Advances in Combat Amputee Care

The VA Systems-Based Approach to Longitudinal Care

Joseph B. Webster, M.D.National Director

VA Amputation System of CareHunter Holmes McGuire VA Medical Center

Richmond, VAjoseph.webster@va.gov

Overview

Systems-Based Approach to Longitudinal Care

• Establishing Standards• Understanding the Population Served• New Service Delivery Models• Unique Rehabilitation Needs• Key Life-Long Considerations

• Case-Based and Clinical Focus

Disclosures

Joseph B. Webster, M.D.

No relevant financial disclosures

Views expressed in this presentation do not represent the views of the Federal Government or the

Department of Veterans Affairs

Case Presentation

36 year-old Army Veteran who required a left knee disarticulation amputation following a parachute accident in 2009.

He lives in the Fredericksburg area with his wife and 6 children. He works full-time for the FBI.

Veteran presents for his annual follow-up.

Lifelong Care

Surgical

Medical

Inpatient - ImmediateTransitional / CommunityRe-entry

Outpatient Care

VocationalEducationalSupport GroupsDay ActivitySupported LivingTotal CareOutpatient Care

Inpatient - Ongoing

Family SupportCare Coordination / Case ManagementBenefits ManagementMedical Information Management

Acute Care Rehabilitation

CommunityReintegration

LifetimeCommunity Care

5

Veteran-Centric Care

Individualized Rehabilitation Program

• Various levels and intensity of care• Continuity of services• Incorporation of rehabilitation technologies• Incorporation of medical care (pain management, wound care)• Incorporation of support services • Services available across continuum of care• Care Coordination

Veteran-Centric Care

Individualized Prosthesis Prescription

• Team approach• Based on clinical indications and justification• Based on identified goals and functional status• Ability to perform device trials• Considerations for activity-specific devices• Considerations for spare or back-up devices• Routine reassessment based on functional

needs and availability of new technology

Advances in Care

Importance of a Systems-Based Approach

VA Amputation System of Care

• Formal initiation in 2008

• Mission: Enhance quality and consistency of amputation care

• Driving forces: Growth and need for specialized expertise• Service members with combat-related amputations• Veterans with amputations from disease processes

• The ASoC is an integrated, national health care delivery system

• ASoC provides specialized expertise in amputation care incorporating the latest practices in medical rehabilitation, therapy services, and prosthetic technology

J Rehabil Res Dev. 2014;51(4):vii–xvi.

ASoC Organizational Components

Regional Amputation Centers - RACs (7)• Medical Director• Amputation Rehabilitation Coordinator• Program Support Assistant• Prosthetist

Polytrauma Amputation Network Sites - PANS (18)• Medical Director • Amputation Rehabilitation Coordinator• Program Support Assistant

Amputation Clinic Teams - ACTs (106)

Amputation Points of Contact - APOCs (22)

J Rehabil Res Dev. 2014;51(4):vii–xvi.

Advances in Care

Setting the Bar

VA Amputation Care Hallmarks

• Veteran-Centric Care• Interdisciplinary Team Approach• Care Coordination• Lifelong Continuum of Care• Integration• Collaboration• Education and Training• Technology Advances

Commission for Accreditation of Rehabilitation Facilities Amputation Specialty Accreditation

• CARF specialty accreditation in amputation care initiated in 2008

• Accreditation status signifiesDistinguished level of amputation care expertiseComprehensive spectrum of services

• 96% of the VA RAC and PANS facilities have achieved accreditation

• 34% of all programs worldwide are VA Medical Centers

Provider Education

• Clinical Practice Guidelines (Joint with DoD)

Lower Extremity CPG (2008)

Upper Extremity CPG (2014)

Lower Extremity CPG Update (2017)https://www.healthquality.va.gov/guidelines/rehab/amp/index.asp

Full GuidelineClinician SummaryPatient SummaryPocket Card

Education and Training

• Military Advanced Amputation Skills Training (MAAST) Course – (2009)

• Amputation Teams, Treatment and Technology Conference – (2009)

• VA Advanced Amputation Skills (VAAMPS) Course – Tampa (June 2010)

• 7 Regional Education Conferences – Each RAC (2010)

• National Education Conference – Indianapolis (July 2011)

• New Horizons Conference – Atlanta (June 2012)

• VAAMPS Course on Upper Limb Amputation – San Antonio (2012)

• FAAST Symposium (Multiple Limb Amputation) – Crystal City (2014)

• FAAST Symposium (Lessons Learned) – San Antonio (2015)

• FAAST Symposium (Practical Integration) – San Pedro (2016)

• FAAST Symposium (Lifelong Outcomes) – Walter Reed (2017)

