Case Study of a 40-Year-Old Patient with a Below-Knee-Amputation due to Uncontrolled Diabetes in Rural Belize: Amputee Case Study

Title

Case Study of a 40-Year-Old Patient with a Below-Knee-Amputation due to Uncontrolled Diabetes in Rural Belize

Abstract

Lower limb amputations are a leading complication resulting from Diabetes Mellitus[1]. Individuals living in low socioeconomic regions of Central America are particularly at risk of experiencing a disability[2]. "Anthony" encountered household and community barriers resulting from his non-traumatic below-knee-amputation. There were few resources in the Toledo District of Southern Belize available to Anthony and his family. A non-profit medical and rehabilitation team was able to provide him with resources and care to improve his quality of life and participation in society.

Key Words

Diabetes, Below-Knee Amputation, Belize, Durable Medical Equipment

Client Characteristics

"Anthony" is an approximately 40-year-old Creole male living in the Toledo District in Southern Belize. Prior to and after his amputation he was unemployed. He lived in a small two-room building (without private bathroom) adjacent to his mother's house. The house was located on a dirt road with a grassy front yard. He has a history of poorly controlled Type II Diabetes Mellitus (DM II), resulting in frequent hospitalizations due to hypoglycemic or hyperglycemic events. His Below Knee Amputation (BKA) was the result of a multi-year history of poorly controlled DM II, and was completed at a Belize Ministry of Health facility. No durable medical equipment was provided to him following his amputation. Anthony was referred to the home care-nursing program at Hillside Health Care International (HHCI), a non-profit organization providing free primary and rehabilitative care to residents in the Toledo District, for assistance with diabetes supplies and management. The home care nurse discovered Anthony crawling around on his hands and knees to negotiate his home environment. He had no wheelchair for traveling between his room and the main house, or for leaving the family compound. His elderly, hard-of-hearing mother was his primary caregiver. The home care nurse referred the patient to HHCI's community-based rehabilitation program for a home evaluation and durable medical equipment issuance and training. The two-room structure in which Anthony lives is only accessible via steps.

Examination Findings

He was seated in a plastic chair, sitting on a pillow cushion, with his residual limb in the dependent position, at the beginning of evaluation. Right BKA observable, residual limb had a well-healed scar. Residual limb was not wrapped. He had scars on his left lower leg from prior medical care, details unable to be provided and records not available. He was tall and thin with limited muscle definition in his left lower and bilateral upper extremities. Non-open abrasions visible on bilateral knees from crawling around his room, covered with bandages. Bilateral upper extremity (UE) strength 3+/5 or greater in all major muscle groups. Left leg: hip flexors, extensors, abductors, knee flexors and extensors, and ankle musculature 3+/5. Right hip flexors 4/5; Right hip extensors, hip abductors, knee flexors and extensors 3+/5. Left LE intact to light touch and sharp/dull. No velocity-dependent tone or spasticity. Intact sensation to light touch and sharp/dull in Right residual limb.
Spent most time in bed due to no assistive device, could crawl and independently rise to sit in a chair. Impaired strength of his bilateral upper extremities and bilateral lower extremities, especially R hip flexors; impaired aerobic endurance
He cannot leave his 2-room building or his family's compound without assistance. No DME. He is unable to participate in an income-generating activities. Anthony is limited in his ability to independently perform ADLs, (bathing, toileting, and cooking)

Clinical Hypothesis

Anthony's primary needs are related to his functional mobility and ADLs. He needs a safe and appropriate way to complete toileting tasks and for transitions between outside/his mother's adjacent house and the 2-room structure in which he lives. He also needs an assistive device for community-distances, i.e. during hospital visits.

Intervention

As stated above, the CBR team provided Anthony with a standard walker (not rolling, due to his fall risk) and with a manual wheelchair5. Gait and transfer training with this new equipment was conducted with Anthony and his mother. Fall risks (such as peeling flooring material) in the house was identified and solutions recommended. Due to prior occurrences of hypoglycemic incidences, pre-cautions for safe walker use/ambulation was discussed. Anthony practiced navigating the small steps with his standard walker, and was able to complete this safely after several visits. The CBR team worked with local craftspeople to fabricate portable commodes out of locally available wooden chairs, with the use of a 5-gallon bucket underneath. We ensured that Anthony had sufficient space/privacy in his bedroom for use of a portable commode. We provided his family with the commode, placed it safely in his room, and practiced bed/wheelchair to commode transfers with Anthony and his mother. The CBR team worked with a US-based service learning team, a local church, and local craftspeople to develop plans for a ramp leading into the front-door of his 2-room home, allowing for safe exit in a wheelchair. The team then fabricated this ramp for free. Therex: Anthony was educated in the importance of proper residual limb strengthening and positioning, including prone positioning, to avoid contractures. Therex: sit to stand from wheelchair, hip flex, hip exten, hip abd, knee flex/ext, w/c push-ups

Outcome

Anthony became independent with the use and management of his DME. He was able to independently ambulate around his home with a standard walker and no seated rest breaks (demonstrating improved aerobic capacity). He could independently and safely transfer between his bed, wheelchair, walker, and commode, without verbal cues. Anthony progressed to being able to navigate the stairs in front of his house with his standard walker, contact guard assistance to close supervision, and very minimal verbal cues. After several months of therapy, he progressed to near-independence with his home exercise program (HEP). He kept his HEP handout (with pictures and descriptions) of the activities near his bed for easy reference.

Prosthesis Options: Anthony was a poor candidate for a below-knee prosthetic limb for several reasons: 1) His medical condition was fragile, with multiple hospitalizations due to hypo or hyperglycemic-related incidences, 2) He had difficulty controlling his DM II due to limited supplies (i.e. free testing strips) in the under-resourced area of Southern Belize and due to limited health literacy and capacity, 3) The only free prosthetic provider in Belize, Project Hope Belize, was located in the northern district of the country, a trip too long for Anthony to make (especially multiple times) given his medical state[3].

Discussion

Anthony experienced a non-traumatic lower limb amputation, an unfortunate and common consequence for people with Diabetes[1]. He was at a greater risk of disability due to residing in an economically and socially disadvantaged region of Central America[2]. Resources, both peer and material, were limited in rural Southern Belize, a country with no medical or rehabilitation-professionals training programs. Anthony was happy to receive care by the non-profit medical and rehabilitation teams. He was thrilled to receive and be trained in the proper use of durable medical equipment! He frequently would sit in his wheelchair at the door and wave as he watched his mother and neighbors passing by, quite an improvement from lying in his bed and feeling depressed. He could finally stand and navigate his house, instead of crawling and risking further injury to his intact leg or other extremities[4].

His quality of life was greatly improved with the portable-in-room commode, as he no longer required his mother's assistance to have a bowel movement. Due to his medical condition, Anthony was hospitalized while the ramp in front of his home was being constructed. Sadly, Anthony passed away shortly after the ramp construction, due to diabetes complications. The ramp serves as a monument to the kindness and love demonstrated by the multidisciplinary team that sought to improve his quality of life and participation in society.

References

[5]
  1. 1.0 1.1 CDC report finds large decline in lower-limb amputations among U.S. adults with diagnosed diabetes 2012.
  2. 2.0 2.1 Disability in Latin America-Public Policy Challenges 2012.
  3. Prosthetic Hope International Belize (Project Hope Belize) 2015.
  4. A Manual for the Rehabilitation of People with Limb Amputation (WHO)
  5. Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation (BACPAR)