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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, [email protected]
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