Acute Inpatient Rehabilitation Care for a Patient Learning to Use an AKA Prosthesis: Amputee Case Study

Title

Acute Inpatient Rehabilitation Care for a Patient Learning to Use an AKA Prosthesis: Amputee Case Study

Abstract

Pt is a 68 yr old woman admitted to acute rehab for dynamic alignment and prosthetic training with her new AKA prosthesis. Pt has a complex medical history but was motivated to increase her independence with the prosthesis. Pt lives alone so her primary goals were to be safe and independent using the prosthesis for mobility in her home environment and to have the knowledge she needs to safely use her prosthesis. Pt was very clear she would only stay for 4-5 days at rehab so PT treatment focused on education, dynamic alignment and prosthetics training to accommodate pt goals

Key Words

transfemoral, inpatient rehab, mutlidisplinary team, prosthetic ex, ICF model, pt education

Client Characteristics

Pt is a 68-year-old female who had surgery for a L AKA 3/5/15 due to gangrene in LLE. She was admitted to acute rehab after her surgery for the amputation. She did well and left at primarily a wc level with limited ambulation in the home with the rw. Pt was staying on 1 level. She received her prosthesis on 6/19/15 and was seen for OP-PT follow up on 6/22/19. Pt was having difficulty managing and donning/doffing her prosthesis independently. She lives alone so it was thought she would benefit from a direct admit to acute rehab for further education and training. She was admitted to acute rehab on 6/22/15 for dynamic alignment and prosthetic training.


Pt has a significant past medical history for: PVD with multiple vascular surgeries and grafts, HTN, claudication, COPD, dyspnea, R shoulder dislocation, scleroderma, pulmonary infiltrates, psoriasis and GERD. Pt is currently a smoker, despite education and assistance available for cessation, pt declines.


Pt lives alone in a multi level home. He has 1 step to enter her home and 1 stepped/slanted step into her kitchen. She uses the wc in the kitchen and is ambulatory with the rw, limited distances in the home. She stays on the first floor. Pt has intermittent assist available from friends. Pt is retired. She enjoys spending time with her 11 yr old foster son.

Pt is very independent and seeks to regain increased independence and function with the prosthesis. Pt wants to pursue follow up OP-PT.

Examination Findings

Pt goals: ambulate and negotiate steps independently with prosthesis, ambulate to/from the car with her prosthesis and perform ambulatory activities with her foster son.

Findings:

  • Occasional phantom sensation/pain
.
  • Pt is motivated/great follow through.

  • Decreased activity tolerance/dyspnea.

  • Well healed skin and AKA site.

  • Shrinker for management of AKA swelling.

  • BUE and BLE ROM: wnl B hip extension: 10 degrees Strength: B hip flexion,extension, abd/add: 4/5 R knee 4/5 R ankle: 5/5
sensation intact
  • BLE
balance: stand close supervision with rw/prosthesis
independent with wc mobility using BUE/RLE.

  • Transfers: stand step with rw, prosthesis, close supervision
  • 
Gait: pt ambulating with rw, prosthesis, 30 ft with close supervision, decreased gait speed, decreased step length, intermittent L knee instability, decreased step width and cues for L HS.
Equipment: check socket, gel liner suspension, safety knee, college park foot and no socks


ICF:


  • Pathology: L AKA/significant PMH

  • Body Function structure: decreased LE strength, functional balance, activity tolerance, skin integrity with prosthetic use and gait impairments.
  • Activity limitations: assist with don/doff of prosthesis/management, assist of 1 with transfers/gait with prosthesis. Unable to negotiate steps/outside surfaces with prosthesis.
  • 
Participation: unable to ambulate to car or in the community or perform activities in standing/walking with foster

Clinical Hypothesis

Anticipate that pt will make nice progress given her motivation, excellent carry over/follow through with education, current mobility status, good general strength,ROM with no contractures, at this time limited limb/phantom pain and no issues with skin integrity. Pt's size is also an asset to her overall mobility. Barriers to pt progress could be pt's significant PMH for COPD, dyspnea and current smoking, which could limit activity tolerance. Significant PVD will also need to be monitored for claudication in RLE. HTN will require close monitor given increased cardiovascular demands placed on pt with AKA prosthetic training. Pt will also put increased demands on BUE with RW training and pt has a history of R shoulder dislocation which will need to be monitored for over use.
Pt does live alone so she will need to be independent with all prosthetic management/education and mobility in the home with the prosthesis.