Integration and Collaboration

VA ASoC VA O&P

EACE

Amputation Prevention

(PAVE)

Primary Care Case Mgmt

DoD

Service OrgsNon-Profit Agencies

Community O&P Providers

Surgery

Internal

External

Advances in Care

Understanding the Population Served

VA Amputee Data Repository

• Part of original conceptualization for the Amputation System of Care

• Development Process2010-12: Planning and Funding Source identification2012-15: Formal project development and completion

• Data Element DomainsDemographics, Service Era, Mortality, Co-morbidities, Amputation Characteristics, Clinical Encounters, Prosthetics Data

OEF/OIF/OND Population Characteristics

37.6 - Average Age 97% Male

3.4% Total Amputee Population

7% Diabetes

3,107 Veterans1937 (62%) Major Limb

Military (OEF/OIF/OND) Veteran Amputees

Vietnam Veteran Population

Total number of OEF/OIF/OND Patients that received a complete limb, or service/repair to an existing limb FY2004 thru FY2017

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

AK-Amputee Care 5 8 65 88 140 177 183 197 279 410 480 497 510 511

BK-Amputee Care 14 18 77 127 180 231 240 297 376 503 664 700 783 822

UE-Amputee Care 4 8 23 36 65 81 80 94 110 148 178 208 232 244

Totals 20 30 138 211 311 408 424 497 653 895 1,102 1,198 1,288 1,332

Source: NPPD

Total number of all VA Prosthetic Patients that received a complete limb, or service/repair to an existing limb 2004 thru FY2017

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

AK-Amputee Care 2,877 1,909 3,413 3,501 3,834 4,073 4,019 4,382 4,542 5,106 5,038 5,026 5,132 5,221

BK-Amputee Care 5,473 4,616 6,665 6,702 7,131 7,030 7,268 7,543 7,788 8,179 8,344 8,743 8,927 8,992

UE-Amputee Care 680 653 694 820 1,094 1,091 1,057 1,159 1,284 1,382 1,577 1,650 1,684 1,796

Totals 8,242 6,888 9,674 9,884 10,752 10,753 10,941 11,495 11,990 12,850 13,135 13,596 13,762 14,059

Source: NPPD

VA Prosthetic Limb Delivery and Services

Functional Outcome Measurement

Functional Outcome Measurement

Case Presentation

37 year-old Army Veteran who sustained extremity trauma from an IED blast in Afghanistan during deployment in 2009 requiring a right knee disarticulation and left transtibial amputation.

He is married and lives with his wife and 2 children in Charlottesville . He works as an attorney.

He presents with socket fitting issues with his transtibialprosthesis.

Advances in Care

New Service Delivery Models

VA TeleAmputation Program

• Key feature of the ASoC

• Part of a broader VA Telehealth Program

• Significant resources dedicated

• Program Development and growthInterdisciplinary Amputee ClinicVA Prosthetist Amputee ClinicSupport Groups

• New technologies

0

500

1000

1500

2000

2500

3000

3500

2644 182

615

1181

1726

2321

28243113 FY 08

FY 09

FY 10

FY 11

FY 12

FY 13

FY 14

FY 15

FY 16

TELEAMPUTATION SERVICES

TELEAMPUTATION SERVICES

VA VIDEO CONNECT

1. Schedule VA Video Connect Visit

2. Open Email & Click on link.

3. Join Virtual Medical Room

Telerehabilitation Specialty Guidance

• Newly Approved Specialty Guidance – Amputation VA Video Connect – Amputee Support Group– VVC to Community Prosthetic Provider

• Guidance Components– Clinical Considerations– VA Video Connect Appointment– Business– Technology– Environment

Service Delivery Modeling

Service Delivery Modeling

Service Delivery Modeling

Viewport Veteran Population Aggregator

Service Delivery Modeling

Potential Site for Service Expansion

Veterans with Limb Loss Densities by Zip Code

Service Delivery Modeling

Service Delivery / Clinic Flow

Case Presentation47 year-old male Army Veteran who sustained extremity trauma as a result of an IED blast in Afghanistan in 2009

Extensive surgical, pain management and bracing interventions over time

Progressive functional limitations secondary to pain and limited ROM in the right ankle

Underwent right transtibial amputation in August 2017

Extremity Trauma Epidemiology

• Extremity Trauma (ET) is a term that encompasses a broad spectrum of injury severity with no consensus definition

• Epidemiology of Extremity Trauma not well defined

• Estimated 30,000 cases of OEF/OIF combat-related ET

• 19,000 required hospitalization

• Epidemiology of Civilian ET and military (non-combat related ET is also unclear)

J Surg Orthop Adv. 2012 Spring;21(1):2-7.J Trauma. 2008 Feb;64(2):295-9.

