The Winston Churchill Memorial Trust was established in 1965 on Sir Winston's death as a national memorial and living tribute to him, and funded by many thousands of people who contributed to a public subscription. This now funds Travelling Fellowships to allow Churchill Fellows to travel abroad and learn lessons that can be brought back to benefit the local community and ultimately the UK as a whole. Both authors were recipients of this prestigious 2009 Fellowship in the category of “Treatment & Rehabilitation of Traumatic Injuries”. Over fifteen weeks we visited hospitals in Germany, Canada, and the USA with expertise in the early care, reconstruction and rehabilitation of the combat casualties of our NATO Allies. We aimed to learn lessons from their experience, exchange ideas and to make contacts. We visited the US military hospital in Landstuhl Regional Medical Center, Germany, the University of Alberta Hospital and Glenrose Rehabilitation Hospital and the two major centres of US military care at the Walter Reed Army Medical Center/National Naval Medical Center in Washington DC, and the Brooke Army Medical Center in San Antonio Texas. We present our experience from this Fellowship, some of the lessons we have learnt and the problems that we face in common with our NATO allies.
Since the recognition of chronic exertional compartment syndrome (CECS) of the leg as a cause of exercise-induced leg pain was made in the 1950s, there has been no universally accepted diagnostic pressure. A 1997 review found 16 papers from 1962 to 1990, which have differing diagnostic criteria. The threshold pressure used at DMRC Headley Court is based on the work of Allen and Barnes from 1986, where in a patient with a suitable history, a dynamic pressure in the exercising muscle compartment above 50 mmHg is diagnostic. We present the data gathered at DMRC Headley Court during the first year of the new protocol on dynamic pressure testing, from May 2007. The new exercise protocol involved exercising patients using a representative military task: the combat fitness test (CFT) using a 15 kg Bergen on a treadmill, set at 6.5 km/h with zero incline. During this period, we performed 151 intra-compartmental pressure studies in 76 patients. 120 were successful in 68 patients, with 31 technical failures. Patients complained of exercise-induced leg pain on performing the CFT and pointed to the muscles in either the anterior or deep posterior muscle compartments and these were exclusively tested with invasive studies. No patients complained of symptoms in the lateral or superficial posterior compartments and therefore neither was tested. The majority were performed in the anterior leg compartment (110 successful), with a few (9 successful) in the deep posterior compartment, and there was only one complication with a posterior tibial artery puncture. The mean age of patient was 28.9 years (SD 6.7). In 119 compartment studies, the mean pressure was 97.8 mmHg (SD 31.7). This data is normally distributed (Shapiro Wilk test, W=0.98 p=0.125). In summary, we present the data using the CFT as the exercise protocol in patients who give a history compatible with CECS and have symptoms of leg pain during exercise. This data has a mean of approximately 100 mmHg, which is double that of the diagnostic criteria of Allen and Barnes, who used running as the exercise protocol. The presence of a weighted bergen as well as the stride and gait pattern used during the loaded march may be contributory factors in explaining why the pressures are higher compared to other forms of exercise. Further work is ongoing with determining the intracom-partmental muscle pressure in normal subjects with no history of exertional leg pain performing the CFT.
Amputation is one of the most feared injuries in service personnel, particularly a worry that it will mean the end of their military career. The aim of this study was to determine the outcome, in relation to military service in UK military amputees. UK service personnel who sustain an amputation undergo rehabilitation and prosthetic limb fitting at the Defence Medical Rehabilitation Centre Headley Court. This includes a realistic assessment of their employment capabilities, and they are graded by a Functional Activity Assessment (FAA). FAA ranges from 1 (fully fit) to 5 (unfit all duties). In addition the Short Form-36 Health Survey (SF-36) is completed on initial admission and at follow-up. We reviewed this information to determine the outcome of military amputees. We identified 53 casualties who had sustained amputations. 8 had sustained an upper limb amputation, 41 a lower limb amputation, and 4 had sustained both an upper and lower limb amputation. 9 patients (including 1 Reservist) have left the forces by medical discharge, with the remaining 44 continuing to serve. 32 of the 44 have returned to work, albeit at a lower level. 49 patients have FAA grades and are at least 6 months post-injury. No patients were graded as FAA 1, 8 as FAA 2 (Fit for Trade and fit for restricted General or Military Duties), 18 as FAA 3 (Unfit for Trade but fit for restricted General or Military Duties), 18 as FAA 4 (Unfit for all but Sedentary Duties) and 5 as FAA 5. All bilateral and triple amputees were FAA 4 or 5. Other injuries such as blindness, severe brain injury or mental health issues also increased the FAA. Of the 32 patients who have returned to work, 8 are FAA 2, 12 are FAA 3, 11 are FAA 4, and 1 has not been graded. SF-36 data was available in 40 patients, available as paired scores for 34. The mean time between SF-36 scoring was 6.7 months (range 0.2 – 17.4). The mean SF-36 scores for Physical Component Summary (PCS) increased from 34.40 (SD 9.3) to 42.06 (SD 11.1), with Mental Component Summary (MCS) 52.01 (SD12.9) remaining similar at 52.92 (SD 12.0). Pre- and post-rehabilitation PCS scores improved with rehabilitation (p=0.0003). MCS scores were similar in these patients to the normal population, 50 (SD 10). No differences could be found within the unilateral lower limb amputation group regarding amputation level (trans-tibial, through-knee disarticulation, trans-femoral) and SF-36 scoring. Furthermore due to the low numbers, no conclusion could be made comparing the unilateral lower limb amputation group with the bilateral lower limb group, the unilateral lower limb plus upper limb, the bilateral lower limb and upper limb (trilateral), and the isolated upper limb groups. This study is the first to report the outcomes, with regards to return to work, of the UK military amputee population injured in Afghanistan and Iraq. There is an almost even distribution of FAA score between 2, 3, and 4 for those back at work. Level of amputation and SF-36 scores do not seem to correlate, partly due to other injuries sustained that confound the patients’ perception of their health. SF-36 PCS scores increase significantly with rehabilitation, whilst MCS remain similar to the normal population.