Expect pt to reach goals of independent: don/doff of prosthesis, increase prosthetic wear time 4-6 hours a day, independent with skin inspection, independent knowing when to add socks and contact prosthetist, independent with home program, independent transfer and ambulating with prosthesis/rw in the home environment.


Discussed that due to pt's short length of stay her goals related to independent stair negotiation, walking to car and progression with walking activities with foster son, she would have to defer these goals to OP-PT. Pt in agreement.

Intervention

Due to short rehab stay of 4 days treatment was very focused.
Our prosthetist was available 3 of the 4 days for collaboration with the PT/PTA/physiatrist regarding alignment and prosthetic fit. Adjusting prosthetic length to accommodate length discrepancy and rotated socket mildly into ER to decrease IR.
Collaboration occurred with nsg and OT regarding wear time of the prosthesis, skin inspection and progression with functional mobility using the prosthesis.
Social work was involved regarding dc planning, transportation home and OP-PT.
Contacted OP-PT to discuss pt status/issues.
Education provided regarding: independent don/doff of the prosthesis, so pt could use it at home. Need for frequent skin inspection with gradual increase in wear time of prosthesis. Pt using mirror to inspect posterior thigh on her own.
Adding: stockings to prosthesis for proper fit and when to stop wearing the prosthesis.
Transfer training with the rw/prosthesis from various surfaces and heights.
Gait training was initiated initially in the parallel bars, progressing quickly to the rw/prosthesis on level and uneven surfaces (ramps/side walk/carpet/inclines)
Standing balance and weight shift activities to facilitate LLE weight bearing: with single and no UE support, ball toss, reaching outside base of support for objects L and R and across body.
standing exercises: with light UE support: hip flexion, extension, abd/add, 10 reps to BLE to facilitate LLE strength and weight shift.

Outcome

  • Pt was independent with don/doff of the prosthesis.
She was independent determining when to add socks and when to call prosthetist.
She was tolerating prosthetic wear time for 1-2 hours, 3 times a day.
  • Independent with skin inspection.
independent with transfers and ambulation in the room with the rw and prosthesis.

  • Pt was independent with her home program.
  • 
Goals not reached due to short length of stay. Pt decline longer stay to achieve these goals. She wanted to address them on an OP-PT basis.
  • She required supervision with outdoor ambulation and was unable to progress to trial with curbs or stairs due to short length of stay.
  • The last day of treatment pt had increased pain over the distal/anterior transfemoral surface, there was no redness or bruising but it was painful with wear time and mobility.

  • Discussed with pt that she should take a break from wearing the prosthesis for 2 days at home and resume again gradual wear time on Monday. Skilled discussion regarding risk of bruising and skin break down. She would need to monitor this closely and work with her OP-PT to assist with activity progression.

Discussion

Since initiating this course I have a new prospective on some of the education and treatments that I would provide. I need to spend more time focusing on the education: regarding the need for physical activity/exercise, protection and inspection of the non-involved limb, diet, smoking and prosthetic care. I realize how important these aspects of care are on the pt's wellbeing and success.[1]

I also realized that I did not initiate any outcome measures, which I am now more aware of. This would be helpful in monitoring pt progress and progression with the use of the prosthesis. There are simple things I could have done that are not time consuming like gait speed, 6 min walk or TUG. I am now aware of Outcome measures available specifically to pt's who have had amputations and will now reference this with my current pt's and use as appropriate to monitor baseline progress.[2]

This course also provided an increased awareness to the stages of grieving that pt's go through and the support that they need. I would love to see a support group develop at our site to support these pt's going through amputations. Peer support would be wonderful for these pts.[3] I also have an increased awareness to exercises and activities from post amputation to exercise with the prosthesis.[4]


I have an increased awareness to the ICF model.[5]

I will presenting/sharing the information that I have learned through this course with my colleagues so we can provide better care. Thank you

References

  1. Pantera, E,Pourtieer-Piotte, C. Bensoussan, L.,Coudeyre,E. (2014). Patient education after amupation: systematic review and experts opinions. Annuals of physical and rehabilative medicine, 57(3) 143-158. From the course work: Discharge Management of the Amputee
  2. (2014)British Association of Chartered Physiotherapists in Amputee Rehabilitatin (BACPAR) Outcome Meaures Toolbox
  3. WHO textbook Chap 2.3 (pages 19-21)
  4. Gaily book Prosthetic Gait Training Program for Lower Extremity Amputees
  5. CF model from pre-course work