Aspirin gives no relief, but anticonvulsant drugs and heavy painkillers like morphine have helped some amputees. Others have been helped by a transcutaneous electrical nerve stimulator, or TENS, a battery-driven device about the size of an iPod that delivers electrical impulses to stimulate nerves in the painful area. Somewhat more effective has been a spinal cord stimulator, an electric impulse-generating device implanted near the spinal cord. Hypnosis, acupuncture, biofeedback, vibration therapy, massage, yoga, ice packs, heating pads, and even steroid shots have also been useful. But what seems most significant is that nothing helps very much. The pain is often most severe when the prosthesis is removed, and so patients are encouraged to use the prosthesis as much as possible.
According to Doidge’s book, Ramachandran’s research led him to think that the absence of feedback from the missing limb to the brain leads not only to the phantoms but to phantom pain. “The brain’s motor center might send commands for the hand muscles to contract but, getting no feedback that the hand has moved, it escalates its command” until, for instance, it feels as if the fingernails are digging into the palm. This oversimplifies Ramachandran’s findings, but he felt that the phantoms were a result of the brain’s mistaken body image. If the image were reinforced, he reasoned, the pain might vanish.
Advances in prosthetic technology have been hugely affected by the Iraq War, and by 2004 new prosthetics were coming onto the market that seemed more products of science fiction than medical technology. The Otto Bock C-leg has a battery-powered “onboard” microprocessor that controls knee movement and communicates with a computer through Bluetooth technology. It can switch between two modes of activity with several taps of the toe.
The C-leg, however, is receiving serious competition from the Ossur Bionic Power Knee, which can synchronize movement with the sound leg to “lift the user to standing from a seated position; support the user while ascending inclines; and power them upstairs.” When the user is walking, the knee’s pendulum motion swings it forward, senses the changing terrain, and “actively lifts the heel off the ground,” according to Ossur’s website. By means of “artificial proprioception,” which is a person’s awareness of his or her posture, movement, balance, and location, the knee “anticipates and responds to the appropriate function required for the next prosthetic step.” There are also power heels to give the walker a boost so the prosthesis won’t, in Glenn’s words, “always [be] dragging at you.”
Yet these bionic prosthetics are nothing compared to what is currently in development. In February, the Defense Advanced Research Projects Agency (DARPA) awarded a contract to the Applied Physics Laboratory at Johns Hopkins University to finish work on a mechanical arm “that will look, feel and perform like a normal limb,” according to the online magazine Gizmag. The Johns Hopkins laboratory, leading a team drawn from about 30 organizations, had already developed two prototypes of prosthetic arms. The first is an arm that “can be controlled naturally, provide sensory feedback and allow for eight degrees of freedom.” The best prosthetic arms now on the market provide for only three degrees of movement. The second prototype uses 25 individual joints “that approach the natural speed and range of motions of the human limb…[and] are complemented by a range of emerging neural integration strategies,” meaning they can be wired to the brain through the nervous system. You think your hand into motion and it moves. The arm should be ready for regulatory clearance in under two years.
So far the Iraq War has led to amputations for more than 750 servicemen and women. The high number is due in part to the body armor that protects the trunk. Without it, many of these soldiers would have died. In fact, about 92 percent of those wounded in Iraq survive their wounds, as opposed to 76 percent in Vietnam.
Founded in 1958 in response to the Sputnik surprise, DARPA is responsible for developing new military technology, while its prosthetic program tries to provide the best “medical and rehabilitative technologies for military personnel injured in the line of duty,” according to Gizmag. The requirement that the soldier be injured in the line of duty may explain what was for me an odd discrepancy. Between 2001 and 2007, the Veterans Administration performed more than 17,000 amputations on former military personnel, most of whom suffered from diabetes. Although these amputees provide a steady business for the prosthetics industry, their needs have not led to anything like DARPA’s “Revolutionizing Prosthetics” program, which has provided funds for “the most advanced medical and rehabilitative technologies.” Nor would these VA amputees necessarily benefit from the new developments. Coverage of prosthetic limbs has been limited to $2500 or $5000 a year by many private health plans. Or the plans will pay for only one device per limb over the patient’s lifetime. And the insurance lobby has been trying to reduce this amount. The cost of basic prostheses ranges between $3000 and $15,000, while models resulting from the new technologies can be priced at more than $40,000.
As with any war, sympathy and attention goes to the soldiers injured in combat, and of these Iraq has provided nearly 100,000. The first Iraq War amputees were treated at Walter Reed Army Medical Center outside of Washington. Then, as their number increased, the Department of Defense opened a second amputee care center at Brooke Army Medical Center at Fort Houston in San Antonio, Texas, in early 2005.
A third amputee care center was officially opened in San Diego on October 15 as part of the Comprehensive Combat Casualty Care Center, or C5, of the Naval Medical Center. The 30,000-square-foot facility is not only a showpiece of new technology, with an accurate motion-capture system and an advanced bionic technology room used for gait adjustment, but also includes a 3500-square-foot obstacle course with a 30-foot climbing wall. It cost $4.4 million to build and another $4 million to outfit and staff. A major focus of C5 is to get the amputees moving as soon as possible, taking them on ski trips, having them engage in sports, and even learning to surf. I decided to visit the facility, but before I spoke to the wounded soldiers, I wanted to talk to Dr. Ramachandran at UCSD.