion, and wound debridement are the mainstays of initial treatment. Second-look debridements and delayed wound closure are mandatory. A multidisciplinary team is necessary in order to treat associated injuries as well assist with eventual rehabilitation. Adherence to specific treatment tenants outlined herein may minimize mortality and secondary morbidity, improving patient outcomes following these devastating injuries.

The complexity of injuries that can arise from combat situations, specifically as a result of the Operation Iraqi Freedom/Operation Enduring Freedom conflicts, is challenging. As injured troops leave the war zone early for medical care, they are treated by an interwoven system of care that includes both the Department of Defense and Veterans Health Administration. Physicians across these settings are increasingly faced with patients who have multiple rehabilitation diagnoses as a result of the severity of blast injuries; therefore, the importance of active communication across the system must be highlighted. This case describes the seamless transition of an injured soldier across the continuum of care.

Introduction: One of the standard measurements in the evaluation process is quantifying the tinnitus frequency. With advancements in the treatments of tinnitus, the need for a simple patient-directed automated tinnitus assessment is urging., Objectives: To investigate the accuracy of a web-based protocol for tinnitus frequency matching in comparison to audiometry., Materials and Methods: Twenty subjects had tinnitus frequency matching in a random order using an audiometer in an anechoic chamber and using a web-based software with a multiple-choice protocol and a slider. Octave challenge testing was performed. Participants were asked to indicate which protocol resulted in the closest match to their tinnitus frequency., Results: Median tinnitus frequency was 6000Hz (range, 2000-12000Hz) using the audiometer and self-directed multiple-choice protocol. Using the slider, the median frequency was 5925Hz (range, 1850-16000Hz). The patients with tinnitus frequency of over 12000Hz experienced a higher level of satisfaction when using the computer-based slider system. Five patients experienced octave confusion with self-directed multiple-choice tinnitus matching that was corrected accurately after the octave challenge step., Conclusion: A web-based protocol for tinnitus frequency matching is as accurate as a standard audiometric protocol. An octave challenge test is necessary for a patient-directed tinnitus frequency matching.

Primary Objective: To learn about and come to an understanding of the recovery process and outcomes experienced by the survivors of the 1995 Oklahoma City bombing, who sustained a traumatic brain injury (TBI) along with other injuries in the blast., Research Design: A phenomenological study was conducted using in-person interviews, document and video-tape review, internet communication and researcher journals as the primary data set., Methods and Procedures: A total of 20 of the 46 bombing survivors with TBI (44%) agreed to be a part of the study. The data collection process focused on stories about service needs, services accessed and long-term outcomes of the participants., Main Outcome and Results: The researchers' data analysis yielded four themes (Trauma-Healing-Support; What TBI?; How I went back to work and life; Now I really need assistance!) that represented the content and meanings of the interviews and supplemental data., Conclusions: A common thread running through the interviews of survivors with TBI was their portrayal of life-long medical, emotional, vocational and residential needs since the bombing. What they experienced in the months--extending into years--after the bombing was beyond their own anticipation and that of their families and healthcare professionals.

In greater numbers than in prior conflicts, service members deployed as part of Operation Enduring Freedom and Operation Iraqi Freedom have an increased risk of experiencing a traumatic brain injury (TBI). The basics of TBI are discussed, with particular attention paid to blast-related events, as this is a common mechanism of injury in this population. Particular attention is focused on the pharmacologic treatment of the sequlae of TBI and common comorbid conditions., (Published by Elsevier Inc.)

