Annemarie: I am excited to be here today with you all. We are going to talk today about amputation rehabilitation, the military experience. The views expressed in this presentation are mine alone, and do not necessarily reflect the official policy or position of the Department of Defense, Department of Veterans Affairs, Department of the Army, or Department of the Navy.
Military Statistics
As of March 2017, there have been a total of 1,700 service members with amputations from the conflicts in Afghanistan and Iraq. Combat casualties resulting in amputations have significantly increased between the years of 2004, 2007, and 2011. Service members with amputations are treated at the military treatment facilities specializing in amputations, which are primarily Water Reed National Military Medical Center, San Antonio Military Medical Center, and the Naval Medical Center San Diego. Of the total number of these service members with amputations, approximately 17% had upper limb involvement. As compared to the civilian population, upper limb amputation usually accounts for approximately 34%, but only 9% of those are considered major, which is proximal to the digits. There is more upper limb involvement in the military than in the general population due to the nature of the conflicts. Throughout the 16 years of war, the mechanisms and magnitude of injury have continued to evolve, resulting in more multiple limb involvement. From conflict-related amputations, there have been six individuals with quadrilateral amputations and 56 with triple amputations.
The Army has seen the greatest number of conflict related amputations, followed by the Marines. But with the war, there also comes advancements in surgical techniques and rehabilitative technologies to support the military mission and provide the opportunity for injured service members to return to duty and redeploy. As you can see from the conflict-related amputations, we have had approximately 325 return to duty and 67 so far have redeployed, which is huge.
While conflict related amputation makes up a large majority of the military amputations, the Department of Defense and the VA also provide care to active duty military retirees, dependents, and veterans who have also sustained an amputation. This can include trauma from motor vehicle accidents, disarticulate amputations, cancer, congenital amputations, or delayed amputations. Combined, there have been a total of approximately 2,000 service members with amputations, both conflict and unaffiliated.
Return to duty and redeployment rates have slightly increased. The cross section between the branches of service have pretty much remained the same, with the Army being most significantly impacted, followed by the Marines. Males make up approximately 97% of military amputations.
As I mentioned, delayed amputation is one cause often seen in the military population. The overall definition of a delayed amputation is the first amputation over 90 days, based on the injury date and initial amputation date. Typically, in the military with blast or high-velocity injuries, the soldier may receive a lot of orthopedic trauma or nerve damage. The surgeons try to save and preserve as much of the limbs as they can. However, the individual may have pain or functional deficits that will cause them to choose to amputate their limb at a later date. As the combat casualties are now slowing down, we are seeing a lot of people who are choosing to electively amputate their limb. As of April of 2017, there have been approximately 328, which is 15.9% of the total amputations.
Let's now look at the general population of amputations. Dillingham et al. examined hospital discharge data from 1988 to 1996 to develop estimates of the annual incidence rate of limb loss and congenital limb difference in the United States. The data revealed an average rate of about 130,000 limb loss discharges per year. Amputations of the upper limb, which was disregarding amputation of the fingers, toes, foot, occurred at a ratio of one upper limb amputation to approximately 35 lower limb amputations. Even in the general population, there is a larger number of lower limb amputations as opposed to upper limb amputations. And as I said before, of the upper limb amputations occurring annually, 91% are distal to the wrist, therefore 9% are proximal to the wrist. So the majority are more partial hand amputations, digit amputations, and things like that. Lower limb amputation is usually from a vascular cause, followed by cancer, congenital, and then trauma. Upper limb amputation is predominately caused by trauma and this is why the upper extremity amputations are more prevalent in the military.
OT's Military History
Overall, our goal as occupational therapists, as defined by the Occupational Therapy Practice Framework, is the "therapeutic use of everyday life activities with individuals or groups, for the purpose of enhancing or enabling participation in roles, habits, routines, in home, school, workplace, community, and other settings." I think the military mission perfectly aligns with this occupational therapy mission, which is to "restore our wounded service members to the highest functional level, to provide them with the best opportunity to return to uniformed service, and/or productive civilian life." Throughout the conflicts in Iraq and Afghanistan over the last 16 years, occupational therapy has played a critical role in the interdisciplinary team of rehabilitation specialists. I think it is really important to acknowledge that our occupational therapy mission really does need to align with the military mission to fully support that rehabilitation of our service members.
Our occupational therapy history is rooted in wartime military efforts. During World War I, OT reconstruction aids used crafts, habit training, and shop work for physical and mental restoration of our wounded service members. It was during the early 20th century that Walter Reed Hospital, under the direction of psychologist Bird T. Baldwin, that the term functional restoration was coined, and the role of occupational actually evolved to help each patient function again as a complete man; physically, socially, educationally, economically. It was also a time when occupational therapists were used more in orthopedic wards. They were beginning to advocate for a scientific approach to treatment during that timeframe.
During World War II, there was a rise in surviving service members from these conflicts which increased the demand again for rehabilitation both with physical therapists and occupational therapists. This was when occupational therapist's value was really highlighted, and we were able to showcase what we were able to do in this setting.
OT's Role
What is our role, what does it really look like in amputation rehabilitation, and what can we do to maximize our role in the military setting? As I said before, the primary role of the occupational therapist is to facilitate the client's return to the performance of daily occupations and roles, which ultimately leads to participation in a meaningful life. As we say in our clinic, the overall goal is independence with ADL and IADL performance with and without a prosthesis. It is very important for individuals to be completely independent with their daily activities without a prosthesis first. And then once they are fit with a prosthesis, they need to integrate that into their roles and their daily life.
It is also important to note that we, as occupational therapists, play a clinical role in the rehabilitation of individuals with both lower and upper extremity amputation. We overlap predominately with physical therapy for both upper and lower extremity amputations. The goals for rehabilitation also overlap.
