DOD Amputation and Extremity Trauma Rehabilitation: Then and Now

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1 DOD Amputation and Extremity Trauma Rehabilitation: Then and Now Stuart Campbell, PT, MPT Chief, Global Health Engagement Extremity Trauma and Amputation Center of Excellence November 2018

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 2

groups Multi Disciplinary teams Rehabilitation move to

3 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 3

4 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

5 Army Policy 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 your hospital 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,

6 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, 1944 My 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 6

7 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 7

8 DOD Rehabilitation Today US Military Health System Levels of Care Clinical 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 Therapist Occupational 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 Prosthetist Orthotist Orthotist Recreational Therapist Recreational Therapist Case Manager Case Manager Case Manager Research Staff Research Staff 8

9 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 9

Transdisciplinary Team Surgical Specialties

Behavioral Health Neuropsychology Infectious

Rehabilitation Sports/Rec/Art Therapy Peer Support

Occupational Therapy Assistive Technology

10 Transdisciplinary Team Surgical Specialties Physiatry Pain Management Integrative Medicine Behavioral Health Neuropsychology Infectious Disease Nursing Speech & Language Path Driving Rehabilitation Sports/Rec/Art Therapy Peer Support Prosthetics/Orthotics Gait Lab Physical Therapy Occupational Therapy Assistive Technology Vocational Counselors Social Work VA Liaisons PEBLO Public Affairs IT/Database Support 10

Advanced Rehabilitation Centers Walter Reed

Patient Care Program (December 2001-2007) Military

Forces Amputee Program (2011-present) Naval

Complex Casualty Care (C5) (November 2006-

San Antonio Military Medical Center Amputee Care

11 Advanced Rehabilitation Centers Walter Reed National Military Medical Center US Army Amputee Patient Care Program (December ) Military Advanced Training Center (MATC) ( ) Armed Forces Amputee Program (2011-present) Naval Medical Center San Diego Comprehensive Combat and Complex Casualty Care (C5) (November present) Brooke Army Medical Center San Antonio San Antonio Military Medical Center Amputee Care Center ( ) Center for the Intrepid (CFI) (January 2007-present) 11

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

12 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 **Ultimate goal is restoration of normal human function** 12

13 Evidence Based Practice VA/DoD CLINICAL PRACTICE GUIDELINE Rehabilitation of Lower Limb Amputation The Management of Upper Extremity Amputation Rehabilitation 13

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 14

15 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 15

16 Blood Flow Restriction Therapy Background for utilization of BFR in rehabilitation History Physiologic effects Results Further research needed 16

17 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 17

18 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 18

19 The Future With the massive changes in the MHS I am going to leave this slide with a? Surveillance/ Epidemiology 19

20 Questions? 20

22 References 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 Technology 5.2 (2010): 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, 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):

23 References Hylden, Christina, et al. "Blood flow restriction rehabilitation for extremity weakness: a case series." J Spec Oper Med 15.1 (2015): 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 (2012): Fry, Christopher S., et al. "Blood flow restriction exercise stimulates mtorc1 signaling and muscle protein synthesis in older men." Journal of applied physiology (2010): Fujita, Satoshi, et al. "Blood flow restriction during low-intensity resistance exercise increases S6K1 phosphorylation and muscle protein synthesis." Journal of applied physiology (2007): 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, 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):

24 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. 24

Curriculum Vitae. Kelly McGaughey PT, DPT Address: 31 Readfield Rd Unit 129 Manchester, ME Phone Number:

Curriculum Vitae. Kelly McGaughey PT, DPT Address: 31 Readfield Rd Unit 129 Manchester, ME Phone Number: Curriculum Vitae Name: Kelly McGaughey PT, DPT Address: 31 Readfield Rd Unit 129 Manchester, ME 04351 Phone Number: 540-239- 8155 Name of Educational Program and Institution: Shenandoah University Division