A decade of combat in Southwest Asia has placed new and expanded requirements on the military medical community. As is common with most wars, “signature” injuries emerge – in this case, traumatic brain injury (TBI) and a significant increase in amputations. Both, but especially the latter, are due in part to a combination of body armor protecting the torso and battlefield medical care that has saved many who would have died where they fell in previous conflicts.
War also leads to new medical technologies and techniques, such as vastly improved prosthetics and a greater attention to and understanding of concussive force injuries. Noting that as he transitioned from the Bush to Obama administrations, then-Secretary of Defense Robert M. Gates issued a memo stating an even greater emphasis was required to ensure the military was doing the research needed to restore severely wounded warfighters to full function.
“We did not have a core program in this area until just a few years ago, so without the current conflict, there would not be a CRMRP [Clinical and Rehabilitative Medicine Research Program], for example,” according to the program director, Army Lt. Col. John M. Scherer. “That doesn’t mean certain aspects would not still be under investigation – burn treatment and rehabilitation, for example. We coordinate closely with our Combat Casualty Care office to look at the continuum of burn injuries – where … the injury stops and rehab begins.
“The previous focus of the U.S. Army Medical Research and Materiel Command [USAMRMC] was on care up to a fixed facility, then the VA [the Department of Veterans Affairs], civilian medical community, NIH [National Institutes of Health], and others would conduct research and find solutions to repairing those traumatic injuries because those people would have been discharged from the military. But it was determined DoD [the Department of Defense] also has a responsibility and we needed a coherent program to research traumatic injuries and restore [wounded warfighters] to full function. But much of that would not have happened within DoD without the current conflict.”
In response to the Gates memo and the requirements of the ongoing war in Southwest Asia, both DoD and the individual services ramped up already existing efforts to improve care by creating additional new programs and agencies focused on those requirements. CRMRP was one such example, created by USAMRMC in 2008 to focus on expanding traditional research to include even more innovative means of rehabilitative care required to “reset” wounded warriors, both in terms of duty performance and quality of life.
According to its mission statement, CRMRP “provides policy and process oversight for all clinical and rehabilitative medicine congressional programs managed by the USAMRMC’s Telemedicine and Advanced Technology Research Center (TATRC) and Congressionally Directed Medical Research Programs (CDMRP). It is the lead for program development and oversight of the Armed Forces Institute of Regenerative Medicine (AFIRM), which is a multi-institutional, interdisciplinary network working to develop advanced treatment options for severely wounded service members. The CRMRP also more tightly links the USAMRMC research and development community with the clinical investigations community of the U.S. Army Medical Command and the Military Health System.”
Although part of the Army’s medical care structure, Scherer emphasizes the program’s comprehensive approach to multiservice needs, especially at the individual warfighter level.
“We’re trying to take basic research that has been done and translate it into clinical practice so we can return function to the most traumatically injured soldiers, sailors, airmen, and Marines from the current conflict. So that is focused on the most severely injured warfighters, returning them to duty or getting them back to function,” he explained. “Our goal is always to restore them back to the function they had previous to the injury – not to get to the ‘good enough’ answer, but the best answer for that person.
“In addition, the medical community at large was expressing a level of interest in progressing into this area because we had been working these traumatic injuries without the ability to treat effectively. Injuries to the head and neck, for example, have gone up substantially in this conflict and we need programs to address those.”
CRMRP came out of the Army’s Combat Casualty Care Program, which already was leaning toward developing and implementing new ways to restore the function of severely damaged tissue. At the same time, Congress increased funding for new efforts in prosthetics, regenerative medicine, and other cutting-edge technologies to address the growing number of service members surviving despite extreme trauma to arms, legs, and head. That also involves advancements in repairing damaged hearing and overall enhancements in rehabilitative care.
CRMRP-sponsored research currently is focused on four key areas:
1. Rehabilitation and Prosthetics: This includes not only advances in returning damaged limbs to full functionality – or replacing them, if necessary, to achieve the same goal – but also dealing with associated problems, from psychosocial recovery and substance abuse to other injuries that may restrict rehabilitation.