LE Amputation:
- ADL/IADL performance
- DME/AE recommendations
- Functional transfers
- Wheelchair skills
- Community reintegration
- Driving rehabilitation
- Adaptive sports
- Psychological support
UE Amputation:
- ADL/IADL performance
- DME/AE recommendations
- Pre-prosthetic training
- Prosthetic training
- Functional mobility
- Community reintegration
- Driving Rehabilitation
- Adaptive Sports
- Psychological support
We look at both ADL and IADL performance. We make DME and adaptive equipment recommendations for both. Functional mobility and transfers are a huge part of our intervention. An example for a lower extremity amputation would be getting them up out of bed. We might do functional transfer training for upper extremity amputations. When you are initially injured, you still need to get up out of bed and be able to independently transfer within your room. For lower extremity amputations, we also focus on wheelchair skills. We often work with the physical therapist on this, but we have taken on that role in my clinic. Community integration, driving rehabilitation, and adaptive sports are other big parts of the occupational therapy role. We can help them engage in previous or new sports to teach them how to use their prosthetics with those different sports. Lastly, we need to provide psychological support. This is something that is extremely important with all individuals with amputations, especially in the military population. It is important to emphasize that during every phase, which is something we will talk about. We need to know when to refer out behavioral health colleagues to add additional support.
Occupational therapists are more dominant in the areas of pre-prosthetic and prosthetic training for upper extremity amputations, while the physical therapist will perform pre-prosthetic and prosthetic training for lower extremity amputations. That does not mean that we do not play a role in the lower extremity pre-prosthetic phases and prosthetic training phases, we just are not the ones who are teaching the individual to operate and control their lower extremity prosthesis.
Phases of Rehabilitation
With every level of amputation, the phases of rehabilitation are the same. They are fluid phases, so individuals will move through them at their own pace. Often times, individuals will also move in and out of these various phases throughout their lifetime. For example, there are individuals who may need to go back in for revision surgeries post-amputation for an infection or different complications. Or, they may go through the prosthetic training phase, but then, they want to try a different type of upper limb prosthesis. They may have to go back through pre-prosthetic training to then move through the prosthetic training phase again.
Like I said, it is a very fluid progression, but at the same time, we want them to flow systematically through them, and it is important to recognize each phase. We will now discuss each phase of rehabilitation and the goals of each phase as they relate to occupational performance.
Immediate Post-Op Phase
The first phase is the immediate post-operative phase. The immediate post-operative phase is from post-op day one after amputation surgery to suture or staple removal. The goals are to:
- Promote Safety
- Pain Management
- Facilitate Healing
- Proper Limb Shaping
- Early Mobilization
We are going to go through each one of those goals, and talk a little bit more in detail about what occupational therapy's role is in each of those.
Promoting Safety
There is daily skin care and inspection of the residual limbs. This is something that we educate both our patients and their family members. It is a very important part of the rehabilitation phase. This includes skin checks and becoming familiar with the residual limb appearance. Often times, you have to introduce the patient to looking and tolerating their limb. They also need to be an advocate for themselves. If they do daily skin checks and understand what the residual limb should look like during the healing phase, then they will know if there are any issues or changes that need to be addressed by the medical team. Typically, we issue a mirror for the patient to be able to perform those skin checks independently. There are also maintenance and precautions as per each surgical technique and surgeon. Often times post amputation for both lower extremity and upper extremity, the individual needs to be non-weight bearing to that limb for a certain period of time. It is important to check with your surgeon to see if there are particular precautions related to the surgical technique. They may need specific equipment during this time, like a bedside commode to allow safe functional transfers. We need to make sure that equipment is available and ready right after the initial amputation. We may also have to adapt the environment like having a wheelchair close for lower limb amputation. It is also good to understand what the home environment is going to look like as not all people stay in-patient after an amputation surgery, and they often discharge home. It is also important to make adaptations for an individual while in the hospital like access to call bells. They may need adaptations for UE amputations.
Usually, comorbidities exist with these type of combat casualties. There can be polytraumatic injuries. Many times the individual will also have a traumatic brain injury, PTSD, or vision impairments. They can also have other orthopedic injuries, nerve injuries, or burns. If it was not a traumatic amputation, they may have some other comorbidities, especially with a dysvascular patient. We need to understand what those comorbidities are because those might affect the safety the person has post-operatively and as they progress through the rehabilitation. Medication management is a huge piece of this as well. Pain medication can effect participation in therapy. It can increase fatigue, lethargy, and make it difficult to concentrate and learn. There can also be an increased frustration and decreased memory and attention. Thus, it is important to understand what the patient's medicine regimen is and make sure that the family members are educated as well.
Pain Management
Along with pain medications, there are a number of pain management techniques that we like to use during this post-operative stage. There is evidence to support mirror therapy being effective with phantom limb sensation and pain. Pain medications can be effective for nerve pain and residual limb pain. Acupuncture has had some really significant results for our patients. Compression is putting some pressure through that distal end of the residual limb, and using a residual limb shaper or shrinker can provide pain management. Tapping and massage to the end of the residual limb is also a technique that is used to help decrease pain. We advise that it is done in the soft tissue area, but not over the suture line while the sutures are intact. Patients or family members can be taught to do this.
It is also very important to know what the different types of pain are. There are post-amputation surgical, residual limb, and phantom pains. Residual pain is in the distal end of that limb, while phantom pain is pain sensation where the limb used to be. There is also phantom sensation, which is when a person feels that their limb is still there, but it is not actually a painful sensation. By knowing the different types of sensations and pains, you can appropriately recommend management strategies. I defer to a pain management specialist for pain medications, but we can also refer and consult for acupuncture and other techniques.
