Pooling specialized knowledge from multiple disciplines and working together to improve outcomes for patients with complex limb loss issues seems like a great idea. As increasing attention is focused on the growth and success of such teams, we asked multidisciplinary team members where the idea started, why it didn’t happen sooner, and where it’s going.
Diane Atkins, OTR/L, FISPO, amputee clinical specialist and assistant clinical professor, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, dates her early work in collaborative care to the 1980s when she worked at the Texas Institute for Rehabilitation and Research (TIRR). Atkins and Robert H. Meier, MD, created a nationally recognized center of excellence in amputee rehabilitation there.
When Atkins, a veteran coordinator of TIRR conferences, was approached with a request to create the 2023 Bionic Reconstruction Conference (BReCON) at New York University (NYU), addressing the future of integrated upper-limb surgical and prosthetic innovation, she recognized an opportunity to build multidisciplinary bridges.
“The premise for this conference began with the international symposium on Innovations in Amputation Surgery and Prosthetic Technologies (IASPT),” she says.
“Dr. [Todd] Kuiken, a physical medicine and rehabilitation physician, saw the unique opportunity and importance of interacting with surgeons. In response, he and Dr. Gregory Dumanian at Northwestern University hosted the first IASPT conference in 2015.”
Among other major surgical and prosthetic innovations, the conference highlighted targeted muscle reinnervation (TMR), developed by Kuiken and Dumanian in 2002.
In 2018, Oskar Aszmann, MD, invited Atkins as a keynote speaker at a similar international upper-limb surgical and rehabilitation conference in Vienna.
“There was such a unique synergy that existed between the multidisciplinary team approach and amputation surgery,” she says, “that based on the success of the IASPT in 2018, it was decided to repeat the conference every three years; but COVID intervened.”
In 2022, however, Jacques Hacquebord, MD, chief, Division of Hand Surgery, associate professor, Department of Orthopedic Surgery, NYU Grossman School of Medicine; and codirector, Center for Amputation Reconstruction (CAR); and Omri Ayalon, MD, assistant professor of orthopedic surgery, NYU Grossman School of Medicine; associate program director, NYU-Langone Orthopedic Hospital Hand Surgery Fellowship; and codirector, CAR, requested her help in creating a Center of Excellence at NYU, built around their surgical hand program.
“Drs. Hacquebord and Ayalon became aware of recent advances in upper-extremity prosthetic technology that correlate with upper-extremity surgery, thanks to a team of outstanding prosthetists who are an integral part of their Center for Amputation Reconstruction at NYU. They also recognized the importance of a surgeon’s awareness of these advances, which enables them to make better-informed surgical decisions.
“Because of my history with both of the earlier IASPT meetings, they asked my help in creating what became the Bionic Reconstruction conference.”
The goals for the conference were:
- To share and advance state-of-the-art knowledge in upper-limb surgery and prostheses, particularly to the upper-limb surgeon who performs hand, orthopedic, and plastic procedures
- To demonstrate the advantages of a multidisciplinary team approach for this unique population of people with limb loss
- To set the stage to encourage future research and collaboration with national and international leaders in the field
Atkins’ primary target audience were surgeons, rehabilitation physicians, prosthetists, therapists, and engineers. She anticipated an attendance of 100-125, yet the conference attracted an international audience of approximately 300, primarily surgeons, and teams from 13 countries.
The program’s unique structure mirrored the multidisciplinary team approach it promoted in practice, attracting some of the most experienced and respected international experts. Major speakers led 30-minute sessions, followed by 30-minute discussions from a multidisciplinary panel that included a combination of surgeons, rehabilitation physicians, prosthetists, therapists, and rehabilitation nurses. The panels highlighted the unique contributions and perspectives of each discipline. Mental health and reimbursement issues were also addressed.
“I knew we were going to have an audience that was rich with experience, so we allowed a full 15 minutes for Q&A, which led to an energizing interaction and dialogue. This led everyone to feel engaged and involved at every level of the conference.” Atkins says. “In retrospect, I believe we found a major key in reinforcing the multidisciplinary approach in this ever-changing and dynamic field of upper-limb surgery, prosthetic innovation, and amputee rehabilitation.”
Where Did the Idea of Specialized Collaborative Care Teams Start?
