Amelia Gentleman meets veterans who will star in next week's Games, and the rehabilitation teams who helped get them there

When Derek Derenalagi hurls the discus in the Paralympic Games next week, the legs he lost in an explosion in Afghanistan will have been replaced by a brand new pair of microprocessor-controlled legs, fitted in late July at a cost of £84,000.

Before his prosthetic legs were upgraded, he was throwing the discus about three metres short of the world record. His coaches hope that with the sophisticated new Genium knees, paid for by the military charity Help for Heroes, he will gain an extra seven metres in throwing distance. Huge expectation rests on these legs – not merely in terms of whether Derenalagi wins a hoped for gold medal for the British Paralympic team, but also in terms of the challenge facing the military as it tries to establish how best to deal with the large numbers of severely wounded servicemen who have returned from Iraq and Afghanistan over the past decade.

One of the unexpected consequences of recent conflicts, particularly in Afghanistan, has been the huge advances in the expertise of the battlefield surgeons, who are now able to save the lives of severely wounded soldiers, by performing rapid amputations on the spot. As a result many more severely injured people are surviving injuries that would previously have killed them. Over 70 double-amputees and 20 triple amputees have already gone through rehabilitation at the military rehabilitation centre, Headley Court.

Derenalagi had both legs amputated in a field hospital in Camp Bastion, after his Land Rover was blown up by an anti-tank mine during a patrol in Helmand Province; his heart stopped while he was being operated on and he was pronounced dead, and was about to be sent to the morgue when someone noticed a weak pulse.

Over the past four years the military has had to develop a large new support network to help servicemen with life-changing injuries to find new meaningful ways to spend the rest of their lives. Clearly only a tiny minority can be funded to take part in the Paralympics, but a significant element of the new rehabilitation programme for everyone is sport, and for those with an exceptional aptitude, there is funding for fast-tracked training to allow them to compete in the Paralympics.

The eight wounded servicemen and women who will compete make up a small part of the 300-strong team, but have attracted disproportionate attention. Those responsible for their training maintain that there is nothing political in their participation, and dismiss the suggestion that their sporting successes serve to put a positive gloss on the wider, less-focused suffering of others injured in conflicts.

"I don't think war is a thing to be celebrated. I think we are celebrating individuals. It shows that there is life after trauma," says Martin Colclough, head of the Battle Back Pheonix programme at Help For Heroes, and helps with the Front Line to Start Line initiative, set up to identify future Paralympians among the wounded.

New strategies



Visits to two rehabilitation centres where severely injured soldiers are recovering, and future Paralympians are being identified, reveal how rapidly the MoD and charities are being forced to work out new strategies to help the very injured pick up their lives.

David Richmond is the Defence Recovery Officer at Help for Heroes, and the head of Tedworth House, an 18th century stately home in Wiltshire which last July became one of five Personnel Recovery Centres for the wounded who have already been through most of their medical rehabilitation but who still need to work out how they are going to cope with the rest of their lives.

"There are certainly guys surviving now who wouldn't have survived five or ten years ago. That brings some pretty significant challenges," Richmond says. "They are very, very young; most of them are between 18 and 26. The youngest, under different circumstances would still be doing their A levels and something dreadful has happened to them. These guys have 60 or 70 years ahead of them. Some of these guys are struggling because they don't really know what they want to do."

Staff at both Tedworth House and Headley Court say the army initially found it difficult to cope with the rising numbers of wounded survivors, particularly in 2009 and 2010, when there was a surge in violence in Afghanistan, and only gradually began to have time to start thinking about how to support the long-term futures of those injured in conflict.

"It is new. How long ago was it that we had so many wounded? A long time ago. The UK has had to wake up to the fact that military operations involve casualties and deaths," Richmond says.

The Paralympics was created in the wake of World War II because doctors believed that sports therapy would enhance the quality of life for injured soldiers, and this is the thinking behind the Ministry of Defence's Battle Back programme and the Help for Heroes' Front Line to Start Line initiative.

"If you have suffered a serious injury, your self-confidence has taken an almighty wallop," Richmond says. "Sport is a really good way of showing guys what they can still do. You see the lights go back on … There is a direct impact on those who do the sport, but the spinoff from the elite guys is the inspiration it offers to others. Self-confidence and self-esteem is rebuilt and redeveloped."

