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DOD Amputation and Extremity Trauma Rehabilitation:
Then and Now
November 2018
Stuart Campbell, PT, MPTChief, Global Health Engagement
Extremity Trauma and Amputation Center of Excellence
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED 2
DOD Amputation and Extremity Trauma Rehabilitation:Then and Now
The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General the Department of the Army or the Department of Defense or the U.S. Government.
I have no conflicts to declare
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
DOD Rehabilitation: History
• Lessons from Previous Conflicts• Specialty Hospitals
• Rehabilitation in cohort groups• Multi Disciplinary teams• Rehabilitation move to lower echelons
• Activities outside of the clinical setting
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
DOD Rehabilitation: History
• Lessons from Previous Conflicts• Specialty Hospitals
• Rehabilitation in cohort groups• Multi Disciplinary teams• Rehabilitation move to lower echelons
• Activities outside of the clinical setting
4
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Army Policy
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Physical reconstruction is the completest form of medical and surgical treatment carried to the point where maximum functional restoration, mental and physical, may be secured. To secure this result, the use of work, mental and manual, will be required during the convalescent period. This therapeutic measure, in addition to aiding in greatly shortening the convalescent period, retains or arouses mental activities preventing hospitalization, and enables the patient to be returned to service or civil life with the full realization that he can work in his handicapped state, and with habits of industry much encouraged if not firmly formed.Hereafter no member of the military service should be recommended for discharge from yourhospital until he has attained complete recovery or as complete recovery as it is to be expected he will attain when the nature of his disability is considered.
MDWW vol.13, p.8. This definition was adopted in April, 1918.
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Army Policy Changes
• November 1919: One year period of treatment for remaining patients
• September 1940 President Roosevelt approved Army discharging patients directly to VA hospitals
• December 4, 1944My dear Mr. Secretary,
I am deeply concerned over the physical and emotional condition of disabled men returning from the war. I feel, as I am sure you do, that the ultimate ought to be done for them to return them as useful citizens – useful not only to themselves but to the community.
I wish you would issue instructions to the effect that it should be the responsibility of the military authorities to insure that no oversees casualty is discharged from the armed service until he has received the maximum benefit of hospitalization and convalescent facilities which must include physical and psychological rehabilitation, vocational guidance, pre-vocational training, and resocialization.
Very sincerely yours,Franklin D. Roosevelt
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
DOD /VA Relationship
• The Veterans’ Bureau stood up in 1921 and by 1940 had become the largest hospital system in the US
• Veterans Administration formed in 1930
• DOD/ VA healthcare relationship
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
DOD Rehabilitation Today
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US Military Health System Levels of CareClinical Specialties Level 1 Level 2 Level 3 Level 4 Level 5
Orthopedic Surgeon Orthopedic Surgeon Orthopeadic Surgeon Orthopedic Surgeon
PM&R Physician PM&R Physician PM&R Physician
Physical Therapist Physical Therapist (in a Special Operations Unit) Physical Therapist Physical Therapist Physical Therapist Physical Therapist
Occupational TherapistOccupational Therapist ( in Behavioral Health role)
Occupational Therapist Occupational Therapist Occupational Therapist
Behavioral Health Specialist
Behavioral Health Specialist
Behavioral Health Specialist
Behavioral Health Specialist
Dietician Dietician Dietician Dietician
Technical Staff Technical Staff Technical Staff Technical Staff Technical Staff
Prosthetist ProsthetistOrthotist Orthotist
Recreational Therapist Recreational Therapist
Case Manager Case Manager Case Manager
Research Staff Research Staff
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
DOD Role of Rehabilitation
• Expert evaluation and treatment for patients throughout the continuum of care from prevention through reintegration
• All specialties within the team have a role in prevention• Physical Therapists teaching classes on proper body mechanics • Occupational Therapists performing ergonomic assessments • Psychologist teaching classes in resiliency
• Rehabilitation after an injury begins as soon as possible• PT’s as Physician extenders• PM&R physician consulting with surgeon to optimize immediate and long term pain
management prior to a surgery• PT and prosthetist consulting with surgeon prior to an amputation surgery to ensure
improved functional outcome
• Intensity and duration of care determined by desired outcomes
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Transdisciplinary Team
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Surgical SpecialtiesPhysiatryPain ManagementIntegrative Medicine
Behavioral HealthNeuropsychologyInfectious DiseaseNursing
Speech & Language PathDriving RehabilitationSports/Rec/Art TherapyPeer Support
Prosthetics/OrthoticsGait LabPhysical TherapyOccupational TherapyAssistive Technology
Vocational CounselorsSocial WorkVA LiaisonsPEBLOPublic AffairsIT/Database Support
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Advanced Rehabilitation Centers
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Walter Reed National Military Medical Center•US Army Amputee Patient Care Program (December 2001-2007)
