Key points

Physiatric management for persons with limb loss remains a nascent subspecialty in physical medicine and rehabilitation, with only 2 fellowship opportunities in the country. The cause of limb loss and diversity of patient population make this a challenging area to gain expertise during brief periods of training during a physiatrist’s residency education. In addition, services available to civilians with limb loss in the private world vary greatly from those for veterans or active service members with limb loss in the United States. Therefore, as physiatrists caring for persons with limb loss in both the civilian sector and the Veterans Health Administration (VHA), the authors review current principles of amputation rehabilitation medicine within these health care systems.

Principles of amputation rehabilitation for the civilian with limb loss

Providing rehabilitation services for the person with an amputation has become more difficult in today’s health care environment. This increased difficulty has occurred because of a confluence of factors that are involved in an amputation, the person undergoing an amputation, health care reimbursement, changes in methods of providing rehabilitation services, the availability of new technology, and changes in professional discipline attitudes toward rehabilitation. In fact, the actual definition of rehabilitation should be challenged in today’s environment.

Previously, rehabilitation was neatly defined as a team effort to restore meaningful function. Currently, amputee rehabilitation is often defined as placing a prosthesis on the amputee, without particular measurement of the outcome achieved by providing the prosthesis. In addition, the prosthesis is often provided by a physician signing a prescription that has been developed by a prosthetist. Thus, in some settings, amputation rehabilitation has been reduced to involving only the patient, the surgeon, and the prosthetist. This trio may not end up with a satisfactory functional result, and really ignores the emotional adaptation to the loss of a limb and its psychosocial consequences. This trio may also not embody the experience or knowledge to address the complex issues of pain, whether acute or chronic.

The period of inpatient rehabilitation has almost disappeared in many locations in the United States. If it is provided, it is focused on mobility function before the fitting of the prosthesis. A period of inpatient or outpatient rehabilitation once the prosthesis is obtained often does not occur in a team setting. Many amputees are trained in the home setting by home-based therapists who may not have much experience with training the amputee in the technology used in the prosthesis. In addition, this method of prosthetic training does not avail itself of the traditional rehabilitation treatment team (ie, amputee, rehabilitation physician, physical therapist, occupational therapist, and psychosocial counselor, at a minimum) to provide comprehensive rehabilitation services. In addition, many inpatient rehabilitation settings are not set up to provide comprehensive rehabilitation services that include the health professionals traditionally included in the rehabilitation treatment team.

Furthermore, therapy services are now rationed for patients sponsored by Medicare and some private health insurance providers. The number of outpatient therapy visits may be limited. In some cases, the therapy visits have been incorporated into the preprosthetic phase, and the number of visits available is insufficient for proper prosthetic training. It has become incumbent on the rehabilitation team to determine how best to use the limited number of therapy visits for the most optimal functional outcome. This management requires careful forethought and planning by the rehabilitation team before therapeutic services are instituted.

Another issue seen in today’s mish mash of what is called rehabilitation is that team members may not understand what the desirable outcome should be. This uncertainty may result from a lack of training, experience, knowledge, or team coordination. Often, the amputee is not told early in the rehabilitation experience what the objectively measureable goals should be and how much time it will take to achieve these goals. Thus, some amputees are not guided to the point of excellent prosthetic function because the therapist, prosthetist, and perhaps even treating physician do not know what the end goal could and should be.

Amputation rehabilitation really calls for specialized, multidisciplinary rehabilitation training. So many new prosthetic designs and technologically advanced, expensive prosthetic components are now available, and therapists, physicians, and prosthetists with experience in training the amputee should be involved in this process. Some prosthetic component manufacturers tout new components as having the supposed advantage that the amputee will need less therapy to learn to use the device. What often happens is that these technologic advances require the same amount or more therapy to get the best result from these newer and more expensive components.

Although keeping up with the many prosthetic advances and changes is difficult, it is important for physiatrists to keep abreast of the latest developments if they are going to sign prescriptions for these devices. The claims for improved function from some of the new technology have not been objectively studied, and often no data are available to suggest that the added expense is warranted. Furthermore, often the hidden motive is that the prosthetist, physician, or therapist wishes to try the newest components at someone else’s expense. With all of this new technology, it is important for the rehabilitation physician to read prosthetic journals and attend the professional shows for the orthotists and prosthetists.

In addition, physicians who sign the prescriptions must know what they are prescribing, just as they would with a medication. Knowing what the prosthetic prescription will cost in usual and customary dollars is also important. A more even-handed way to keep track of prosthetic costs is to know what the Medicare allowable amount will be for a particular set of “L” codes.

Principles of amputation rehabilitation for the veteran with limb loss

The VHA has developed the model for an integrated system in which Veterans Affairs (VA) physicians, therapists, and prosthetists work together to provide specialized expertise in amputation care incorporating the latest practices in medical rehabilitation, therapy services, and prosthetic technology. Developed in the early part of the 21st century, the system was implemented in 2008 to enhance the environment of care and ensure consistency in the delivery of rehabilitation services for veterans with limb loss. The VA Amputation System of Care (ASoC) provides support for salary, training, education, travel, and equipment to allow VA professionals the ability to provide veterans with the most advanced technology and state-of-the-art care. This system provides care through more than 375,000 clinical visits to more than 30,000 veterans with limb loss, including more than 1300 veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn.

The ASoC consists of 4 levels of care. Seven Regional Amputation Centers provide comprehensive rehabilitation care through an interdisciplinary team and serve as resources across the system through the use of telerehabilitation technologies. These centers provide the highest level of specialized expertise in clinical care and technology, and provide rehabilitation and consultation to patients with the most complex conditions. The 7 locations are Bronx, NY; Denver, CO; Minneapolis, MN; Palo Alto, CA; Richmond, VA; Seattle, WA; and Tampa, FL. Eighteen Polytrauma/Amputation Network Sites provide a full range of clinical and ancillary services to veterans closer to home. A total of 108 Amputation Clinic Teams provide specialized outpatient amputation care, and 22 Amputation Points of Contact facilitate referrals and access to services.

The organizational structure of the ASoC strives to provide ease of access to high-quality care for veterans with limb loss. A focus on virtual care using telemedicine equipment allows Regional Amputation Centers to connect with veterans with limb loss in rural areas to provide specialized clinical decision making and prosthesis prescription writing. With a detailed prosthesis prescription, all enrolled veterans may receive any prosthetic item prescribed by a VA clinician, without regard to service connection, when it is determined to promote, preserve, or restore the health of the individual and is in accord with generally accepted standards of medical practice.

A dedication and commitment to education and advancing research is apparent within the ASoC working collaboratively with the VA Research and Development Centers of Excellence in Limb Loss Prevention and Prosthetic Engineering and joint VA/Department of Defense programs (ie, Extremity Trauma and Amputation Center of Excellence). To date, the ASoC has published the “Clinical Practice Guidelines for Rehabilitation of Lower Limb Amputation: a Clinician Toolkit,” focusing on pain management, management of the residual limb, and analysis and treatment of abnormal gait, and a patient-focused publication titled The Next Step: The Rehabilitation Journey After Lower Limb Amputation . In addition, the “Clinical Practice Guideline Following Upper Limb Amputation” is expected to publish in 2014.