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Limb Loss, Amputation Resources, Advances from Military Health System

Image of Limb Loss, Amputation Resources, Advances from Military Health System. Earl Granville, a retired U.S. Army National Guard staff sergeant, discusses fixing his artificial limb with Tyler Cook, a prosthetist at Walter Reed National Military Medical Center in Bethesda, Maryland, on April 23, 2022. Granville lost his leg in a combat mission abroad. (Photo by Alpha Kamara)

Losing a limb to trauma, or amputation from any cause, creates undeniably serious life adjustments. That’s why it’s crucial for clinicians helping patients experiencing limb loss to have the tools they need.

For providers treating individuals with limb loss—inside and outside of the military—the Defense Health Agency is a source of continuing education, ongoing research, and outcomes measures. DHA’s resources are based on data obtained by treating more than 1,700 deployment-related amputations since 2001. Those clinical resources are updated as the science advances across the Department of Defense and the Department of Veterans Affairs.

“All amputation is major,” said Andrea Crunkhorn, chief of clinical affairs at DHA’s Extremity Trauma and Amputation Center of Excellence who also holds a doctorate in physical therapy. “In a society where communication is now typing with all 10 fingers or your thumbs, loss of even part of a digit severely impairs efficient and effective communication as well as makes all activities of daily living more difficult, with huge functional implications for anyone.”

A physical therapist assists a patient on the treadmill.A physical therapist assists a patient on the treadmill during a visit at the Walter Reed National Military Medical Center’s Advanced Rehabilitation Center. The Defense Health Agency recognizes and honors the more than 30,000 beneficiaries with some level of limb loss for whom we’ve had the privilege to provide care. Photo by Aisha Lomax, Walter Reed National Military Medical Center Office of Command Communications)

Clinical Practice Guidelines

EACE was established in 2011 and joined the DHA in 2022 as the fifth center of excellence in the Defense Health Agency’s Research and Engineering Directorate. One of the major efforts EACE supports is the development of clinical guidelines. EACE clinicians, Military Health System clinicians, and VA clinicians work with the Department of Veterans Affairs/Department of Defense Evidence-Based Practice Guideline Work Group, which has issued two amputation focused clinical practice guidelines. These CPGs provide the framework for evidence-based best practices, and include:

“It is essential, particularly in a field that is emerging and changing as quickly as amputation and limb trauma care, that all providers look for well-produced guidelines such as these,” Crunkhorn said.

The 2017 Lower Limb Amputation Rehabilitation CPG was based on a review of 3,500 articles on lower limb amputation. Only 73 articles were of high enough quality that the VA/DOD working group creating the guidelines included them in the results for building recommendations, Crunkhorn said.

The working group assesses the research-based evidence and other factors such as results from a patient focus group, patient values, likelihood of harm of doing or not doing the recommended action, and burden on clinicians and health care systems (time, resources, staffing),” Crunkhorn said. The working group also addresses research and clinical gaps both as part of the CPG and in crafting additional documents to assist clinicians and patients.

For example, last year the work group realized there was zero content on pregnancy, parenting or childcare in the Upper Limb Amputation Rehabilitation CPG. The work group published a novel patient handout on pregnancy and added content on parenting and child care to the patient handbook “Within Reach.” This content was primarily written by former U.S. Army Maj (Dr.) Megan Loftsgaarden, who was then chief of the Physical Medicine and Rehabilitation Service at the Center for the Intrepid at Brooke Army Medical Center in San Antonio, Texas.

Additional EACE Resources

There are many other resources at providers’ fingertips.

EACE has an archive of on-demand training modules on provider-requested health outcome measures related to limb loss and amputation. This resource hosts 32 archived sessions from the multidisciplinary information-sharing series. Monthly sessions introduce new material, case studies, and best practices into the clinical setting.

Monthly DOD-VA Grand Rounds provide evidence-based educational opportunities designed to improve the quality and consistency of care. There is also a continuing education course, the 2021 Federal Advanced Amputation Skills Training, for at-home study.

EACE partners with three Advanced Rehabilitation Centers. ARCs provide state-of-the art, patient-centered, sports model-based care for limb dysfunction and amputation to DOD beneficiaries, allied military personnel, and select civilians. The three ARCs are Walter Reed National Military Medical Center’s Military Advanced Training Center (MATC); Brooke Army Medical Center’s The Center for the Intrepid (CFI); and Naval Medical Center San Diego’s Comprehensive Combat and Complex Casualty Care (C5) Program.

The EACE has a resource page for all providers, patients and caregivers. For MHS providers, the EACE developed an internal page on Carepoint for additional content: the ARC Resource Page.

The ARC documents website has DHA outcome measures information “as we drive toward a standardized outcome set to improve amputation rehabilitation across the DHA,” she added.

Both websites provide background information on the ARCs, their capabilities, how to refer patients to them, as well as treatment protocols, and other useful information, according to Crunkhorn.

Limb Loss Recovery as a Career

Dr. Tawnee Sparling is the medical director for amputee care and the director of combat casualty care at Walter Reed National Military Medical Center in Bethesda, Maryland.

“New clinicians interested in entering this field [should] spend time with providers in all of the different specialties involved in the care of this patient population,” Sparling suggested. “You should learn about wound care, observe in the OR, ask your prosthetist questions, spend time in their lab, observe therapists doing their evaluations, and ask your patients about their goals,” Sparling advised.

At WRNMMC, Sparling works in the Military Advanced Training Center, which is one of the three ARCs, a state-of-the art rehabilitation facility that works with prosthetics and athletic equipment to further recovery from limb loss or amputation.

Her daily patient practice crosses many areas, including clinical, educational, and research components. “I coordinate their rehabilitative care, manage their pain, and help them achieve their functional and quality-of-life goals.”

The MATC is “a unique multi-disciplinary clinic where providers from PM&R, physical therapy, occupational therapy, prosthetics/orthotics, and case management teams work together to achieve a patient-centered care model,” Sparling explained.

She works with EACE weekly “to improve our use of validated clinical outcome measures within our clinics, develop training principles for providers within the realm of amputee rehabilitation, and develop educational content for providers through our state-of-the-science symposiums.”

New Technologies

Newer providers with an interest in limb loss should stay up to date with research and new technologies and innovations as much as possible, Sparling advised. These include:

  • Osseointegration, or the direct anchoring of a prosthesis to the bone structure
  • Agonist-antagonist myoneural interfaces to improve proprioceptive control for enhanced prosthetic use, decreased residual limb atrophy, and maintain appropriate phantom limb sensations
  • Implantable peripheral nerve electrodes to improve motor prosthetic control and provide sensory integration into prosthetic terminal devices

DHA has developed advanced practice knowledge, skills and abilities in amputation care for physical therapists, occupational therapists, physiatrists, orthotists and prosthetists, Crunkhorn pointed out. “We share knowledge and skills with civilian colleagues to ensure that the lessons learned from war have a greater impact on our Nation and whole society.”

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