Organization of Amputee Clinic at VAMC

Organization of ‘Amputee Clinic’ Within a

VA Medical Center

Capstone Project by Anne H Hammonds, PT, MPH

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BACKGROUND

It has been estimated that 75% of lower extremity amputations occur in patients older than 65 years old¹ . A vast majority of the patients at the Charles George VA Medical Center fit into this age category.  This population is at greater risk than the general public due to co-morbidities related to the aging process or to exposure to environmental toxins while serving in the military. In 2016, the VA Medical Center spent an estimated $777,500 on lower extremity prosthetic limbs for ‘first time users’. ‘First-time users’ are those individuals utilizing a prosthetic limb for the first time. This figure does not include the cost of pre-existing limbs that need upgraded componentry or a new socket to be fit. It is implied that the individuals in this latter group are successfully using the prosthetic limb on an ongoing basis. Research has indicated that many prosthetic limb users are not successfully using the limb at the year-anniversary mark^1-3 . Additionally, the one-year mortality rate following lower extremity amputation ranges from 26-39%² (Using financial information from the 2016 estimate listed above, this extrapolates to $201,000-$302,000 spent on prosthetic limbs that may only be used for a years time).   In lieu of not ambulating with a prosthetic limb, alternative methods of mobility should be considered, such as a wheelchair. The average cost of a power wheelchair at the VA Medical Center ranges from $4000-$12,000. In addition to this major medical equipment expense, there may include potential medical costs associated with limited mobility. Extrapolating these costs are difficult and unpredictable. Ultimately it is more beneficial to keep an individual mobile through ambulation than with a power wheelchair.

Rehabilitation following amputation is multifaceted. Certain skills have been identified that are required for success. These skills have been categorized into a physical skill set (strength, range of motion, coordination, praxia, balance,) and a cognitive skill set (memory, attention, initiation, concentration, visuospatial, organization, memory, problem solving, reasoning, judgment) ^{4, 5} . With early awareness, physical deficits can be corrected through rehabilitation.  Physical factors that have been shown to predict successful use of a lower limb prosthesis include: age and ability to ambulate prior to amputation^{1, 6} , single leg stance on the prosthetic limb^{1, 2, 7} . The Amputee Mobility Predictor (AMP) tool utilizes multiple activities, incorporating many physical skills, to predict walking ability.  Studies have shown the AMP tool to have good construct validity for ‘readiness to ambulate’^{8, 9} . Cognitive deficits are more difficult to detect. Cognitive impairment has been shown to be a reliable predictor of successful use of a lower limb prosthesis^{2, 4, 5, 11} . Many times, however, cognitive impairments are not discovered until well into the rehabilitation phase. As a result of cognitive impairment, adverse consequences can occur if steps are missed or incorrectly sequenced when donning the prosthesis^{3, 10} . Verbal fluency, an indication of initiation, has been found to predict the amount of time the prosthesis will be worn daily¹⁰ . Research by Fleury, et al. (2013) specified that cognitive impairment was contraindicated for using a lower limb prosthesis¹ .

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PROJECT OVERVIEW

This capstone project rose from the need to provide veterans with lower extremity amputation clearly defined expectations and guidelines necessary to trial a prosthetic limb.   The purpose of the Amputee Clinic is to evaluate the veteran for medical issues and to make recommendations for specific prosthetic limb components. When I began working at the VA Medical Center, a portion of my responsibilities included working as a team member with a physician, a kinesiotherapist and several prosthetists of the Amputee Clinic. Initially, my primary responsibility was to educate the veteran on how to use the prosthetic limb for gait and transfer training.

After settling into my new position, it became more apparent that the successful use of a prosthetic limb was multifactorial. In addition to medical stability, the veteran required adequate physical capabilities and cognitive abilities to safely and successfully use the prosthesis at home or in the community. Various studies show vascular disease (including peripheral vascular disease and diabetes mellitus) account for 82-90% of all lower extremity limb loss^{1, 4} . Peripheral vascular disease shares the same pathophysiology as cerebral vascular disease, which results in varying degrees of cognitive impairment⁴ .

Previously, veterans were issued a prosthetic limb with little scrutiny regarding the individual’s rehabilitation potential and no assessment of the veteran’s cognitive status. The need for having guidelines as a threshold to trial a prosthetic limb developed after treating a veteran for gait training with significant cognitive deficits. This veteran underwent a trans-tibial amputation that was a result of uncontrolled diabetes mellitus and non-healing foot ulcerations. Prior to surgery, this individual lived alone and he chose to return to this same living situation upon discharge. During his time in rehabilitation, it became more apparent this individual did not have the ability to correctly perform the sequential steps needed to successfully wear the prosthesis without risk of injury. Cognitive testing revealed this individual had borderline cognitive impairment, specifically in areas of short-term memory loss and executive function. Because the guidelines were not in place at the time, the patient and family were not accepting of why this veteran was not being issued a prosthetic limb. In their eyes, ‘the VA took my leg, so they owe me a new leg’. They did not understand the risks associated with issuing the prosthesis to this individual.   Potential risks included skin breakdown, infection or falls. These risks greatly outweighed the benefit of the patient not using the prosthetic limb safely. Without the cognitive skills to properly sequence the steps of donning the prosthesis, the judgment to correctly manage limb volume throughout the day, or the physical ability to balance and walk safely, this individual was a risk for injury.