Help for Heroes is spending £22m on a swift conversion of this Palladian mansion near Salisbury into a recovery centre that will be able to accommodate 50 wounded soldiers, installing state of the art gyms fitted with specially adapted sports equipment for the disabled.

A similarly comprehensive redevelopment is under way at the army's medical rehabilitation centre, located in another former stately home, Headley Court in Surrey, to expand its capacity. The centre's new Jubilee complex with 48 beds will formally open in September, though beds are already being occupied, creating space for about 120 patients at any one time.

A £440,000 on-site cinema, with seatless rows for wheelchairs, has just been opened, funded by the Royal British Legion. In 2008, the then Labour defence secretary Des Browne promised £28m would be invested in the centre, which receives patients once they are well enough to leave the Queen Elizabeth Hospital Birmingham, where acute injuries are treated as soon as patients are flown back from the battlefield.

The MoD says 117 new patients were referred here in April, but much of the space and expertise is needed for servicemen severely injured two or three years ago, who require long-term help with their recovery.

The on-site prosthetics unit has been forced to undergo enormous expansion to respond to the increased demand, and has had to refine its equipment to accommodate a previously-unseen cohort of very active and energetic newly-limbless patients, who are being encouraged to take up sport as a key part of their recovery.

In the prosthetics unit, Matthew Webb, who lost both legs above the knees and his left arm in Helmand last July, is having his legs refitted to make them less uncomfortable. It is a process that will take repeated appointments, and dedicated attention and care from Ian Jones, the head prosthetist, employed by the private company Blatchford, which is subcontracted by the Ministry of Defence to provide artificial limbs for all the wounded.

Webb recently participated in the Wounded Warrior games – a US games for the injured military, which took place in the Colorado Olympic centre this year – and received a standing ovation from the audience for completing a swimming race with one arm.

"It was really good. It was almost like a mini-Olympics. Michelle Obama gave a speech," he says. In that context he said his injuries were "pretty standard, really". "When you get blown up, anything can happen," he says.

He is looking forward to watching the Paralympics. "I've never been interested before. But I'm like this now," he says, matter-of-factly and gesturing with his prosthetic arm to his metal legs, fitted into a pair of black trainers. "I'm interested to see what I could achieve."

He says he will think about finding a sport he might be able to compete in later, once his rehabilitation is further progressed, but longer term he hopes to find work in engineering.

Ian Jones has been at Headley Court for six years and has had to transform his department to cope with the influx of severely injured patients. When he began working he was on duty one morning a week, with a colleague who also worked one morning a week, treating about nine patients a year. "Within the next year we were inundated. It has snowballed. Now there are 11 prosthetists and 23 technicians," he says. "We used to work in the shed under the stairs; we now have three departments; we are able to spend more time with the patients."

Before he worked with the military, the vast majority of people he treated who were recovering from double leg amputations were patients with diabetes or smoking-related illnesses, with an average age of 68. "They are going to be much less active anyway and may only live six to eight years. The type of legs they use are cheaper," he says.

The demands of the young injured soldiers are very different and the use of sport in rehabilitation has forced the prosthetists to refine their expertise to cope with the intensive pressure put on their new equipment.

A normal amputee might take their new leg home and use it occasionally, he says. "These guys were on them five or six hours every day. They were trying to do knee squats, and one-leg stands and jumping and all that sort of thing.

"These guys who are very driven, fantastic characters, they just want to get out there and do a lot. On the NHS you'd make new sockets, and you wouldn't have to touch them for six months, whereas here we were refitting sockets every other day. They were getting in the gym and working out – their stumps were changing, their muscles were changing, they were very dedicated to their rehab. It meant that we had to have a different approach – we were having to use technology that would allow them to get up and go.

"Every one of the 300 patients we have treated is a potential Paralympian. Most of them are very fit individuals before they are injured, and they remain very fit once they have lost their legs."

Staff training trips to London to help patients improve agility on their new legs, forcing them to run up spiral staircases at the Tower of London as part of a gruelling programme that would be unthinkable for most recovering amputees. The military gives every double leg amputee four pairs of legs, to accommodate this desire to do sport.

In addition to their main, electronically engineered C-legs (worth about £16,000 a pair), they are allocated stubbies (short training legs, with no knee joints, which can be used for rock climbing and bungee jumping, Jones says), running blades, and a pair of spare legs.

Injured servicemen could leave Headley Court with £50,000 worth of equipment. Difficulties come later when they leave the military, and the NHS does not have the budget to replace the equipment.