Rickard Brånemark, a Swedish physician and researcher who founded the Brånemark Osseointegration (OI) Center in 1989 in Gothenburg, Sweden, exemplified the multidisciplinary approach, says Michael Jenks, CPO, Integrum, who first learned about collaborative care in 2016 as a clinician attending the ISPO conference where Brånemark was presenting. He joined Integrum in 2023 after being inspired by the experience he and his wife shared in researching OI as a treatment for her transfemoral amputation.
“Since Integrum has seen the importance of the team-based rehab program to the success of the patient, we select centers that can provide resources to support patients throughout recovery,” says Jenks. “The team typically includes experts in physical therapy, physiatry, psychology, and nutrition.”
Rob Dodson, CPO, FAAOP, clinical manager, Arm Dynamics, first saw the value of a collaborative, holistic approach to prosthetic rehabilitation during his residency at a Level One trauma center that treated many prosthetics patients.
“An amputee patient requires care from so many specialized providers—medical care, funding, psychology—that it’s impossible for us as prosthetists or orthotists to try to fill all those roles.
“When I joined Arm Dynamics in 2005, we were contracted at Walter Reed, and were knee deep in the Walter Reed experience. During the first few years, 20 to 30 soldiers were seen each day in a clinic that included a surgeon, occupational therapist, physical therapist, psychologist, nurse care managers, and more. Injured soldiers’ needs were being met at the same time, with every person hearing the same response at the same time.
“That experience taught us the value of having a therapist on staff in each of our centers and has helped shape our care model over the last 20 years. Arm Dynamics and now others are starting to do this for the greater benefit of patients,” Dodson says. “Whether your focus is on lower limb, or you’re in a Scottish Rite type of environment, as an orthotic-prosthetic clinician to have the ability to step down the hall to the therapist’s office and discuss a particular case is invaluable.
“A collaborative environment does not exist everywhere, but you can create it if you’re willing to reach out and connect with those individuals.”
Collaboration with surgeons is being done on a daily and monthly basis at certain clinics, says John Rheinstein, CP, FAAOP(D), Hanger Clinic. For those interested in developing and participating in a team approach to limb reconstructive care, he recommends contacting a surgeon or hospital team member, or trying to join an existing collaborative team. “Look for a progressive surgeon who is willing to dialogue with you.
“The multidisciplinary team has always been the gold standard, but it was very different when I entered the O&P field 30 years ago: Physicians managed the group and said ‘this is what you’re going to do’ for each patient. For the most part, it was very hierarchical. Today we have a more progressive approach where everyone participates equally in the decision-making. Each team member is valued, and amputation is considered a reconstruction rather than a failure to save the limb.”
Haris Kafedzic, CPO, Eschen Prosthetic & Orthotic Labs, New York, has been a multidisciplinary team founding member since 2016, when S. Robert Rozbruch, MD, Hospital for Special Surgery (HSS), New York, approached him with the concept and an invitation to help develop their program at the Osseointegration Limb Replacement Center.
“We jumped into the deep end with our first case, and we’ve been doing them ever since—more than 140 of them.”
Ayalon notes that their collaborative care team was formed out of pure need.
“We recognized a big void in our patient care picture. We were inspired by the team at OrthoCarolina and tried to build on that successful multidisciplinary care program and framework. Since then, we’ve seen that the team concept is starting to catch on because the effectiveness of this model of care has been demonstrated time and again.”
Laura Katzenberger, CP/L, chief operating officer and director of Clinical Services, Handspring Clinical Services, had already collaborated with Hacquebord regarding a shared hand patient who had recently undergone TMR. “Through that engagement in late 2019, we were invited down to join him at about the time when they were just starting to think about the concept of the multidisciplinary clinic—which became CAR. It was really fortuitous timing that we were building our relationship right when they were starting the clinic, and we were invited in at the beginning.”
Jason Stoneback, MD, University of Colorado School of Medicine, defines their Limb Restoration Program as a team that was put together to treat patients with complex limb issues, such as infections, bones that didn’t heal, short limbs that need to be lengthened, or extreme trauma with missing segments of bone. By recruiting and interviewing candidates from within the University of Colorado School of Medicine, Stoneback created and directs an interdisciplinary team of experienced orthopedic surgeons, plastic surgeons, peripheral nerve specialists, musculoskeletal radiologists, orthopedic infectious disease experts, and many others who specialize in the treatment of patients with conditions that put their extremities at risk for limb loss.
“Its purpose is to restore a patient’s form and function, getting them back to being their most optimal self. That may mean getting a nonhealing bone to heal, lengthening a leg, or, more recently, performing osseointegration for an amputee who is having a challenge with traditional socket wear.”