This was the impetus for my Capstone Project,  the tipping point that inspired the development of the process and guidelines for obtaining a lower extremity prosthetic limb through the VA Medical Center.

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PROJECT PRODUCTS

• A 20-minute PowerPoint presentation for key players in the guidelines and referral process for Amputee Clinic. These players include the vascular surgeons, vascular mid-level clinicians, orthopedic surgeons, orthopedic mid-level clinicians, primary care physician, rehabilitation physician and rehabilitation mid-level clinicians.   Link to CAPSTONE presentation
• A brochure to help the veteran understand of the process of Amputee clinic, clarify the guidelines for trialing a prosthetic limb, and define the benchmark abilities required for being issued a prosthetic limb through the VA Medical Center. Link to  Amputee brochure
• A flow diagram for the referral source (key players listed above) that indicates who is in charge of making the referral to Amputee Clinic. Link to Amputee clinic Flow diagram

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EVALUATION and REFLECTIONS

The PowerPoint presentation and the Flow Diagram were designed for the medical staff of the VA Medical Center.  As a result, I took the liberty of composing it for participants with a higher-education level.  To evaluate the reading levels of the Amputee Brochure, I watched the the Health Literacy module (Voicethread) provided on the Sakai website prior to creating the document.  After watching the Voicethread, I drafted the Amputee Brochure at a sixth grade reading level.  In order to meet the timeline for the Capstone Project, I asked my committee members, as well as other mentors in the physical therapy profession, to read the brochure for content and reading level.  I have provided a link to the Amputee Brochure under ‘Project Products’, but in order to be utilized within the VA Medical Center it must go through the Health Literacy Committee.  I will make amendments according to their feedback from the official committee.

This presentation has not been fully completed as of this date.  The topic research, the information organization and the material preparation has been very interesting and rewarding.  I am very pleased with the products created and believe it will help veterans better understand the guidelines and navigate the process of Amputee Clinic.  The greatest hurdle has been confirming of a ‘face-to-face’ meeting time with the key players (surgeons, mid-level medical providers, and primary care physicians).  I have resigned myself that I may not be able to accomplish this in a one-time event, but may have to set up a separate meeting with each service (Vascular, Orthopedics, and Primary Care).  Each medical player is essential in helping the veteran obtain the most appropriate level of mobility.   Making sure all medical caregivers are on the same page is important to determining what is the appropriate level of mobility.

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ACKNOWLEDGEMENTS

This project is still a work in progress and I have discovered how challenging it can be to make small changes within a large organization.  Thank you to my colleagues, Jeff Shelton and Bill Hillerman, for providing feedback,  helping me keep my composure throughout this process, and providing humor to our work environment.  Thank you to  Karen McCulloch, PT, PhD, NCS, for the gentle reminders of keeping me on track for this course and for your flexibility throughout the entire tDPT program in general.  Thank you to my children, Ellie and Will, for their patience and understanding when I was not available.  I hope someday you, too, will realize what it means to be a life-long learner.  And finally, a special thank you to my husband, Ryan, for his unwavering support and willingness to take over many of the household tasks so I could study.  I don’t know how I got so lucky!

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REFERENCES

1. Fleury AM, Salih SA, Peel NM. Rehabilitation of the older vascular amputee: a review of the literature. Geriatr Gerontol Int. 2013;13:264-273.
2. Schoppen T, Boonstra A, Groothoff JW, de Vries J, Goeken LN, Eisma WH. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees. Arch Phys Med Rehabil. 2003;84:803-811.
3. O’Neill B, O’Neill BF. Cognition and mobility rehabilitation following lower limb amputation. In: Psychoprosthetics. London: Springer; 2008:53; 53-65; 65.
4. Coffey L, O’Keeffe F, Gallagher P, Desmond D, Lombard-Vance R. Cognitive functioning in persons with lower limb amputations: a review. Disabil Rehabil. 2012;34:1950-1964.
5. Larner S. Do psychological measures predict the ability of lower limb amputees to learn to use a prosthesis? Clin Rehabil. 2003;17:493; 493-498; 498.
6. Mundell BF, Kremers HM, Visscher S, Hoppe KM, Kaufman KR. Predictors of Receiving a Prosthesis for Adults With Above-Knee Amputations in a Well-Defined Population. PM R. 2016;8:730-737.
7. Kahle JT, Highsmith MJ, Schaepper H, Johannesson A, Orendurff MS, Kaufman K. Predicting Walking Ability Following Lower Limb Amputation: an Updated Systematic Literature Review. Technol Innov. 2016;18:125-137.
8. Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee’s ability to ambulate. Arch Phys Med Rehabil. 2002;83:613-627.
9. Gailey. Predictive outcome measures versus functional outcome measures in the lower limb amputee. Journal of prosthetics and orthotics. 2006;18:P51; P51.
10. O’Neill BF, Evans JJ. Memory and executive function predict mobility rehabilitation outcome after lower-limb amputation. Disabil Rehabil. 2009;31:1083-1091.
11. Sansam K, Neumann V, O’Connor R, Bhakta B. Predicting walking ability following lower limb amputation: a systematic review of the literature. J Rehabil Med. 2009;41:593-603.