Case Study: Amputee Case Study

Title

Case Study: Amputee Case Study

Abstract

The NHS has developed a clear pathway for amputee rehabilitation (NHS, 2014b) involving prosthetists, physiotherapists, consultants, occupational therapists and councilors, but provides no time scale. Each person recovers and progresses at their own pace, no matter how experienced the health care professionals involved in their rehabilitation. This case study explores how pain in the limb can have a dramatic effect on achieving a comfortable socket fit and therefore the speed of rehabilitation for Transfemoral amputees and the creativity required of the prosthetist involved

Key Words

Amputation, Pain, Rehabilitation

Client Characteristics

  • Age: 79
  • Gender: Male
  • Amputation Details: 01/01/12, Right Transfemoral
  • Amputation Cause: Critical limb ischaemia, non-diabetic arteriosclerosis
  • Medical history: 1987 Deep Vein Thrombosis (DVT) in left leg 1991
  • Vertebrae L4-5 fixed, chronic lower back pain
  • 1994 Triple heart bypass, 2008 & 2010 Femoral popliteal bypasses, 2012 Angiogram, thrombectomy, fasciotomy and femoro distal bypass
  • Condition of 'sound' leg: DVT 1987, pain in foot which limits standing time.
  • Flexion contractures at both the knee and hip have developed since amputation.
  • Prescription history: Polypropylene quadrilateral socket with Ortho-Europe Easi knee and Endolite Senior foot. (Socket recast and remade several times over 2 years) TES belt suspension, shoulder strap added to improve suspension.
  • Current prescription: Polypropylene brim supported by steel struts connected distally to a cup, Easi knee and Senior foot.

Examination Findings

After several femoral bypasses, this patient finally underwent a Transfemoral amputation on his right leg in January 2012, aged 76. Despite previous medical history and the less than ideal condition of his remaining left leg, the patient was highly motivated with a positive attitude toward rehabilitation and gait training. Achieving a comfortable socket fit so he could begin gait training however, turned out to be a challenge. Challenges

  1. Hip flexion contractures: Despite early physiotherapy intervention, the patient developed and has maintained hip flexion contractures of 20-30o in both legs. This has to be accommodated in the socket or the pressure on the cut end of femur would be too great.
  2. Increasing volume: Initial residuum shrinkage post-amputation was quickly reversed once the patient left the hospital. Over the last 3 years he has continuously gained weight resulting in the residuum increasing in volume and sockets becoming too small.
  3. Pain: This patient suffers from strong phantom limb pain, residual limb pain and allodynia. These have developed and worsened over time, particularly the allodynia which is focused over the distal end and in the groin area.

Clinical Hypothesis

Initially, the patient was prescribed and provided with a polypropylene quadrilateral socket (Smith, Michael, & Bowker, 2004) suspended via a TES belt and a shoulder strap. New sockets were manufactured regularly either to accommodate increased volume or more hip flexion. A true suction socket[1] was considered at the start of 2013. This would minimise pistoning and therefore hopefully not aggravate the distal end so much (Kapp & Miller, 2009). It would also apply greater compression around the residual limb, possibly relieving some phantom and residual limb pain.

An added benefit would be removing the need for a TES belt, increasing patient comfort. However this system requires a consistent residuum volume and toleration of this greater compression force. The patient did not have a stable residuum volume and at the time could barely tolerate his compression sock, both big contra-indications. For the same reasons, a seal-in liner was contra-indicated (Jarvis & Verrall). The patient was provided with the same prescription as before, with all factors accounted for and this socket was successful for almost a year. The patient was seriously ill in 2014. This worsened the allodynia at the distal end, led to more allodynia in the groin area and led to a massive increase in weight.

Intervention

Interventions

  1. The patient has had regular physiotherapy since leaving hospital. This has kept his muscles from deconditioning between sockets and provided gait training whilst limbs have fitted. His left leg has become stronger and his gait training has progressed albeit slowly.
  2. Several pain management regimens have been tried. Recently, the most effective pain relief has been pernaton gel. Botox injections were tried but these only provided relief for 10-15 days rather than the 3 months expected (Kern, Martin, Scheicher, & Muller, 2004).

