Amputee Rehabilitation: a case study : Amputee Case Study

Title

Amputee Rehabilitation: A Case Study

Abstract

In this case study of a patient treated in 2014, pre-prosthetic rehab and prosthetic gait training are outlined. The patient was a good prosthetic candidate and satisfactory results were obtained.

Key Words

Transtibial, hemiparesis, gait

Client Charactoristics

69 y.o. male with R TTA due to necrotizing fasciitis. Admitted to Rehab unit 3 weeks post surgery. Associated medical conditions included DM type 2 and history of stroke with resulting R hemiplegia and some cognitive impairment.
He previously worked as an accountant, but stopped working due to his stroke. He lives with his spouse who still works 5 days/week, and an adult daughter who is attending school. Previously he was ambulating independently without an assistive device, independent for all his ADL’s, but was mostly housebound. He went out of the house only rarely when accompanied by family, mostly due to lack of motivation.
Due to the emergent nature of the amputation, the patient was not able to participate in any pre-op education. On the acute care unit, basic bed exercises to maintain ROM and strength were initiated and the patient was getting up daily to a wheelchair properly fitted with an amp board.

Examination Findings

No complaints of pain or phantom pain (0/10). His goal was to ambulate independently with a prosthetic and return home.
ROM: R hip extension to neutral only. Hip abd 20o o/w WNL (within normal limits)
Strength: R hip ext 2+/5, hip abd 2-/5, knee ext 4/5
Increased tone of R hip add/IR and knee ext

Well healed incision along anterior aspect of distal stump. No areas of skin break down on stump or contralateral limb. No edema.
Static sitting balance was good, but decreased ability to move outside BOS to the Right. Berg = 4/56

He was able to roll side to side in bed independently, using bed rails. He was able to move from lying to sit, and sit to lying independently. He required 1 person assist to transfer from the bed to wheelchair. Once in the wheelchair he was able to mobilize independently. With assist he was able to stand for a few seconds with a standard walker, or in parallel bars.
Unable to perform ADL’s, IADS’s independently (assessed by OT) and unable to return home safely.
(AMPnoPRO not assessed at time of assessment but would have scored 3/39)

Clinical Hypothesis

Adult male with history of stroke with right sided hemiplegia, now 3 weeks post R TTA. His main problem is lack of independence with his functional mobility, thus he is unable to manage at home. Other problems include weakness of the right hip and knee, decreased balance and some pre-existing cognitive impairments (impulsive, decreased memory, poor judgement at times). He is a good candidate for prosthetic fitting due to adequate wound healing, good skin integrity and shape/ length of stump, and good social supports.

Intervention

This patient was provided with information on stump care and prosthetic. Initially elastic bandages were used for shaping of the stump, and shortly after a silicone shrinker sock was provided. The prosthetist casted his stump in order to fabricate a temporary prosthetic – total surface bearing with silicone liner.
He participated in daily ROM and strengthening exercises[1] for both legs (notably, hip ext, knee ext, hip abd) and arms. Transfer training progressed from sliding board to standing pivot transfer with a walker. Sitting balance exercises were performed as well as core strengthening exercises with a medicine ball.
Pre-prosthetic standing exercises in the parallel bars included weight shifting, and standing balance. When the prosthetic was delivered, the patient and his spouse were educated on proper fit and care of the prosthetic, use of socks, inspection of skin on the stump. He practised weight shifting, standing balance and progressive gait in the parallel bars. Gait progressed to the use of a wheeled walker.
The prosthetist consulted weekly, gait analysis was performed.

Outcome

The patient was discharged home after 12 weeks of rehabilitation. He was able to mobilize independently in his home with a wheeled walker although supervision was recommended initially due to cognitive deficits. He was able to tolerate 200m of ambulation without rest.
Right knee ext = 4/5. Right hip ext and abd 2+ (difficulty due to motor control deficits post stroke).
He was able to correctly don/doff prosthetic and was able to problem solve various incidences where readjusting fit or number of sockes was required.
Gait analysis showed narrow base of support due to excessive R hip add (adductor tone) with significant right hip Trendelenberg (R hip abd weakness) persisting. Prosthetist was able to adjust prosthetic alignment to account for these gait deviations with excellent results. The gait became much more stable especially during turning.
TUG: early prosthetic use =34 sec. at discharge =11.3 sec
BERG = 24
Referral made for follow-up therapy in an out-patient rehab facility to continue gait training with prosthetic. Follow up appointment with prosthetist scheduled.

Discussion

This case was unique in my practice as the prosthetics training was complicated by the past history of stroke with hemiplegia on the same side as the TTA. The cause of the amputation was necrotizing faciitis. The patient did not suffer from phantom pains, possibly as there was no history of pre-surgical pain.
Participation of the Prosthetist in the gait analysis proved vital in optimizing the patient’s overall safety with gait. The prosthetist was able to make adjustments to the alignment of the prosthetic to compensate for persistent weakness of the R hip due to the hemiparesis.
It was felt the patient was a good candidate for a prosthetic [2] due to his motivation, good ROM, good condition of the stump and good family support. The patient did not achieve a high level of function with the prosthesis during his inpatient rehab stay and remains at risk for falls[3] given his low Berg, cognitive impairments and ongoing weakness (esp R hip abd). This is due to his low pre-morbid activity level, his associated medical conditions and limits of the in-patient program. It was felt that he would benefit from ongoing rehab in the community to progress his gait training and attempt to reduce his risk for falls.
In future, I would choose additional outcome measures that I was not familiar with at the time, notably the AmpPro[4]

References

  1. Engstrom B, Ven CDv. Therapy for Amputees. 3rd ed. Churchill Livingstone, London. 1999
  2. Benyaich A, Lowe T, Airt L, Lowe R, Hafeez A. Assessment of the Amputee. Accessed July 19 2015. http://www.physio-pedia.com/Assessment_of_the_amputee
  3. Stark A. Falls in the Amputee Population: A literature review. 2004. http://www.physio-pedia.com/images/4/44/Falls_in_Amputees.pdf
  4. Benyaich A, Lowe T, Airt L, Lowe R, Hafeez A. Assessment of the Amputee. Accessed July 19 2015. http://www.physio-pedia.com/Assessment_of_the_amputee