2. Pain Management: Improving ways to reduce chronic and acute pain while also establishing safe levels of medication for each individual, identifying and treating pain generators, and developing new ways to empower patients in the management of their own pain.
3. Vision: Advancing procedures to repair retinal/corneal or optic nerve damage, create artificial eyes that are functional rather than merely cosmetic, improve ocular diagnostics, and treat vision problems associated with TBI.
4. Regenerative Medicine and Transplants: Improving wound healing, reducing scarring, improving function and appearance following craniofacial injuries, eliminating the need for tissue rejection therapy, improving surgical techniques, regenerating missing tissue (muscle, bone, skin), repairing nerve gaps, and developing the architecture to integrate “created” tissue.
While DoD, the individual services, the VA, National Institutes of Health, academia, and industry had been pursuing research and implementing advanced care capabilities in many of those areas, CRMRP was deemed necessary to create a “critical mass” of coordinated research expertise on definitive and rehabilitative care innovations. Success will be measured by reducing permanent disabilities, enabling a more rapid return to duty, decreasing long-term care needs and costs and, by resetting wounded warriors to their full health and capabilities, increasing warfighter morale.
Each of the four key focus areas is important in itself – and even more so in combination – to achieving that goal. But the level of effort by CRMRP and the programs and institutions with which it works is perhaps most clearly seen in efforts to repair injuries to the head and face, a complex task still in the nascent phase of research, despite recent headlines about face transplants and other components.
“If you look at a fractured leg, you basically have a one-dimensional direction, with the bone going up and down the leg. But on the face, you have multiple contours, which make repairs much more complicated than a simple leg fracture,” Scherer explained. “The bone scaffolds, molding, even tissue types are different.
“If you have a leg burn, you are dealing with one tissue type. But a facial burn has different tissues and unique functions – lips, eyelids, etc. – that cannot be repaired with a simple skin graft. You have to be able to replace an eyelid, for example, to save the patient’s sight. So we’re not only trying to repair major deformities resulting from a blast injury to the face, but also regenerate different tissue types so they can function as normal. And that has been a challenge.”
Unfortunately, just as CRMRP came into being, the global economic downturn began having an impact on budgets. While that is expected to slow some work, at least in the near term, Scherer said efforts are under way to ensure critical programs and treatments continue to advance. Whatever the status of U.S. combat or the federal budget, the intent is to provide the best care available to those wounded in Afghanistan and Iraq – including after they leave the military and the VA takes over, from rest-of-life health care to furthering future advances through the Veterans Health Administration (VHA) Rehabilitation Research & Development Service.
“We have a wide variety of interaction with the VA, from sitting on our programmatic committees to making sure projects of interest to both continue on from the research side. A good example of that is the DARPA-developed prosthetic arm; we are providing funds to get the next generation of the arm into clinical trials by the VA, probably in the spring of 2012,” Scherer said.
While major advances in prosthetics, especially for lower limbs, have garnered considerable media and public attention, that is only one part of CRMRP’s portfolio.
“We’re looking across the spectrum of severe combat injuries. The face transplants in the news recently were DoD-funded efforts managed by CRMRP. We also have a program in hand transplants,” he said. “We’re also looking at regenerating lost tissue. In a traumatic injury, can we salvage those parts of the limb that are not removed by basically regrowing the muscle, bone, and nerves that have been lost? The program is relatively new, but a lot of promising clinical trials are under way looking at many of these aspects.
“Some other efforts, including burn products, are in clinical trials now and likely will move into standard clinical use in the U.S. in the next several years. Cloning is a bit further down the road, although some investigators are working on those things – just not necessarily with DoD funds. And a doctor at Wake Forest has developed a tissue 3-D printer to make small [body] parts.”