While the original idea for their specialized limb-salvage collaborative team may have been developed in 2015, Stoneback recognized that doing the best amputation for those who needed or desired an amputation sometimes required a new solution.
“We began thinking outside the box and using innovative techniques to spare amputation levels, allowing us to save the knee or the hip joints, which allow improved function. A certain subset of patients were obviously having trouble with sockets. So when osseointegration of bone-anchored limbs was developed, we realized that it would be game-changing for those amputees that are having trouble with sockets.
“We are often asked how we developed such a great osseointegration program; the answer is that we had a great program before we started doing osseointegration as a component of it.” Their OI clinic is identified as one of the few sites in the United States routinely performing the procedure.
While clinical expertise is the cornerstone of the program, Stoneback also recruited biomechanical engineers, physical therapists, physiatrists, and clinical and translational researchers who comprise the University of Colorado Bone-Anchored Limb Research Group (BALRG) to further study the impact OI surgery has on patients. Their research is proving the profound effect OI has on individuals with amputations—from improving gait symmetry to improving overall function and well-being, Stoneback notes.
“Osseointegration can restore normal limb alignment with the bone-anchored implant, allowing stretching of the flexed and shortened muscles back into a more normal position. So when the amputee stands up straight they are able to have a better and more symmetrical gait. It takes a specialized team to recognize these factors, and to help a patient transition from a position of fixed contracture to more normal alignment by stretching, aligning, and strengthening them while restoring balance.
“Osseoperception offers a proprioceptive ability that enables them to feel through the limb; therapists work quite intensively to help patients feel the difference between textures, and improve their walking confidence, balance, and gait. This is best done by a team of physical therapists with specialized experience and training, so it’s important that we have a large team that specializes in this type of physical therapy. We have ‘grown our own’ by developing a training program that teaches physical therapists the specialized nature of osseointegration rehabilitation. We’ve recruited dedicated rehabilitation physicians, and also an athletic trainer who coordinates the osseointegration program, and we’ve also added a dedicated prosthetist with extensive experience in osseointegration to our team.”
The list of supportive specialized care providers on the Limb Restoration team is lengthy, and includes wound care specialists, physical medicine and rehabilitation physicians who specialize in the rehabilitation of the multiply-injured patient; physical therapists dedicated to the OI program; nurse navigators/case managers, vascular surgeons and interventionalists, a musculoskeletal radiologist, mental health and social workers, and nurse practitioners and physicians’ assistants, all of whom meet regularly to go over complex cases.
Stoneback estimates that since his team began offering OI solutions, the team has treated hundreds of referrals from the United States and international patients who also seek their services.
Pioneering New Possibilities Through Collaboration
Taylor Reif, MD, orthopedic surgeon and oncologist, Limb Lengthening and Complex Reconstruction Service, Limb Salvage and Amputation Reconstruction Center, HSS, shares an example of how blending the expertise of orthopedics and prosthetics leads to innovative solutions and results in better outcomes: “Our group inserted an osseointegration implant into the residual ulna of an upper-extremity patient. The prosthetist wanted to maintain the elbow motion, but faced a challenge in building a socket prosthetic that did not extend across the elbow and thereby limit their motion. Osseointegration allowed the prosthetist to build the prosthesis directly off the implant in the ulna, and house the Coapt system, which analyzed electromyographic signals from the arm, into the forearm component. This allowed control of a robotic hand and wrist unit.
“Because the osseointegration forms a really strong skeletal bond with the remaining bone and can support the weight of the prosthetic piece and the robotic hand and wrist, we were then able to build an entire prosthetic that didn’t cross the elbow, yet still had input from the surface electromyography signals to control the robotic hand.
“After training on the system, the patient was able to use the hand in many different ways.”
As more such original solutions are created through the collaboration of skilled members of multidisciplinary teams, their shared knowledge and potential leads to more innovative and successful outcomes.
How Far Have We Evolved With Communication/Collaboration?
And how can we continue to develop similar readily accessible teams?
Alta Fried, MS, OTR/L, CHT, director of Hand Therapy, Atlantic Hand Therapy Center, and cofounder, Amputation Rehabilitation Medicine and Surgery Clinic, says that “our medical system is very disjointed and specialized, for better or for worse. There are many highly specialized physicians across so many disciplines that unless you have something wrong with you within that specialty, you’re not aware of them.”