•Military Advanced Training Center (MATC) (2007-2011)•Armed Forces Amputee Program (2011-present)
Naval Medical Center San Diego•Comprehensive Combat and Complex Casualty Care (C5) (November 2006-
present)
Brooke Army Medical Center San AntonioSan Antonio Military Medical Center•Amputee Care Center (2004-2006)•Center for the Intrepid (CFI) (January 2007-present)
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Advanced Rehabilitation Centers
• Integrated, transdisciplinary teams• Expert surgeons, PM&R, PT, OT, PCM, NCM, SWS,• BH, O&P, Dermatology, Neurology• GS Civilian based rehabilitation and support
• Efficacious rehabilitation to optimum function
• Individualized and unique to the MHS • Well developed system of care with contract – based expansion capability• State of the art prosthetic and orthotic devices crafted with
industry• Integrated with 26 ARC embedded EACE researchers
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**Ultimate goal is restoration of normal human function**
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Evidence Based Practice
• VA/DoD CLINICAL PRACTICE GUIDELINE– Rehabilitation of Lower Limb Amputation– The Management of Upper Extremity Amputation Rehabilitation
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED 14
Virtual Rehabilitation
• Virtual Reality in clinical practice
• Becoming more popular and common
• Utilization has not been maximized
• Advantages or VR vs. real world
• Needs more study
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Training Based on Technology
• Genium• Evolution from C-leg to X3• Variation of training X3 vs. Total knee
• Powered Prosthesis• Ankle foot• Knee• Upper extremity
• IDEO• Improved training for limb salvage patients• Return to Run program
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Blood Flow Restriction Therapy
• Background for utilization of BFR in rehabilitation
• History
• Physiologic effects
• Results
• Further research needed
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Training Based on Surgical Advances
• Targeted Muscle Reinervation• Progression of limited use of TMR in UE to LE for Pain management• TMR concerns for rehabilitation
• Osseo-integration• Rehabilitation of patients with lower extremity osseo-integration
• Advanced Limb Salvage Procedures• Rehabilitation protocols for limb salvage
• Timelines• Alter-G
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
Outcomes Assessment
• Functional Outcomes measures• AMP• CHAMP• 10- meter walk• Sit to stand• Four square step test• Timed stair ascent
• Patient reported outcome measures• List a couple PRO
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
The Future
• With the massive changes in the MHS I am going to leave this slide with a
?
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Surveillance/ Epidemiology
Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
References
• https://smallbusiness.chron.com/difference-between-transdisciplinary-team-multidisciplinary-team-18762.htm
• Keshner, Emily A., and Patrice Tamar Weiss. "Introduction to the special issue from the proceedings of the 2006 International Workshop on Virtual Reality in Rehabilitation." Journal of neuroengineering and rehabilitation 4.1 (2007): 18.
• D'angelo, M., et al. "Application of virtual reality to the rehabilitation field to aid amputee rehabilitation: findings from a systematic review." Disability and Rehabilitation: Assistive Technology5.2 (2010): 136-142.
• Keshner, Emily A. "Virtual reality and physical rehabilitation: a new toy or a new research and rehabilitation tool?" Journal of NeuroEngineering and Rehabilitation (2004): 1:8.
• M. Jason Highsmith, Leif M. Nelson, Neil T. Carbone, Tyler D. Klenow, Jason T. Kahle, Owen T. Hill, Jason T. Maikos, Mike S. Kartel, Billie J. Randolph; Outcomes Associated With the Intrepid Dynamic Exoskeletal Orthosis (IDEO): A Systematic Review of the Literature, Military Medicine, Volume 181, Issue suppl_4, 1 November 2016, Pages 69–76, https://doi.org/10.7205/MILMED-D-16-00280
• Tennent, David J., et al. "Blood flow restriction training after knee arthroscopy: a randomized controlled pilot study." Clinical Journal of Sport Medicine 27.3 (2017): 245-252.
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
References
• Hylden, Christina, et al. "Blood flow restriction rehabilitation for extremity weakness: a case series." J Spec Oper Med 15.1 (2015): 50-6.
• Nielsen, Jakob Lindberg, et al. "Proliferation of myogenic stem cells in human skeletal muscle in response to low-load resistance training with blood flow restriction." The Journal of physiology 590.17 (2012): 4351-4361.
• Fry, Christopher S., et al. "Blood flow restriction exercise stimulates mTORC1 signaling and muscle protein synthesis in older men." Journal of applied physiology 108.5 (2010): 1199-1209.
• Fujita, Satoshi, et al. "Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis." Journal of applied physiology 103.3 (2007): 903-910.
• Gailey, Robert S., et al. Development and reliability testing of the Comprehensive High-Level Activity Mobility Predictor (CHAMP) in male servicemembers with traumatic lower-limb loss. WALTER REED ARMY MEDICAL CENTER WASHINGTON DC, 2013.
• Charles Scoville PT, D. P. T. "Construct validity of Comprehensive High-Level Activity Mobility Predictor (CHAMP) for male servicemembers with traumatic lowerlimb loss." Journal of rehabilitation research and development 50.7 (2013): 919.
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Mr. Stuart M. Campbell/DASG-ACE/210-221-6896/[email protected] UNCLASSIFIED
References
• Gaunaurd, Ignacio A., Robert S. Gailey, and Paul F. Pasquina. "More than the final score: development, application, and future research of comprehensive high-level activity mobility predictor." J Rehabil Res Dev 50.7 (2013): ix-xv.
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