Amputee Case Presentation - The Diabetic Amputee: Amputee Case Study

Title

Amputee Case Presentation- The Diabetic Amputee

Abstract

Mr. S is a 62 year-old male 2 weeks post Left BKA who was discharged home from hospital with Rehab in the Home (RITH). RITH is an early supported discharge program, and he was referred for physiotherapy, occupational therapy and social work. He usually lives alone, but his brother is staying temporarily on discharge to assist. I am seeing him at home for physiotherapy in his pre-prosthetic stage of rehabilitation. The goals were to maximize independence and safety within the home environment prior to being seen in the outpatient amputee clinic in 3 weeks time.

Key Words

transtibial, early supported discharge, diabetes, physiotherapy

Client Characteristics

  • 62 y/o male seen at home 1 day post discharge for admission post L) BKA

  • Previous Function- Independent with mobility nil aids 300m limited by leg pain due to claudication, Independent with all ADLS. Previously driving. Nil active exercise program.
  • Social History- Owner of a bar and usually works at the bar 5-6 days/week when not travelling. Regularly travels to and from Thailand. Has a partner who is from Thailand, who is currently trying to get her visa to be able to live in Australia. Brother staying temporarily on discharge to assist, but usually lives 1⁄2 hour away. Nil other family in Perth. Threshold ramp at home at front access, otherwise level throughout. Good access for wheelchair around home.
  • Equipment provided from hospital on d/c: Shower chair, bed rail, and manual wheelchair.

  • PMHx- PVD, Type 2 DM, Hypercholesterolemia, Hypertension, current smoker, IHD, Gout, and Previous IVDU- ceased 5 years ago.
  • Previous Treatment- Failed Bypass Surgery for PVD. In combination with poorly controlled Type 2 Diabetes, and poor lifestyle factors including heavy and current smoker, and previous IVDU, decision made to perform BKA.

Examination Findings

Subjective- Main complaints are reduced independence (I) with ADLs, transfers and mobility. C/o pain and increased sensitivity at end of stump.
Patient goals- To be as independent as possible at home with minimal assistance required from family and support services, including (I) with transfers and ambulation with ECs. OCM: TUG- 27 seconds with ECs, Lawton's ADL - 16/30

Objective:
 Bed Mobility: Independent
Sit-Stand: Independent Standing Balance: Able to stand with supervision for 10 seconds Transfers: with stand-by assist x 1, Floor: 1 x modA
Ambulation: (I) with ZF. SBA x 1 with Elbow Crutches Wheelchair: (I) on flat surfaces. s/v over ramp. Power- LL- (L) Gr 3+/5 Left Knee F/E, Hip F/E and Add/Abd (R) Gr 4+/5 Globally LL, UL- (L) + (R) UL Globally 5/5. Good hand dexterity Sensation- Intact, some increased sensitivity at end of stump


ICF: Body Functions and Structures: (L) BKA- transtibial Impairments: Reduced standing balance, reduced LL and core strength, reduced endurance, reduced mobility, and increased pain. Activity Limitations: Independent with w/chair on flat surfaces but requiring supervision over threshold, Requiring 1 x A to transfer, 1 x A to ambulate with Elbow Crutches, Assistance required for domestic tasks and community transport. Participation Restrictions: Reduced work capacity and unable to drive
Environmental Factors: Temporary support from brother staying. Stress present as partner unable to assist currently as waiting for visa

Clinical Hypothesis

My clinical evaluation of Mr. S's main problem is reduced independence due to reduced mobility post amputation. He has reduced strength, balance and endurance, and pain from the stump. He is also at increased risk of falls, which increases risk of damage to his stump. His is very motivated to improve, but also likely to engage in risk taking decisions, and unlikely to cease smoking, which could adversely affect his rehabilitation.

Intervention

2 wks of RITH at home including:


  • Standing Balance Practice including single leg stance and reaching in standing

  • Transfer training in combination with the OT. Including bed-wheelchair transfers, wheelchair-chair transfers, car transfers and floor transfers. During transfer practice it is important to teach Mr. S to move his body in smaller increments and ensure that the transfer is done in a safe and slow manner to prevent micro trauma to the right foot.

