Case presentation on a Left BKA: Amputee Case Study

Title

Case presentation on a Left BKA

Abstract

A high level rehabilitation BKA who has been fitted and now wearing patellar tendon bearing socket prosthesis. Patient is independent in all activities of daily living has been receiving post prosthetic physiotherapy intervention. Thus far patient has been compliant with management and demonstrates a high level of competence.

Key Words

below knee amputation, phantom pain,, weakness, 
prosthesis, high level rehabilitation

Client Characteristics

Patient X is a 26-year-old female who is a business student who was diagnosed with osteosarcoma of the left ankle and bilateral breast cancer. Patient has no known chronic illnesses had several chemo, surgical and physiotherapy management.

Examination Findings

  • Weakness in the limb, not able to walk for >5 minutes without fatigue & phantom pain in her toes& heels when standing for long periods intensity of 10/10, relieves with rest.

  • 15 years ago playing netball she hurt her left ankle was taken to the MD. RICE done. 2 wks later pain & swelling persisted went back to the doctor X-rays done revealed osteosarcoma of the left ankle. A week later was admitted for 2 months biopsy done & Left BKA. A month later 6 courses of chemo. After which prosthetic fitting done, PT.
  • 
Drinks- occasionally

  • PG wants to participate in a 2 k walk/ run.
  • 
Rivermead mobility index score 15
 [1]
  • Surgical scar on the stump healed, mobile, non-tender
Stump is viable, functional & cylindrical in shape, normal temperature.
  • Pressure points - dry, callous and dark.

  • Slightly widen based stance, decrease heel strike bilat, excess right knee flexion, Longer stance time on the right leg, left hip hike, slightly decreased trunk rotation, left lateral trunk flexion in stance on the right leg.
Left osteosarcoma & bilat breast ca.
  • MSK- ROM, Ms strength, Atrophy of residual limb
  • Somatosensory-Phantom pain, impaired, Sensatio  and proprioception
  • Integumentary - dry and pale skin

  • CP-endurance / easily fatigue
Limitations- run, jump, walking > 5min
  • Restrictions - gym, netball & party
+ve good family support, prosthesis, high level of education , financially able , cooperative & motivated no steps at home , elevator at school, home is accessible by transportation.

Clinical Hypothesis

The patient's main problems are phantom pain, difficulty walking for greater than five minutes and weakness in the left lower limb. The Phantom pain could be from the trauma that the patient received prior to amputation and excessive loading that is applied during walking and weakness and difficulty walking is due to decrease muscle strength in the left hip and knee muscles and endurance.

Intervention

Patient to be seen 2 times per week.


  1. Education on residual limb care

  2. Stretching of bilateral knee flexors for 20 min with hot pack in place

  3. Bridging 3x10 reps with 5 seconds hold

  4. Bilateral SLR 3x10 reps

  5. Stationary bike cycling with resistance within patients tolerance for 15 min

  6. Hip flexion, extension, abduction, adduction exercises with thera-band using the Oxford regime

  7. Gait training in parallel bars with therapist giving approximation at the left hip to encourage weight acceptance and decrease hip hike.
  8. Stretching of knee flexors for 30 seconds 4x 10 reps

  9. Dynamic balance training

  10. Quads setting

  11. Mirror box therapy x 30 min

  12. TENS to the 2 electrodes placed below the left knee for 45 minutes -4Hz , 200ms


HEP: to be done 3 days per week


  1. Dance work out

  2. Bird-dog exercises 1x10 reps with 5seconds hold

  3. Massage to the residual limb

  4. Mirror therapy

  5. Pool activities- flutter kicks, pulsed hip adduction, abduction while reclining on a noodle.

Outcome

Reaction to treatment tolerated well. Nil adverse effects, Patient demonstrates competence with her management.

Discussion

This patient can be considered a high level rehabilitated left below knee amputee secondary to her been independent in activity of daily is motivated, cooperative and was very active prior to amputation and wants to get back to the level where she can participate in a one or two kilometers walk run competition. It is said that over time with prolong physiotherapy and home exercise programs as prescribed the patients energy expenditure should decrease and the level of participation increase[2].

However, because this patient is experiencing phantom pain on long standing or walking for prolong periods. According, to Grumiller et al,[3] if there is increasing load this might intensifies the pain in the amputated limb this might impact on the patient's overall goal. Therefore a training program should be specifically designed to improve this patient hip strength and thus resulting in sufficient improvement in prosthetic walkers to afford running, Nolan 2012 and this must be maintained to prevent regression and will then impact solely on how progression is done to achieve goals.

References

  1. Collen FM Wade DT et al. The Rivermead Mobility Index: a further development of the Rivermead Motor Assessment. Int Disabil Studies. 1991; 13: 50-54.
  2. Takaaki, C et al. (2002). Physical fitness of lower limb amputees. Am J Med Rehabilitation. 81:321-325
Nolan L. (2009) Lower-limb strength in sports-active transtibial amputees. Prosthet Orthot Int. Sep; 33(3):230-41.
  3. Grummillier C, Martinet N, Paysant J, Andre JM and Beyaert C. (2008) Compensatory mechanism involving the hip joint of the intact limb during gait in unilateral trans-tibial. J Biomech. Oct; 41(14):2926-31.