DOD Amputation and Extremity Trauma Rehabilitation: Then ... · DOD Amputation and Extremity Trauma Rehabilitation: Then and Now The view(s) expressed herein are those of the author(s)

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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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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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.


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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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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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




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


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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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


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)


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**


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


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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Blood Flow Restriction Therapy

• Background for utilization of BFR in rehabilitation

• History

• Physiologic effects

• Results

• Further research needed

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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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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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The Future

• With the massive changes in the MHS I am going to leave this slide with a

?

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Surveillance/ Epidemiology


Questions?

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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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https://smallbusiness.chron.com/difference-between-transdisciplinary-team-multidisciplinary-team-18762.htm

https://doi.org/10.7205/MILMED-D-16-00280


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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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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DOD Amputation and Extremity Trauma Rehabilitation: Then ... · DOD Amputation and Extremity Trauma Rehabilitation: Then and Now The view(s) expressed herein are those of the author(s)

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