Above Knee Amputee: Amputee Case Study
Above Knee Amputee
This case presentation will discuss the assessment and treatment of an above knee amputee (AKA) with the main focus being the Physiotherapists role in the patients’ rehabilitation. I will identify the treatment given to the patient evaluate its effectiveness and use the learning from the Lower Limb Amputee Rehabilitation Course to reflect on the care provided.
Transtibial,Diabetes,Geriatric, Peripheral Vascular Disease
The patient is a 69 year old female, widowed with one daughter and supportive friends. She lived alone, was a smoker and retired nurse. Her medical background increased her fear and anxiety around amputation due to not wanting to be the one being cared for.
The patients’ past medical history (PMH) included peripheral vascular disease (PVD) and Type 2 diabetes. Consequently she suffered with chronic left leg and foot ulcers described as circumferential ulceration and ischemia of the foot resulting in constant leg pain subsequently leading to the need of amputation. Diabetes is the leading cause of UK amputations with the NHS estimating sufferers being 15 times more likely to require amputation. It is also identified that poor circulation predisposes sufferers to ulceration leading to amputation. This combination of conditions predisposed this patient to be at higher risk of requiring an amputation.Previously declining amputation due to fear she returned one week later to see the consultant as she was struggling to sleep and had come to terms with the need for surgery. Progression of PVD resulting in further reduction in circulation and therefore tissue necrosis is likely the cause for the increase in pain. Admitted to the vascular ward an elective AKA was conducted and resulted in a long AKA stump. This provided her with the best lever, better energy efficiency, muscular balance, preserving the strength of the adductors and a candidate for ischial tuberosity bearing prosthesis
The subjective examination identified the details above and provided insight into her home set-up to aid discharge planning. Psychological impact of low mood and de-motivated and how this was impacted by her occupational background was identified. This was therefore incorporated into therapy goals making short-term goals to increase her independence on the ward as well as long-term with the aim to return home. The objective assessment included range of movement (ROM), strength, balance and functional ability. The patient presented with good Active ROM (AROM) but hip extension was reduced and difficult to perform in lying. Hip extension is the most commonly limited ROM in the geriatric population and has the highest potential to limit prosthetic success. Simple physical performance measures were used to ensure measures were meaningful to the patient; assistance required, increased clearance/number of hops, wheelchair use. These could have been used as part of the Amputee Mobility Predictor Assessment Tool to provide a more objective approach to determinant the patients’ ability to ambulate and measure function post-rehabilitation. This can be performed with or without a prosthesis therefore could be used throughout the rehabilitation process. The International Classification of Functioning, Disability and Health (ICF) could also have been used as part of the examination of this patient. The residual limb wound was healing well however some phantom limb pain was present.
From a Therapists perspective the patients’ main issue was the patients physical ability including reduced ROM hip extension but linking closely with this was her motivation and mood. Although low in mood due to the reasons behind this the Therapists were able to use this to help motivate and encourage participation in treatment. The phantom limb pain was also an issue identified for a need for treatment.
With the patients aim being to return home the patient was required to be able to mobilise a few meters to access her property. Therefore close working with the Occupational Therapists was required to facilitate returning home at a functional level. An environmental and a home visit (with patient) was conducted by the Occupational Therapist to ensure the patient had the equipment required and could function within her own property.
At the acute hospital she had been taught deep breathing exercises and AROM exercises post-surgery (BACPAR exercises). Therefore treatment consisted of AKA exercises review and transfer assessment. The patient practiced banana board transfers and sit to stand to a patient turner/ zimmer frame. Once standing balance achieved and duration increased “hopping” transfer practice was initiated. A zimmer frame was chosen over a wheeled frame despite the increase energy demand due to the increased stability. A zimmer frame was also favourable over elbow crutches as it provides a more stable base of support, reduces the falls risk and therefore potential injury as both older and diabetic patients are at higher risk of injury if they were to fall.
Incorporated was the encouragement of individual completion of AKA exercises as well as desensitisation techniques. The techniques encouraged were tactile stimulus on the residual limb using a variety of textures/pressure. From the course I have also learnt that “mirroring” the intact limb into a position of comfort can aid the feeling of an improved position in the phantom limb.
A wheelchair was measured and ordered to suit the patient taking into consideration the stump length (no stump board required). The patient required encouragement to use the wheelchair this was implemented by the MDT. Wheelchair mobility/rehabilitation indoors and out was also included to promote independence.
The patient returned home with the intermediate care team consisting of one care call a day, nurse to monitor wounds and Therapists to progress strength and mobility. On discharge the patient was self-propelling in a wheelchair and managing to mobilise a few meters with a zimmer frame. Her phantom limb pain was settling and wound was healing satisfactorily however remained oedematous. The patients’ attitude towards her ability and future had changed significantly. The patient was also referred to the artificial limb fitting centre for prosthesis assessment and ongoing care. Here she would be assessed for the appropriate prosthesis and mobility progressed with the prescription of a prosthetic being an MDT process including (minimal); the patient, orthoprosthesist and physiotherapist. The prescription process will take into account the type of device that should be fabricated and also the socket design, the various types of components and the choice of suspension. Due to this patient having an AKA she will have an increased energy requirement to mobilise. The course identifies that vascular transfemoral gait having an 100% increase in energy requirement. This is due to the increased demand on the hip and trunk muscles and the contra lateral limb to generate the energy required for stability and movement throughout the gait cycle. The rehabilitation process will therefore include exercise tolerance, muscle strengthening and correction of deviations to aid energy conservation.
Although the treatment provided was adequate to achieve the patients’ goals the author has learnt additional assessment and treatment approaches. However an assessment tool such as the Amputee Mobility Predictor Tool would have provided a valid and reliable measure to assess progress, intervention effectiveness, guide treatment and aid prediction of prosthesis mobility. The early rehabilitation process was applied with the exception of a compression sock due to a sock of appropriate size not being available. This would have aided to reduce the oedema and shape the stump in preparation for prosthesis assessment. Risk assessment and evidence-based practice was used to identify an appropriate walking aid for the patient taking into account her age and PMH of diabetes. A Pneumatic Post Amputation Mobility Aid could have been included prior to discharge however due to lack of resources and training this was not included in treatment highlighting a training need. An MDT approach was included throughout including referrals to the appropriate on-going services. The Therapy team particularly assisted this patient with the psychological impact of her amputation and loss of independence by ensuring goals where patient centred and realistic. This course has enabled the author to reflect on current practice. It has also increased the understanding of pathology and factors affecting successful mobilisation with prosthesis which will therefore be applied to practice to optimise patient care.
- BACPAR Clinical Guidelines for the Pre and Post Operative Management Management of Adults with Lower Limb Amputations, 2006
- BACPAR Toolbox of Outcome Measures Version 2, November 2014
- Engstrom B, Ven CVd. Therapy for Amputees, 3rd edition. Churchill Livingstone, London. 1999