Bilateral Below Knee Amputation due to Diabetic Complications: Amputee Case Study

Title

Bilateral Below Knee Amputation due to Diabetic Complications 

Abstract

Due to improper care of his first below knee amputation, a 65 year old male patient developed a complication to his contralateral limb that resulted in a second below knee amputation seven years later. The patient was then fitted with bilateral below knee prosthesis and was given training at a rehab hospital. Upon his discharge, he was still lacking balance and was referred to outpatient physiotherapy. This is a case assignment describing a diabetic amputee that was assessed and treated in an outpatient physiotherapy setting with bilateral prosthesis.

Key Words

transtibial, bilateral amputee, diabetic amputee, below-knee prosthesis

Client Characteristics

BC is a 65 year old male patient with bilateral below knee amputation. His first amputation was his R leg in 2008 and his L leg amputation was in Jan 2015. His L leg amputation was secondary to a necrotic diabetic foot ulcer. His co-morbidities include: poorly controlled Type II diabetes, sleep apnoea, smoking and bladder cancer. He is currently retired and living with his wife in his house. He was previously admitted for rehab in Feb 2015 but he discharged himself without against medical advice and was managing at home. Patient then went on to a rehab hospital and was fitted with bilateral below knee prosthesis in May 2015. Patient was trained at the rehab hospital with bilateral below knee prosthesis for 4 weeks and is now able to ambulate with crutches with stand by assistance. Patient is currently attending outpatient physiotherapy to improve is balance and progress to ambulating independently with prosthesis.

Examination Findings

Subjective:
Patient reports he has pain with both right and left foot and he reports his phantom pain in his right foot is 7/10 and 5/10 with his left foot. Pt states that he had an excellent rehab training with his bilateral below knee prosthesis, however, he still has difficulty with balance. Pt states he has not had a fall with the new prosthesis. Patient had a history of poorly controlled type II diabetes, but he states that he is managing his condition well. Patient’s goal is to ambulate independently without any gait aids, increase his balance, able to go hunting and boating.

Objective:

  • Bilateral Knee ROM: both flexion and extension within normal limits.
  • Manual Muscle Testing:
  • L – quads, hamstring, glut medius 4/5
  • R – quads, hamstring, glut medius 4/5
  • Gait Analysis: increased trunk flexion, wide stance, decreased stance time on Leg, increased body lean on left side
  • Length tension: increased tightness on bilateral hamstrings
  • 6MWT: unable to complete to fatigue; only able to ambulate for 50m.

ICF Findings:

  • Body Functions and Structures: MSK/Joint: Bilateral below-knee amputation
  • Impairments: bilateral phantom pain; decreased strength in bilateral hip muscles; pain due to pressure points with prosthesis
  • Activities Limitations: requires prosthesis for ambulation; decreased balance with ambulation and standing; requires standby assistance for ambulation
  • Participation Restrictions: Unable to drive; unable to participate in leisure activities

Clinical Hypothesis

This patient has bilateral below knee amputations six years apart and he also has history of poorly managed type II diabetes. Patient recently spent 4 weeks learning how to use bilateral below knee prosthesis and has completed basic ambulation training. Patient is able to ambulate with standby assistance with decreased balance. Further balance and strength training will benefit patient and be more independent with ADLs and leisure activities.

Intervention

  • Gait: Practised ambulating in heel to toe pattern; education for patient to decrease trunk flexion, decrease body/hip swaying, increase hip extension and bigger stride length.
  • Balance: Patient worked on improving balance between the parallel bars, first beginning with weight shifting from side to side and shifting forward and backwards with support. Patient progressed to weight shifting without support. Patient then worked on standing balance without support and progressed to catching a ball being thrown at him to his sides.
  • Strength: Open chain exercise for hamstrings, quads, glut med and glut max. 3 sets of 10 reps a day.
  • Flexibility: Hamstring and hip flexors stretches, 30s hold, 3-4x a day or as tolerated.
  • Endurance: Ambulation with supervision as tolerated to improve endurance. Start off with one to two minutes and increase endurance up to six minute to be able to complete the six minute walk test.

Outcome

  • Gait: Pt was able to ambulate with heel to toe pattern and less body/hip swaying and less trunk flexion. Patient is more confident with using both below knee prosthesis. Stride length has increased to within normal limits.
  • Balance: Patient has improved balance compared to before outpatient physiotherapy training. Patient is able to stand without support for up to 1 minute. Patient is able to stand with his feet together for up to 30 seconds. Patient is able to walk along a straight line without supports. He is also able to catch a ball thrown at him easily without losing balance without supports.
  • Strength: Hamstring, quads, glut med all has improved strength to 4+/5.
  • Flexibility: Hamstring and hip flexors bilaterally both has decreased tightness compared to initial assessment.
  • Endurance: Ambulation has improved and patient is able to perform the six minute walk test. His results are 150m in the 6 minute walk test. Patient previously was not able to complete the test.

Discussion

The leading cause of non-traumatic lower in the US is diabetes and it accounts for 60% of the total non-traumatic amputations[1]. A main goal of is of rehab is to prevent further injury and a potential amputation of the contralateral limb[2]. Patients with diabetes are more susceptible to injury and tissue failure due to compromised healing rates. This specific patient originally had his R leg amputated in 2008, however, he failed to manage his diabetes and he developed an L leg necrotic foot ulcer. That resulted in a contralateral limb amputation in Jan 2015. The goal for this patient currently is to be able to ambulate with prosthesis safely and prevent injury due to falls, which could result in further complications due to his diabetic condition. After an initial assessment, a number of contributing factors can be account for his poor balance using bilateral below knee prosthesis. Strength training for the hip muscles has been shown to benefit persons with lower limb amputation [3]. A personalised exercise using stretching and strengthening exercise to maintain and/or improve joint mobility has been recommended based on an evidence based clinical guideline [4]. After 4 weeks of training and treatment, the patient did improve in all objective measures and resulted in the patient being an independent and safe person with prosthesis.

References 

  1. The Diabetic Amputee. http://www.physio-pedia.com/The_Diabetic_Amputee
  2. The Diabetic Amputee. http://www.physio-pedia.com/The_Diabetic_Amputee
  3. Nolan L. A training programme to improve hip strength in persons with lower limb amputations. J Rehabil Med. 2012; 44(3):241-8
  4. Broomhead P, Clark K, Dawes D, Hale C, Lamber t A, Quinlivan D, Randell T, Shepherd R, Withpetersen J. Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses, 2nd Edition. Chartered Society of Physiotherapy: London. 2012