Jones believes that sport helps his patients, but he worries about their long-term future. "They are very upbeat. They have friends, colleagues … there is a military bubble here and they are protected by the bubble," he says. "In 20 years time when these guys have been out of the military for a long time, we might see different aspects – I guess clinical depression, it must hit them at some point. At the moment they get everything that they need, clinically. If they go out into the big wide world, there are a lot of constraints on the NHS."

Colclough, says both the Battle Back and the Front Line to Start Line initiative to identify and train future Paralympians, are actually the means to the more important end of broader rehabilitation and recovery. Success for some in the Paralympics, is important, he says, but it is really a sideshow in the bigger mission to help the injured rebuild their lives.

The current military Paralympians act as informal mentors to newly injured servicemen. They talk about how sport gave them hope and some kind of focus.

Often they meet them at an early point in their recovery, when perhaps they haven't come to terms with their injuries. "Because there is a rapport, from shared experiences on the battlefield, it does seem to shine a light into the dark corners of the mind of someone who is really struggling with what life they can hope for in the future," he says.

"Sport is merely a device for developing transferable skills," he adds. If staff encourage newly amputated soldiers to take up water-skiing, it is partly so they can enjoy the sport, but it also a way of making them see that they can achieve something apparently unattainable, and crucially the exercise also forces them to take part in shopping expeditions to buy food for the barbecue they will cook afterwards – possibly one of the first occasions they have gone shopping since their injuries. "The water-skiing is almost secondary."

Talent-spotting



When Derenalagi was at Headley Court he was spotted in one of the first talent-spotting sessions. "It is a very positive thing – sport is the best rehab for any injury. Both physically and mentally – when you do work out at the gym you just forget about everything, and focus on what you're doing," he says.

He doesn't view the involvement of injured veterans in the Paralympics as an uncomfortable reminder of the severity of the fighting in Afghanistan and Iraq.

"It's not a sad reflection of what's happened in Afghanistan. It's soldiers' role to go to the frontline. Things happen. I can't change what has happened, I can't change that I have lost my legs. All I can do is accept it and move on. Seeing other soldiers in the [Paralympic] squad, to me it's quite encouraging that they haven't stayed as they are, especially being injured, but that they are looking to a new chapter in their lives, and moving on."

Richmond does not believe that pushing some into the Paralympics creates unrealistic aspirations for others who are still struggling with the basics of everyday life – getting to the shops, finding work.

"We shouldn't be putting more pressure on people. No-one is pushing anybody. The elite guys have become Paralympians because they have that natural ability," he says. "It is easy for the spotlight to focus on the elite. The focus of having these people competing at an international level means [people think] 'I'm going to have a go at this. These guys can do it, so can I'. For me, that's a good thing. That outweighs the possible criticism that it takes attention away from the plight of others.

"Sport is not for everyone, I wouldn't suggest that for a minute. If it can enhance the lives of a significant number of them, then it's worth it. We have to make sure that we find other ways to inspire people who are not interested in sport."

In 2009 the comedian Jimmy Carr remarked that one good thing about the rise of injured soldiers in Iraq and Afghanistan would be the excellent Paralympics team we would have in 2012. The joke was generally very ill-received, and with only eight people in the squad of 300, the prediction hasn't really been realised. But Jon-Allan Butterworth, another veteran who lost an arm in Iraq, and was spotted in Headley Court as a talented cyclist, says he was not offended.

"It's funny. I've got a black sense of humour though," he says. "Everybody thought that all these guys, already fairly fit could transfer their skills, courage, bravery, physical fitness, to doing anything, any sport. But it hasn't appeared that way.

I think that people are in top of the sport who are limbless would be at the top of their game if they hadn't lost their limb. You can't just become a good sportsperson by losing a limb."

Colclough hopes that there will be at least double the number of ex-military participants in the 2016 Paralympics. Several team members say they were inspired to compete when the watched the Beijing Paralympics from their hospital beds, he says.

Neither he nor Derenalagi are clear if injured personnel from the Afghan national forces will be competing, but stress that they do not view the event as political.

"It's about celebrating the fortitude of our servicemen," Colclough says.

Richmond agrees: "Why shouldn't they be given these great opportunities? They have sacrificed a large part of their life. People like Derek just about died and here he is competing in the Paralympics. That's to be celebrated."

Polly Toynbee, page 37