  • Mobility Practice with a Zimmer Frame and ECs, including how to effectively and safely step with a soft landing of the right foot, to once again reduce micro trauma.

  • Set Up and Practice of a home exercise program including UL, Trunk and LL strengthening, endurance and ROM exercises
- Prone Stretching Program to minimize risk of shortening and contractors

  • Teaching and reinforcing stump desensitization and distraction techniques including tapping and massage, to help reduce phantom limb pain
  • Wheelchair practice including slopes, curbs, over thresholds and around obstacles.

  • Falls Prevention Education

  • Carer education, to improve compliance of recommendations[1]r
  • Reinforcing stump and scar management education to ensure good healing and ensuring stump is in best condition possible for consideration of prosthesis[2]
  • Continuing education on improving lifestyle factors

  • Working with SW to ensure adequate supports in place

  • And ensuring appropriate equipment in place

Outcome

After 2 weeks of RITH intervention at home, Mr. S improved significantly with his transfers and mobility.

  • He achieved independence with all transfers, including car and floor transfers.
  • He was able to stand for 1 minute unaided independently on his right leg. He was able to independently and safely ambulate with elbow crutches short distances within the home, and continued to use a wheelchair for outdoor use.
  • He was able to safely negotiate his manual wheelchair over a threshold ramp to get in and out of his house, and could independently go up and down small slopes and curbs.
  • He was independent with his home exercise program and performing prone stretching x twice/day.
  • He did have one fall when practicing ambulation unsupervised on day 3-post d/c home due to not waiting for his brother to supervise his ambulation. He did not sustain any injuries, and after this was more receptive to falls prevention education. He did not have any further falls during his time with RITH.
  • His Timed Up and Go improved to 16 seconds with elbow crutches, and Lawton's improved to 24/30.
  • Pain was still present at the end of his stump, but was improving.
  • He was able to perform all personal care and dressing independently, able to cook simple meals independently and able to shop for small purchases independently.
  • A HACC referral was organized, to provide him with domestic assistance and shopping assistance x 1 week.

Discussion

Mr. S improved significantly in the 2 weeks post discharge from hospital with rehabilitation in the home. We were able to assist with the transition home, and maximize independence in the home environment, enabling an effective early supported discharge. Mr. S's mood improved significantly on discharge home, as he was able to leave hospital but continue his rehabilitation in the home environment.

Whilst there is much evidence to support early supported discharge programs in mild-moderate stroke population[3], there is definitely a role in the amputee population to assist with this transition home, where these services are available. The challenges with Mr. S where that whilst he was very motivated to be as independent as possible, he initially was reluctant to take on education to reduce risk of falls and wait for supervision to ambulate when not yet independent. A fall on day 3-post discharge from hospital increased his receptiveness to falls prevention education.

Falls prevention is important in the amputee population to reduce incidence of future falls, to ensure reduced risk of injury and to maintain quality of life. Quality of life has been shown to be reduced with increased number of falls with amputees in the community[4]. The benefits of staying on a frame were discussed, but Mr. S was insistent on continuing to ambulate with elbow crutches. Mr. S was very keen for a prosthesis, which will be reviewed in the amputee outpatient clinic

References

 
  1. Gaily RS, Clark CR.Physical therapy management of adult lower-limb amputees. In: Michael, JW editor. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. Rosemont, IL, American Academy of Orthopedic Surgeons,1992.
  2. Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M and Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-59
  3. Hofsted H, Naess H, Moe-Nilssen R and Skouen J. Early supported discharge after stroke in Bergen (ESD Stroke Bergen): a randomized controlled trial comparing rehabilitation in a day unit or in the patients' homes with conventional treatment. International Journal of Stroke (2013) 8: 582-587
  4. Hordacre B, Barr C, Crotty M. Community activity and participation are reduced in transtibial amputee fallers: a wearable technology study . BMJ Innov 2015;1:10-16