Introduction
Using telerehabilitation for the management of patients with limb loss and amputations enhances the care of a challenging patient population. This care may begin after an acute inpatient rehabilitation stay following an amputation or, just as importantly, as a presurgical virtual consultation. In either case, telerehabilitation can be a valuable initial phase of the rehabilitation process. Using available technology, telerehabilitation provides timely and quality clinical care that can improve the functional outcome of patients with limb loss throughout their lifespans. As with other diagnoses and other disciplines, telerehabilitation can also provide an opportunity to connect clinical experts to patients in more remote or underserved areas with a concomitant goal of reducing health care disparities.
Telerehabilitation advantages include (1) timely access to care, (2) improved clinical communication and transitions between locations of care, and (3) reduced or streamlined travel for patients with limb loss and mobility impairments and their families. Telerehabilitation affords practicing clinicians an opportunity to observe how patients ambulate, navigate, and participate in activities of daily living (ADLs) in their homes. This provides essential information and improves recommendations for mobility equipment, assistive devices, and home environment modifications, to improve safety and facilitate greater independence. Prior to the use of telerehabilitation, this knowledge was only gained by performing house calls.
Patients can experience limb loss throughout their lifespan, and caring for the individual, not what is missing, is a core principle of amputee rehabilitation. Patients who experience an amputation present with many unique challenges beyond their respective limb loss. Most patients with lower-limb amputation have an expected impact on mobility. Upper limb loss can dramatically impact an individual’s ability to perform ADLs and thus their overall independence and their ability to work and play. Unlike a traumatic amputation, a single or first amputation may be part of an ongoing pathophysiological process, leading to additional amputations and impairment. Medical management of comorbidities, for example, coronary heart disease, renal insufficiency, and neuropathies, is essential for the patients’ overall health and for prevention of secondary amputations. Others who develop pain or skin issues may also require revision surgeries, restarting the preprosthetic rehabilitation process. The psychological loss experienced by these patients also needs acute management, counseling, and peer mentor support. Education throughout the rehabilitation process is key to a safe return to their community, work, and avocational pursuits. Due to many factors, including local environments, health care access, and the increase of individuals with diabetes mellitus, vascular disease, trauma, and cancer, the number of patients with amputations is expected to grow.
Although not unique to rehabilitation care, the interdisciplinary team plays an essential role in the management of the patient experiencing an amputation. For limb loss patients, the interdisciplinary team consists of a physiatrist, physical therapist (PT), occupational therapist (OT), and prosthetist. This team, along with the patient and family, should meet in real time to listen, examine, discuss, and plan the course of pre- and prosthetic rehabilitation. The interdisciplinary team can be expanded to include advanced practice providers (physician assistants/nurse practitioners), psychologists, case managers, surgeons, wound care nurses, engineers, and recreational therapists, as needed. Interdisciplinary team membership may change or shift over time to reflect the patient’s needs and goals, and telerehabilitation can promote access to the required team as a foundation of the system of care.
Telerehabilitation Experience in a US Military/Veterans System of Care
In the United States, the health care system for the military, the largest national health care system in the country, encompasses all aspects of care for active duty members and veterans. With the possibility of both polytrauma—including traumatic amputations incurred as part of their service—and a lifetime that may include the development of dysvascular disease and complications of limb loss, the Veterans Administration (VA) and Department of Defense (DoD) have developed extensive clinical practice guidelines for the rehabilitation of individuals with lower-limb amputation. This highly advanced and innovative care in amputation rehabilitation has included the use of a telerehabilitation approach in their amputee clinics model system of care for many years. VA-based telerehabilitation often focuses on advanced mobility training with an emphasis on community-based, adaptive sports and recreation involvement.
In 1998, a monthly clinic run by the Milwaukee VA team was developed in a rural medical facility 206 miles away from Milwaukee, Wisconsin (a larger city). The rural clinic was attended by a PT, a community prosthetist, and a patient. Physical examination, directed by the physiatrist in Milwaukee, was performed either by the PT or the prosthetist. Challenges included technical issues, such as broken video equipment resulting in clinic cancelation and relocation to a different building, and clinician difficulty with controlling a remote camera. The small clinic limited gait assessment and the echoing sound quality at times interfered with communication. Perhaps the greatest challenge felt by the clinician was in assessing skin conditions on the residual and intact limbs. Despite the challenges, the patient satisfaction survey indicated a high level of satisfaction. The VA continued with early investigation, investment, and research that demonstrated that telerehabilitation can be effective and practical for many individuals. A 2004 study showed improved outcomes for veterans with lower-limb ulcers for whom trips to the clinic are too difficult.
The VA’s telehealth services have evolved with the mission to “provide the right care, at the right place and at the right time” and, through technology, meet the needs of those with limb loss. Since 2008 there has been steady growth in the VA’s teleamputation services. The VA currently provides different types of teleamputation services with the interdisciplinary team amputee clinic as the most common. At the interdisciplinary amputee clinic provider site, the team is joined by the patient and a telepresenter who is at the patient site. The telepresenter is typically a PT or nurse, who assists in the telerehabilitation visit, by serving as the team’s “hands”, and supports the technical and administrative functions needed. Services provided can include the initial patient evaluation and follow-up visits, prosthesis(es) and rehabilitation prescriptions, new prosthesis “checkout” after delivery, and follow-up for comorbidities and complications involving the residual and/or unaffected extremities. Amputee support groups and direct peer support are also conducted under the structure of the VA telerehabilitation system.