Lower Extremity Assessment Project (LEAP)

• Project funded by NIH/ 8 Level 1 Trauma Centers

• 569 patients with severe lower extremity injuries (24 month f-up)

• Functional Outcome measure: Sickness Impact Profile (SIP)

• 42% with residual “severe disability” as measured by SIP

• Re-hospitalization rate higher in with limb reconstruction

• No differences in functional outcomes between limb reconstruction and amputation

• Outcomes influenced by socioeconomic status

N Engl J Med 2002;347:1924–1931.

Lower Extremity Assessment Project (LEAP)

• 397/569 patients contacted by phone (Average 84 months post-injury)

• Most of the patients reported that physical and psychosocial functioning had deteriorated since their 24-month follow-up

• 50% of the patients indicated severe disability

• One third in both groups re-hospitalized between 2 and 7 years

• No difference in SIP scores across both treatment groups

• Evidence-Based Orthopedic Trauma Working Group Meta Analysis• No significant differences in functional outcome including

competitive employment at least up to 7 years

J Bone Joint Surg Am. 2005 Aug;87(8):1801-9.J Orthop Trauma. 2007. 21(1):70–76.

Strat Traum Limb Recon (2012) 7:57–66.

The Military Extremity Trauma Amputation/Limb Salvage (METALS) Study

• Retrospective cohort study of 324 OEF/OIF Servicemembers with lower-limb injuries requiring either amputation or limb salvage

• The Short Musculoskeletal Function Assessment (SMFA) questionnaire was used to measure overall function

• Amputation group had better scores in all SMFA domains

• Amputation group with lower likelihood of PTSD and a higher likelihood of being engaged in vigorous sports

• There were no significant differences between the groups with regard to the percentage of patients with depressive symptoms, pain interfering with daily activities, or work/school status

J Bone Joint Surg. 2013 Jan 16;95(2):138-45.

Intrepid Dynamic Exoskeletal Orthosis (IDEO)

Mil Med. 2016 Nov;181(S4):69-76.J Surg Ortho Adv. 2011; 20(1):8–18.

JBJS Am. 2012; 94:507-15.J Trauma Acute Care Surg. 2012 Aug;73(2 Suppl 1):S112-5.

Clin Orthop Relat Res. 2014 Apr 18.J Orthop Trauma. 2014 Apr;28(4):e70-4.

IDEO Outcomes• Well-tolerated• Improved agility, power, and speed• Improved functional performance• Potential return to exercise/recreation• Potential to serve as an alternative to late

amputation• Potential to return to duty

• Return to Run Clinical Pathway importance

Dynamic Bracing Considerations

• Persistent functional mobility impairments following severe lower extremity trauma

• Persistent loss of motor function

• Pain with weight-bearing (mechanical) vs. neuropathic pain

• Desire and potential to return to higher level activities including running

• Dynamic Bracing trial should be considered in most cases

• Delayed Amputation should not be considered a failure

Case Presentation28 year-old male Marine Corp Veteran with depression, PTSD and substance abuse

Motorcycle accident in January 2017 with left lower extremity injuries requiring a left transfemoral amputation

Admitted to Richmond Polytrauma Unit for acute rehab

Residential Rehab admission following prosthesis fitting

Advances in Care

It’s not just about the amputation

Trauma Associated Injuries

• Combat-related amputations are associated with moderate to severe injury severity scores (Scores in the 9-15 range)

• Higher Injury Severity Scores associated with: upper extremity amputationsproximal or bilateral lower extremity amputations

• Commonly associated injuries include: TBI, extremity injuries, burns, vision and hearing loss

• Personal Protective Equipment partial mitigation of life ending chest and torso injuries

• Extremities at greatest risk for complex blast injuries

Military Medicine. 2010;175(3):147-154.J Surg Orth Advances. 2012; 21(1):2-7.

J Am Acad Orthop Surg. 2006;14(10 Spec No.):S188-90. Review.

Trauma Associated Injuries

Military Medicine. 2010,175(3):147-154.JRRD. 2010,47(4), 275-97.JRRD. 2013;50(2):161-72.

Trauma Associated Conditions

Mental Health Considerations

• PTSD 66%• Depression / Adjustment Disorders 46%• Anxiety Disorders 38%• Substance Abuse 16%

• Some association with co-morbid injuries, injury severity, but not necessarily with the number of limb amputations

• Can be a primary concern with significant functional implications

• Symptoms may not improve with physical health improvements

• Longitudinal care is essential JRRD. 2010;47(4):373-86.OIG Report. Prosthetic Limb Care. May 2012.