Military medical R&D also has to follow the mandates of Congress, which typically specifies how funding it provides is to be spent – so many dollars on face or hand transplants, another specific amount on cranial injuries, TBI, damage to sight or hearing, etc.
“We prioritize what we do based on the types of injuries and degree of trauma from the current conflict, but also the current state of the art. Are industry, DARPA, the VA already working on this problem? We base our effort not only on the type, number, and severity of injuries, but how our funds fit into existing efforts so we don’t over-fund one area and under-fund another,” he explained.
“So the priorities we set, to get the most benefit from the resources we have to apply, are not easy to articulate. We may bump something up to the top just because it is close to going into clinical trial, for example, even though other efforts may be considered more urgent – but that one can get the most immediate impact from available funding.”
This generation of warfighters also has shown a determination to use advances in military medicine, especially prosthetics, to either remain in uniform – including returning to war – or re-enter civilian life with at least the same capabilities as before they were injured. An unexpected development, however, has been an increase in the number of “elective” amputations – patients whose limbs were saved by surgery, but with some loss of function, believing they would have a better life with a prosthetic.
As a result, military researchers now are looking not only at how to improve prosthetics, but how to achieve full recovery without prosthetics.
“I don’t have the statistics, but we have had a lot of elective amputations, where the surgeon saved the limb but it did not function to the patient’s satisfaction. Looking around at others who are functioning better with prosthetics, they elect to do the same,” Scherer said. “And I find that a tragedy – that a limb the surgeon was able to save is still amputated because the individual believes a prosthetic will be better than keeping an injured real limb.
“Basically, the loss of a limb or multiple limbs is an area in which we are very, very focused. There are lots of approaches to restoring some level of function. If you lose a lower limb, obviously you could do a prosthetic replacement. But is there something else we can do? Did that individual even have to lose that limb? Is it an issue of muscle loss, bone loss, nerves? How can we take what we know and apply new techniques coming into clinical trial so individuals do not elect amputation when the limb can be saved?
For military personnel, both while still in uniform and in later life as veterans under VA medical care, any advancements in artificial limbs, new ways to restore or improve hearing or vision, reconstructive surgery or other techniques for skull, dental, facial, or other severe injuries are covered by the nation’s contract with those who fight its wars. While those same advances also become available to the civilian population at large, ease of access does not.
“Medicare is looking closely at what should be paid for for civilians, especially prosthetics,” Scherer said, “but we are here to look at what can be developed and made available.”
After only three years of bringing a new level of coordination and focus to some of the most difficult and cutting-edge technologies and procedures in combat medical care, CRMRP is anticipating the development and eventual clinical use of a number of products. Those include:
- engineering skin products, bio-printing artificial skin in the field, and using stem cells to effect repairs to burned skin;
- Compartment syndrome treatments to reduce post-surgical inflammation, a potential cause of impaired blood flow, nerve damage, and muscle death.
- products to heal severe wounds without scarring, leading to both increased function and improved cosmetic appearance;
- improved and more “natural” foot and knee prosthetics and the capability to rebuild lost bone and tissue by capitalizing on advances in neural interfaces, nanotechnology, and prosthetic design; and
- improved eye injury diagnostics, treatments, and technologies to rehabilitate and restore vision.
Even with U.S. forces withdrawing from Iraq and Afghanistan and ever-tighter budgets anticipated through the next few years, Scherer believes the military will continue to push forward in developing new medical technologies and techniques. It is a requirement not only to meet the lifelong needs of those injured during Operation Enduring Freedom-Afghanistan and Operation Iraqi Freedom, but also wounded warriors from previous and future conflicts.
“Combat casualty care, infectious research, and so on were in existence prior to 9/11, so I would say we will continue on in this office because the injuries already sustained will still be there,” he concluded. “Just because the conflict is over, those injuries already have been sustained and our job is to return their function. The future is uncertain with budget cuts, but I have heard no talk of what we are doing here being disbanded.”
This article first appeared in The Year in Veterans Affairs & Military Medicine: 2011-2012 Edition.