Telerehabilitation in a Civilian Amputee Program: A Rapid Changeover Due to COVID-19
The Limb Restoration Program (LRP) based at Spaulding Rehabilitation Hospital (SRH) in Boston is a principal program of the Department of Physical Medicine and Rehabilitation (PMR) at Harvard Medical School. As a free-standing, inpatient rehabilitation facility, SRH admits new patients with limb loss from tertiary acute care hospitals in the city, region, nation, and internationally. Patients receive early postoperative rehabilitation including postoperative wound care, edema control, and residual limb shaping. Patients participate in preprosthetic training with several hours of intensive PT and OT daily. Amputee education, psychological counseling, and dispositional planning are all components of the program. Upon successful completion of the inpatient stay, patients return for follow-up in the Limb Restoration Clinic (LRC) after several weeks. This postdischarge visit allows the clinical team to evaluate residual limb healing and ongoing rehabilitation training needs. In consultation with their surgeons, the readiness to begin the prosthetic phase of their rehabilitation is determined and initial prosthetic prescriptions generated. Patients return to the LRC for prosthetic checkout once they have received their prosthesis to confirm proper fit and function before initiating prosthetic therapy training.
The success of the LRP within the amputee system of care is directly linked to visits to the LRC, held weekly. Here, in a first-floor clinic space with one large examination room outfitted with a set of parallel bars and a wall-length mirror, as well as an adjoining consultation room, a meaningful therapeutic milieu is established to enable outpatients to be seen in follow-up. Additionally, new inpatient amputees can meet prospective prosthetists, and all patients can learn about adaptive sports and ongoing research activities with the LRP. The LRC typically work with 10 or 12 patients in a half-day session, requiring a high level of administrative coordination amongst the patients and their respective prosthetists. This physical setting has historically and practically allowed decision-making with the patient, physicians, therapists, and prosthetists in real time to establish the “gold standard of interdisciplinary care.” The timing of the LRC is also linked to a monthly amputee support group for both inpatients and outpatients.
Despite the relative satisfaction of all participants in the LRC, several gaps and challenges in the delivery of “pre-telerehabilitation” amputee care have been identified. For example, not all patients live locally; some live outside the state or country. It is sometimes “too long a drive” to get to the LRC, and the hospital is not fully accessible by public transportation. The LRC is not available every day of the week, so scheduling conflicts arise, especially for patients on hemodialysis. The LRC works with a number of community-based prosthetists who are strongly encouraged to free up time in their busy offices to attend the clinic. If the clinic starts running behind, or if the patient cancels at the last minute, prosthetist team members may be frustrated with the loss of operational efficiency. Some patients simply cannot participate in the LRC. Patients who are acutely hospitalized in referring institutions are not currently able to access the LRC for valuable presurgical consultation, and so they miss out on postsurgical rehabilitation planning and expectation management.
The global health care response to COVID-19 led to accelerated adoption of telerehabilitation worldwide and at SRH. During the early “shutdown,” with no weekly typical LRC possible, managing the amputee patients changed “as we knew it.” Patients’ appointments had to be canceled, prescriptions for prostheses were put on hold, and patients could not be evaluated for therapy needs. The impact on the amputee inpatients was also significant, including the prohibition of family visits and training, no amputee peer visitation, and elimination of the monthly amputee support group. Having an established hospital network telehealth system operational for several years, virtual visits allowed the LRP to quickly pivot to embrace telerehabilitation.
Without the ability to have scheduled outpatients come to the hospital, the LRC quickly became fully virtual. Patients were seen in their homes with the use of their computers, smartphones, and occasionally, the smartphones of their visiting nurses or therapists. Each patient’s respective prosthetist was able to join the interdisciplinary telerehabilitation visit according to a published schedule. Initially the number of patients scheduled was reduced out of caution, but this was quickly advanced as the team gained experience, which allowed patient volume to closely match pre–COVID-19 numbers. The conversion of the LRC to a telerehabilitation model did require enhanced coordination with regular preclinic communication among the interdisciplinary team members. This allowed the LRC to run on schedule and ensure timely connections with patients and providers.
Later in the spring of 2020, with overall improvements in the local COVID-19 response, universal mask usage, and a decrease in community viral spread, the hospital was able to reopen clinics to outpatients. The LRC team was able to triage during preclinic meetings to determine which patients should be seen in person and which patients could continue to be seen virtually. In-person visits continued to have all prosthetists participate virtually (which continued in 2021). Other hybrid versions of the telerehabilitation visits included clinic visits with the patient attending outpatient therapy sessions and/or visits to their prosthetist’s office. These hybrid models have continued since then ( Fig. 7.1 ).