Study Design: Retrospective analysis of civilians with spinal cord injuries (SCIs) due to terror explosions., Objectives: To analyze and describe the clinical characteristics and rehabilitation outcomes of civilians with SCI due to explosions admitted for in-patient rehabilitation from 2000-2004., Setting: SCI rehabilitation service, Tel Hashomer, Israel., Methods: Retrospective chart review. Civilians with SCI due to terror-related gunshot wounds (GSWs) served as a control group., Results: Eleven civilians with SCI caused by penetrating atypical foreign objects (PAFOs) and eight with GSWs were identified. The male-to-female ratio was approximately 2:1. Foreign objects were present within the spinal canal in seven patients, causing bone injury without canal penetration in three, and one patient had both bone injury and canal penetration. The most common level of injury was thoracic. Seven had complete motor SCI. Three individuals improved in American Spinal Injury Association status: one individual improved from B to C (cervical); one from C to D (thoracic); and the third from D to E (lumbar). Despite the similar acute hospital length of stay and functional independence measure (FIM) scores on admission, the PAFO group had a shorter rehabilitation length of stay with higher FIM scores and higher FIM efficiency at discharge., Conclusions: Although the pathophysiology of PAFO blast injuries is similar to the high-velocity GSWs or the high-energy military munition injuries, better rehabilitation outcomes were seen, with slightly higher FIM efficiency and efficacy at discharge. This result is likely to be caused by less neurological tissue damage at impact.

Background and Purpose: Traumatic brain injury secondary to blast exposure is a significant international concern and a growing rehabilitation issue. Our objective was to determine whether a novel battery of vestibular-visual-cognitive interaction tests provides objective data to document functioning, and the changes in functioning associated with vestibular physical therapy (VPT) treatment, in individuals with blast-induced balance disorder., Methods: Eighty-two individuals with blast-induced mild traumatic brain injury were evaluated at baseline using a set of vestibular-visual-cognitive tests. Testing was repeated at 4-week intervals after beginning VPT. The tests included static visual acuity, perception time, target acquisition, target following (TF), dynamic visual acuity (DVA), and gaze stabilization tests. The VPT program consisted of exercise procedures that targeted the vestibulo-ocular reflex, cervico-ocular reflex, and depth perception. Somatosensory balance exercises, dynamic gait, and aerobic function exercises were also included. Participants attended VPT twice weekly for 1-hour appointments and were instructed to perform the exercises at home on other days. Mean test values were determined and compared with normative values previously collected in our laboratory from individuals without vestibular dysfunction., Results: Mean participant pre-VPT measures for perception time and target acquisition were similar to normative values, and there was no significant change in these measures. Initially, TF and DVA scores were below normative levels but returned to normative levels after 8 weeks of VPT. Gaze stabilization scores were below normative levels pre-VPT but improved by the time of the week 8 evaluation., Conclusions: This battery of vestibular-visual-cognitive tests seems to be reasonable to establish initial status and to evaluate participant progress associated with participation in VPT. Our data suggest meaningful improvement in TF and DVA after 8 weeks of treatment. A treatment period of 12 weeks or longer may be required for gaze stabilization scores to return to normative values.

This position paper, prepared by the Communication Sciences and Disorders Clinical Trails Research Group, describes communication and swallowing disorders associated with blast injuries and delineates the roles of speech-language pathologists (SLPs) and audiologists in the management of these deficits. Recovery of individuals with mild, moderate, or severe swallowing, speech, hearing, and cognitive-communication impairments is best facilitated by a team of multidisciplinary specialists including SLPs and audiologists. Speech-language pathologists and audiologists have the knowledge and skills to evaluate, treat, and research swallowing, speech, hearing, and cognitive-communication functions, and they should have a primary role in determining the clinical management of, research agenda for, and public health policies regarding individuals with blast-related head injuries from the time of injury to their return to maximized life participation and quality of life.

The Center for the Intrepid (CFI) is a unique facility among the three amputee care centers that comprise the Armed Forces Amputee Care Program. The mission of the CFI is threefold: (1) to provide the best possible patient care to the severely war-wounded, (2) to educate providers in the most advanced methods of rehabilitation for the severely wounded, and (3) to perform research to improve the care of these war-wounded patients. The center's program is based on three critical factors: (1) concentration of similarly injured patients as a cohort, (2) a multidisciplinary approach to patient care, and (3) the concentration of subspecialty skills that ensures the best possible care at an institutional level. The center's active training program benefits professional and ancillary personnel from military community hospitals that may subsequently treat the center's patients as they transition back to duty or retirement. The center's research may ultimately be generalized to amputees of various ages and etiologies, with the goal of returning these patients to productive, fulfilling lives., (Published by Elsevier Inc.)