Comorbidities further complicate the pursuit of best outcomes. “An insult to one part of the body affects another, whether it’s a lower-leg amputation that affects your mind so that you can’t socialize because you look different or feel different. On the other hand, a devastating cancer diagnosis may have nothing to do with a preexisting bladder issue, but a cause-and-effect connection is presumed because of a lack of communication between doctors. They’re so specialized in their nerve reconstruction, but then they just give an amputee the prescription for prosthetics and say, ‘See you later, there’s not much more we can do.’”
Dodson points out that prosthetists have the unique perspective, and the ability to oversee and direct the patient toward the source he needs to consult for specialized help—e.g. with a neuroma (surgeon) or an idea for a prosthetic solution (design engineers).
“Thankfully,” he says, “the paradigm is shifting, as we see with events like BReCON. Oddly enough, one of the comments made during this conference was that surgeons are finally starting to outpace what we as prosthetists can provide patients; they’re starting to do surgeries for which we don’t necessarily have a good prosthetic solution, e.g. to control an arm. Now they’re pushing the envelope in the other direction and waiting for us to catch up. With the advent of TMR, RPNI [regenerative peripheral nerve interface], and OI, surgeries are decreasing people’s pain and enhancing their ability to control increasingly sophisticated prostheses.
“Together, we’re modifying the human body to provide an interface with a prosthesis so a person can be functional again—whether it’s with the pinkie or the whole arm, or their whole leg.
Ayalon believes that the more advocacy we express, and the more conversations we have, the more visibility we will raise for the population that needs coordinated care. His CAR team’s effort in sponsoring the BReCON event was an important step.
“Surgeons, prosthetists, mental health specialists, occupational and physical therapists, and even individuals with limb loss attended and spoke at the conference, and it was a real privilege to see the community come together and acknowledge the level of need—and the immense benefit achieved when you bring together people from different disciplines.”
Atkins notes that putting people in touch with others who can help them develop their own specialized multidisciplinary team was one of her intentions in creating the BReCON experience.
“Virtually everyone on this faculty was part of a team that worked hand in glove with that philosophy and shared the goal of reinforcing that message.”
Stoneback agrees that conferences like BReCON bring people together from specialized disciplines for a real meeting of the minds and serve as a great tool for proliferation. He and members of his BALRG research team spread the word at similar conferences as they share the growing body of knowledge.(For more information, visit Bone-Anchored Limb Research Group | Jason Stoneback MD | CU (cuanschutz.edu).
“That’s exactly how the seeds are planted, about how to create these high-functioning highly specialized teams.”
The best way to nurture those seeds and continue to create and evolve specialized multidisciplinary centers is to encourage interested professionals to visit, observe, and learn, Ayalon says. “Visitors frequently come from other disciplines to observe and to help,” he says. “We welcome patients who have prosthetists and invite their prosthetists to come as well. We are very much an open book and happy to have people come, observe, help out, and spread the word.” Ayalon can be contacted at [email protected].
Kafedzic also welcomes the opportunity to educate the interested. “Every time a prosthetist sends their patient to Drs. Rozbruch, Hoellwarth, and Rief’s Amputation and Reconstruction Center, we’ve invited them to come and spend a day with me when their patient is getting a prosthesis. I’ve trained them in everything I know and answered their questions so that when they go home, their patients have a prosthetist able to take care of them and treat their needs appropriately.”
When Stoneback’s patients are sent home to a prosthetist and therapist in their own neighborhood, he also stresses the importance of mentoring and training those distant members of a patient’s care team.
“Imagine if your patient is going to be cared for by someone who has no previous experience with osseointegration. It’s a lot easier when you have things set up for success and have a robust high-functioning program like ours that can mentor people. We feel it’s important to mentor the patient’s home prosthetists, home physical therapists, and home PCP’s—and we do that to make sure the patient is successful when they return home. That’s part of how the knowledge grows.”
While no one seems to know how many such multidisciplinary centers exist, “They’re popping up all over,” Ayalon observes. “But there are not more than ten centers that are doing this in a dedicated, concerted way. I’m hopeful that number will grow; and I’m confident that it will.”
“Most clinical care providers have heard of ‘the team approach’ and understand the concept,” Dodson says. “We think it’s important, but are we actually facilitating it? That may not be happening; we as a profession need to be more active in promoting it.
“The O&P profession is going through quite an adjustment, and I think sometimes forces outside of our control can get in the way of collaboration. But we’re still here to treat a human being dealing with a terrible situation, and our job is to get them as whole again as we possibly can.”
Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.