A night sock which provides electromagnetic shielding that can alleviate phantom limb pain[2] was prescribed a few months post amputation. This helped the patient sleep until the allodynia at the distal end became too great to tolerate the sock any longer. The patient has tried the desensitising techniques advised post amputation (NHS, 2014b), but these have had no effect.

Outcome

Pain in both his remaining limb and his residuum have slowed this patient's rehabilitation dramatically. The allodynia at the distal end combined with hip flexion contractures made achieving a comfortable socket fit particularly challenging. This prescription is still not perfect. There is currently a lot of pistoning as the patient walks, so a rigid pelvic band is soon to replace the TES belt and a silicon cushion liner is to be tried instead of terry socks to prevent rubbing on the skin. The patient himself is very happy to be on his feet again and on the way back to independent mobilisation.

Discussion

Pain in both his remaining limb and his residuum have slowed this patient's rehabilitation dramatically. The allodynia at the distal end combined with hip flexion contractures made achieving a comfortable socket fit particularly challenging. This prescription is still not perfect. There is currently a lot of pistoning as the patient walks, so a rigid pelvic band is soon to replace the TES belt and a silicon cushion liner is to be tried instead of terry socks to prevent rubbing on the skin. The patient himself is very happy to be on his feet again and on the way back to independent mobilisation.

[3][4][5][6][7][8][9][10][11][12]

References

  1. Gholizadeh, Osman, Eshraghi, Ali, & Yahyavi (2013), Satisfaction and Problems Experienced With Transfemoral Suspension Systems: A Comparison Between Common Suction Socket and Seal-In Liner
  2. Fisher, K., Oliver, S., Sedki, I., & Hanspal, R. (2015). The effect of electromagnetic shielding on phantom limb pain: A placebo-controlled double-blind crossover trial. Prosthetics and Orthotics International. doi:10.1177/0309364614568409
  3. Alley, R. D., Williams III, T. W., Albuquerque, M. J., & Altobelli, D. E. (2011). Prosthetic sockets stabilized by alternating areas of tissue compression and release. Journal of Rehabilitation Research & Development, 48(6), 679-696.
  4. Barsby, P., Ham, R., Lumley, C., & Roberts, C. (1995). Amputee Management. London: King's College School of Medicine & Dentistry
  5. Behr, J., Friedly, J., Molton, I., Morgenroth, D., Jenson, M. P., & Smith, D. G. (2009). Pain and pain-related interference in adults with lower-limb amputation: Comparison of knee-disarticulation, transtibial, and transfemoral surgical sites. Journal of rehabilitation research and development, 46(7), 963-972.
  6. Brånemark, R., Brånemark, P.-I., Rydevik, B., & Myers, R. R. (2001). Osseointegration in skeletal reconstruction and rehabilitation:. Journal of Rehabilitation Research and Development, 38(2), 175-181.
  7. Cooper, R. A. (1995). Rehabilitation Engineering Applied to Mobility and Manipulation. CRC Press.
  8. Diabetes UK. (2011, December). Diabetes in the UK 2011/2012: Key statistics on diabetes. Retrieved from Diabetes UK: https://www.diabetes.org.uk/documents/reports/diabetes-in-the-u k-2011-12.pdf
  9. Ehde, D. M., Czerniecki, J. M., Smith, D. G., Campbell, K. M., Edwards, W. T., Jensen, M. P., & Robinson, L. R. (2000). Chronic Phantom Sensations, Phantom Pain, Residual Limb. Archives of Physical Medicine and Rehabilitation, 81(8), 1039-1044.
  10. Ehde, D. M., Czerniecki, J. M., Smith, D. G., Campbell, K. M., Edwards, W. T., Jensen, M. P., & Robinson, L. R. (2000). Chronic Phantom Sensations, Phantom Pain, Residual Limb. Archives of Physical Medicine and Rehabilitation, 81(8), 1039-1044.
  11. Gaskin, M. E., Greene, A. F., Robinson, M. E., & Geisser, M. E. (1992). Negative affect and the experience of chronic pain. Journal of Psychosomatic Research, 36(8), 707-713.
  12. Gholizadeh, H., Osman, N. A., Eshraghi, A., & Razak, N. A. (2014). Clinical implication of interface pressure for a new prosthetic suspension sy