Mil Med. 2017 May;182(5):e1619-e1624

TBI and PTSD Management

• Patience• Listen and Acknowledge• Caregiver Involvement• Written Instructions• Cognitive Assistive Devices• Team Collaboration• Encourage Engagement in Treatment• Peer Support• Suicide Awareness

Suicide Prevention is Everyone’s Business. #BeThere.

Lifelong Care Focus

• Comprehensive Medical, Rehabilitation, and Prosthetics Care

• High Standards for Function and Outcomes

• Proximity and Accessibility to Care Continuum

• Unique Primary and Specialty Care Considerations

• Incorporation of Care for Co-Morbid Injuries / Conditions

• Incorporation of Care for longer-term conditions and potential complications

• Incorporation of New Technology and Medical Advances

• Cardiovascular Disease

• Deep Venous Thrombosis

• Heterotopic Ossification

• Chronic Pain

• Infection / Osteomyelitis

• Mental Health Conditions

• Osteoarthritis

• Joint Pain

• Osteopenia / Osteoporosis

• Low Back Pain

• Overuse Syndromes

• Weight gain / Obesity

Secondary Health Conditions

JRRD. 2008;45(1):15-30.J Trauma Acute Care Surg. 2017; 82(3): 592-5.

British J Surg. 2012; 99(Supp 1):75-86.

Osteopenia and Osteoporosis

• Decreased Bone Mineral Density (BMD) reported in amputated residual limbs compared to intact limbs

• Severity of loss significant (28% difference) and not limited to the residual limb (lumbar spine)

• Potential relationship to decreased weight-bearing and force transmission (worse with TF level amputation)

• Osteoporosis characterized by a decrease in the outer bone width

• Concern for increased fracture risk, esp. with aging

J Bone Miner Res. 2008;(9):1449-57.JRRD. 2008;45(1):15-30.

J Clin Densitom. 2012;15(2);135-45.

Osteoarthritis / Joint Pain

• Greater force transmission through the intact limb with unilateral amputation (TFA > TTA)

• Greater hip involvement with TFA compared to TTA (Contralateral knee pain 75% with TFA)

• Contralateral knee pain and OA 65% greater compared to age-matched controls (knee and patellofemoral)

• Knee Osteoarthritis see in 27% of those with lower limb amputation

• Can also occur in proximal joints of the residual limb

JRRD. 2008;45(1):15-30.Clin Rehabil. 1998;12:348–353.

Arch Phys Med Rehabil. 2005;86:487–493. J Rheumatol. 2001;28:169–172.

Mil Med. 2016 Nov;181(S4):38-44.

Low Back Pain

• Common problem (LEA > UEA and TFA > TTA)

• Altered lumbopelvic mechanics frequently present

• Associated with:Poor prosthetic fit/alignment with abnormal posture Leg-length discrepancyGeneral deconditioningMuscular imbalance and contractures

• Significant pain levels and resulting functional limitations

• LBP and intact leg pain associated with decreased health-related QOL

JRRD. 2008;45(1):15-30.JRRD. 2005;2:155–166.

Arch Phys Med Rehabil. 2001;82:731–4.J Orthop Trauma. 2009.

Other Musculoskeletal Considerations

Overuse Syndromes• Remaining extremities, proximal joints, and spine• More common following upper extremity amputation• More common in bilateral lower limb amputation• Joint and energy conservation techniques important

Weight gain / Obesity• Very common• Potential to occur early or late• Multiple limb amputees at greater risk• Education and counseling important

JRRD. 2008;45(1):15-30.Clin Rehabil. 2005;19(1):81-6.

Arch Phys Med Rehabil . 2011;92:1967-73.Arch Phys Med Rehabil. 2017; 31. pii: S0003-9993(17)31333-3.

Multiple Limb Amputation Longitudinal Considerations

• Self-rated health status: Excellent or Very Good (61% OIF/OEF)

• Performance high-impact aerobic activities18% (OEF/OIF) versus 3% (Vietnam)

• Long-term consequences and needs not fully known– Higher rate of co-morbid injuries– Potential increased risk of secondary complications – Medical and metabolic consequences

• Increase or decrease in prosthetic needs over time?

• Greater need for DME, other mobility devices, and assistive technology

JRRD. 2010;47(4):333-48.J Trauma Acute Care Surg 2012; 73(6):1590-5.

Questions and Discussion

Individualized care is enhanced by a Systems-Based Approach

• Establishing Standards • Understanding the Population Served• New Service Delivery Models• Unique Rehabilitation Needs• Key Life-Long Considerations