Amputation secondary to Diabetes Mellitus: Amputee Case Study

Original Editor ­ Offniel Lamont

Title

Amputation Secondary to Diabetes Mellitus

Abstract

Amputation is the surgical removal of a limb due to complications associated with disease or trauma. There are two main categories in which amputees are grouped: Traumatic and non-traumatic. Diabetes Mellitus (DM) is one of many causes of non-traumatic amputation. Engstrom and Van de Ven (1999)[1] defines DM as a systemic disorder in which blood glucose may be intermittently raised above the normal range. In the United States (US) studies have shown that DM is the leading cause of non-traumatic Lower Extremity Amputation (LEA). Hence, treating these patients requires knowledge of the condition

Key Words

Transtibial, Non-traumatic, Lower Extremity Amputation, Diabetes Mellitus, Secondary, Rehabilitation

Client Characteristics

55 years old Male, recently hospitalized for elective surgery where he underwent a transtibial amputation.

Past Medical History

  • Diabetes Type 2
  • Hypertension
  • Gangrene of the right Hallux which was amputated
  • Fractured left Forearm

Vascular investigations:

  • Doppler studies- indices of 0.3,
  • Angiography
  • Arterography.

Medication:

  • Enalapril
  • Metformin

Present Medical History:

  • Reason for amputation: Peripheral vascular disease with atherosclerosis.
  • Associated medical problems: Chronic fonitaine's stage 4 foot ulcer and critical limb ischemia.
  • History of deterioration of limb: Chronic
  • Claudication history
  • Skin condition: Poor
  • Sensation: Impaired on right Lower extremity
  • Smoking and drinking history
  • Pain

Social History:

  • Occupation:Former Construction worker, currently unemployed for the last 6 months
  • Dependent: 6 children and 4 grandchildren
  • Housing: 2-bedroom board house with no modern conveniences
  • Hobbies and interest: Social (playing dominoes and going to the race horse track)
  • Wheelchair mobility: Good for level surface and up/down ramps
  • Driving: Nil
  • Good family and friends support

Examination Findings

ICF Table

Pathology: Transtibial Amputaion

Body structure and function:
1. Integumentary system- Poor skin condition and surgical wound
2. Somatosensory system- Impaired sensation and pain
3. Cardiopulmonary system- Decrease endurance
4. Musculoskeletal system- Decrease Range of motion and strength, Dependent ambulation
5. Neuromuscular system- Impaired balance
6. Psychological Issues- Depress

Activity Limitation:
1. Unable to ADLs such as cooking, washing, going to the shop and showering
2. Unable to ambulate independently
3. Unable to have sex

Participation Restriction:
1. Unable to work as construction worker
2. Unable to take care of his common law wife and children along with grandchildren

Contextual Factors:
Personal: Positive- 1. Good family and friends support
Negative- 1. Poor financial status
2. Unemployed
3. Patient has several co-morbidities such as DM and HTN
4. Patient is depressed and has history of smoking and drinking
Environmental:

Positive-

1. Access to free health care
2. Nil steps at home and flat terrain


Negative-

1. Lives in 2-bedroom board house with no modern conveniences

Clinical Hypothesis

Based on the clinical examination done the clients main problems are as follows:
1. Pain
2. Decrease Range of motion and muscle strength for bilateral lower extremity
3. Poor balance- short sitting dynamic, standing static and dynamic
4. Decrease endurance
5. Impaired sensation
6. Depressed

Intervention

There were four main goals that were establish in order to guide the treatment sessions:
1. Prevent complications
2. Manage the wound and stump
3. Restore mobility and independence
4. Manage pain and to begin to think about discharge

The treatment modalities (Interventions) used were:
1. Education and teaching of both patient and family about the following- DM, Skin care and sensory deficits

2. Pain Management with the use of TENS and Ice

3. Stump Management- a.Teaching of Desensitizing techniques which included end weight bearing and the use of different materials such as cotton b.Scar Mx patient taught massage c.Shaping of stump using elastic bandage d. Wounding healing was addresses with UV to increase healing process

4. Patient Positioning- Proper sleeping and sitting positions were explained to patient such as not to cross legs when sitting or put pillow under knee

5. Exercise therapy- a.strength training, ROM exercises, functional activity training and general conditioning b.Transfers, balance training- sit to stand exercises, sitting on therapeutic ball with nil assist and standing in parallel bars with hands then to no hands
c.Throwing and cathching exercises in sitting and standing d. Ambulation with assistive device such as walker and then progressed to crutches

6. Pre-gait training- a.Orientation to the center of gravity and base of support b.single leg standing c. Stepping over and around obstacles

7. Patient referred to a Councillor

Outcome

Intervention 1: (Patient education)- Patient demonstrated that he could manage his sensory deficit along with skin care management effectively

Intervention 2: Patient reported having decreased pain throughout treatment sessions and rated pain as 0/10 NRS

Intervention 3: (Stump Management)- Patient demonstrated he was able to manage his stump appropriately and had decreased sensitivity, oedema and the scar tissue was mobile and wound healed

Intervention 4: (Patient Positioning)- Due to the fact that patient was taught proper positioning, common problems such as muscle tightness and contractors did not develop

Intervention 5: (Exercise Therapy)- It was observed over the weeks of treatment, that the patient regain normal range of motion. He had increase in muscle strength for bilateral lower extremity, trunk and maintain normal upper extremity strength

Patient's balance and coordination also improved, that is sitting and standing static and dynamic balance improved. Patient also showed improvements in endurance and ADL's such as carrying objects while walking and picking up objects from the floor

Finally, patient's physiological status improved, he was now hopeful and looking towards the future.

Discussion

Diabetes based on studies done, have shown to make up 60% of all non-traumatic LEA. Hence, majority of the patients a Physiotherapist will see for amputee rehab have diabetes. It is therefore important for the physiotherapist working with such patients to have a good understanding of the condition in order to rehabilitate these patience successfully. Additionally, the rehabilitation process should not only focus on the amputated limb, however the rehab should also focus on the sound limb. In the article entitled risk of re-amputation in diabetic patients, stratified by limb and level of amputation: 10 year observation. It was found that the risk of amputation is greater in diabetics with the rate of major amputation of the contralateral limb is 11.6% at 1 year and 53.3% at 5 years. In the case presented the patient had a number of issues, all of which were addressed through strategies for range of motion, strength, balance, coordination, agility and endurance. Safety should also be a number 1 priority for the physiotherapist, as their healing rates are slower than non-diabetics which puts then at risk of significant post-operative complications. Safety goals should take 2 main forms; A- prevent injuries due to falls and B- prevent damaged to the sound limb by reducing abnormal stresses. Ir should be noted that use of crutches for a diabetic amputee may place them at increased risk of fall and injury of their intact limb. It is recommended that a walker be used instead.

[2][3]

References 

  1. Engstrom B, Ven CVd. Therapy for Amputees. 3rd Edition. Churchill Livingstone. London. 1999
  2. Izumi Y, Satterfield K, Lee S. Harkless L. Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year obeservation. 2006; 29 (3):566-570
  3. CDC reports finds large decline in lower-limb amputations among US adults with diagnosed diabetes 2012