The rehabilitation of soldiers returning from Operation Iraqi Freedom and Operation Enduring Freedom after combat-related trauma poses significant challenges. Polytrauma from high-energy blasts are common and frequently associated with mangled extremities, axial fractures, and traumatic brain injuries. Current evidence in the physical therapy literature is scant for this population and an empiric approach is often used. This article highlights the challenges encountered and techniques used in the rehabilitation of soldiers with foot and ankle injuries sustained in recent combat operations., (Published by Elsevier Inc.)

The study gives up findings of ground reaction force (GRF) measurement in traumatic transtibial amputees (TT) equipped with prosthesis. Results disclose significant asymmetries between the amputated and healthy legs, as well as between transtibial amputees and non-disabled persons. Decreased GRF of prosthesis (max. horizontal force Fx2 and medio-lateral Fy1 (p < 0.05), max. vertical force Fz1 during the loading response phase and Fz 3 - max. vertical force in late terminal stance; Fx 1 - max. horizontal force and Fy 2 - max. lateral force) were registered in comparison to healthy legs of amputees. The only exception represents vertical force Fz2 showing larger magnitude on prosthetic legs (p < 0.1). Nearly all forces (Fz1 and Fz3 - max. vertical force, Fx1 and Fx2 - max. horizontal forces and Fy1- max. medial force) were decreased for prosthetic legs in comparison to the healthy legs of amputees and to able-bodied persons.

Blasts or explosions are the most common mechanisms of injury in modern warfare. Traumatic brain injury (TBI) is a frequent consequence of exposure to such attacks. Although the management of orthopedic, integumentary, neurocognitive, and neurobehavioral sequelae in survivors of blasts has been described in the literature, less attention has been paid to the physical therapist examination and care of people with dizziness and blast-induced TBI (BITBI). Dizziness is a common clinical finding in people with BITBI; however, many US military service members who have been exposed to blasts and who are returning from Iraq and Afghanistan also complain of vertigo, gaze instability, motion intolerance, and other symptoms consistent with peripheral vestibular pathology. To date, few studies have addressed such "vestibular" complaints in service members injured by blasts. Given the demonstrated efficacy of treating the signs and symptoms associated with vestibular pathology, vestibular rehabilitation may have important implications for the successful care of service members who have been injured by blasts and who are complaining of vertigo or other symptoms consistent with vestibular pathology. In addition, there is a great need to build consensus on the clinical best practices for the assessment and management of BITBI and blast-related dizziness. The purpose of this review is to summarize the findings of clinicians and scientists conducting research on the effects of blasts with the aims of defining the scope of the problem, describing and characterizing the effects of blasts, reviewing relevant patients' characteristics and sensorimotor deficits associated with BITBI, and suggesting clinical best practices for the rehabilitation of BITBI and blast-related dizziness.

The article is devoted to solving questions of complex medical rehabilitation of military service men, became invalids owing to military trauma, participants of the armed local conflicts and controterror operations. Was formed a unitary organizational system of rehabilitation treatment and social adaptation of injured persons by optimization of prosthetic-orthopedic aid, as out-of-alternative method of rehabilitation of patients with amputating defects of limbs, caused by mine wounds. Were determined methods of explorations of patients, medical conditions to surgical and conservative preparation of stumps, criterions of preparedness of stumps and terms of beginnings of prosthesis, was introduced an algorithm of rehabilitation measures. All that has permitted to accelerate the process of rehabilitation, to raise quality of prosthetic-orthopedic aid, attain good functional results and, finally, to create conditions of promotion of health, rising of health quality of invalids and appropriation of psychological assurance and of independence.