Case presentation on geriatric transtibial amputee: Amputee Case Study

Title

Case presentation on geriatric transtibial amputee

Abstract

Mr. L is a 75-year-old transtibial amputee with multiple co-morbidities. This case presentation follows Mr. L through the pre-prosthetic fitting phase. Discussion is made on treatment for his impairments and considerations for the geriatric amputee.

Key Words

transtibial, geriatric, amputee, pre-prosthetic

Client Characteristics

Mr. L is a 72-year-old gentleman who presented at our outpatient clinic with a right transtibial amputation. He had his amputation 3 months prior to appointment, and has only just referred to our clinic as his wound is now fully healed. The amputation was a result of gas gangrene of the right foot from a non- healing wound.

His past medical history are as follows: Diabetes mellitus (DM), Hypertension, Ischaemic Heart disease (IHD) with recurrent congestive cardiac failure (CCF)- 2D echo results shows ejection fraction of 35%, peripheral vascular disease, previous first and second ray amputation of the right foot secondary to gangrene, cataracts in both eyes which are treated by surgery 2 years ago.

Premorbidly, he was ADL independent, community ambulation independent without aid. He was a retiree. He is currently staying with his family, and his main caregiver is his domestic helper. He is ambulant with wheelchair at home, and a motorized scooter outdoors. He reports to be ADL independent and independent in transfers.

Post amputation he was seen in an acute ward at the hospital and subsequently transferred to a step down rehabilitation ward. He was discharged from the rehabilitation ward after 3 weeks when he was able to transfer independently and caregiver was competent is assisting him at home for supervision of transfers and care of wound.

Examination Findings

Subjective:

  • 
Mr. L reports some phantom limb sensation such as itch on the absent foot, no phantom limb pain.
  • 
He also complains of being tired easily when he has to perform transfers multiple times when he goes to the toilet.

  • He is able to go out on his motorized scooter independently and is previously trained to use it safely by the occupational therapist at the rehabilitation ward.
  • He goes out to mingle with his friends at the nearby coffee shop.

  • He wants a prosthesis so that he is able to walk at home to increase his mobility.
  • He feels that if he is able to walk, he would be more active and is better for his health. He also feels that it will reduce the effort for going to toilet.


Objective:

  • 
Stump: Wound is fully healed. Minimal scar adhesions. Noted skin is dry and flaky. Some tenderness on palpation at tibia bony end. Oedematous.

  • Residual limb: Dry skin. No visible wounds.

  • Range of movement: Full range for upper limbs. Both knees have reduced knee extension of 5 degrees. Bilateral hip extension lacking 10 degrees.

  • Muscle length: Reduced length of hip flexors, hamstrings bilaterally.

  • Muscle strength: Upper limbs 4/5, Lower limbs 3-4/5

  • Reduced sensation and proprioception on residual limb oIndependent in bed mobility, transfers, sit to stand with a walking frame
o
  • Standing balance: require a walking frame, unable single limb stance without support

  • AMPnoPro score- 16

Clinical Hypothesis

Mr. L has a few problems that need to be addressed before he would be suitable for prosthetic fitting.


  • Hip and knees reduced range- this will affect prosthetic fitting and alignment. Reduced hip range will affect standing posture and thus balance and stability during gait.
  • Reduced hip strength- Will affect gait pattern and gait endurance
  • Reduced exercise tolerance (tiring easily)- Prosthetic gait will require at least 60% more effort for transtibial amputees thus he would need to increase exercise tolerance to be able to walk effectively.
  • Stump oedema- Prosthesis will not be able to be fitted until oedema is reduced. Stump volume needs to be relatively stable as well.

  • Phantom limb sensation- increases risk of falls if he forgets that he had an amputation and tried to stand normally

Intervention

The interventions are targeting the main problems.


  • Reduced hip and knee range-Stretching- hamstrings and hip flexors. In view of his IHD, I would not wish to put him into prone position, thus stretching would have to be done either in side lying for hip flexors.

  • Positioning- education on propping up stump when sitting for long hours in the wheelchair or scooter. Frequent change of positions if possible. Lying supine for short periods of time (about 15-20 mins) multiple times a day.

  • Reduced hip strength-Resistance exercises targeting hip flexors and extensors either with use of weights or elastic bands. Ideally to be done at home as well, 3 times a day. Intensity to be progressive in nature, as he gets stronger.

  • Reduced exercise tolerance- Cardiovascular training e.g. seated cycling, starting off at 10 mins or as tolerated and slowly progressed to 30 mins.

  • Standing practice to increase standing tolerance. Balance exercises also incorporated in standing.

  • Stump oedema-Positioning as above to reduce dependent position of stump. He was given a stump shrinker and taught how to don and doff it.
Phantom limb sensation- He was taught desensitization and massaging on the stump.

  • Early walking aid- Use of PPAM. It assists in giving an understanding of verticality, some weight-bearing on stump, early gait practice in parallel bars. It also helps with stump oedema.

Outcome

Mr. L was able to increase his knee and hip range after stretching. He attained 0 degrees knee extension on bilateral knees but still had a 5 degree hip flexion contracture bilaterally. Hip abduction and extension strength increased to 4/5 bilaterally. After practice, he was able to complete full 30 minutes of seated cycling. He reported feeling less tired with transfers to toilet.

After wearing the stump shrinker, his stump has reduced in size and was able to be successfully fitted with a prosthesis. However due to his recurrent CCF, his socket was fitted to allow accommodation of volume changes in stump. During normal days he would be wearing 2 prosthetic cotton socks. When he was having an episode of CCF, his stump would increase in size and the cotton socks would have to be taken out to accommodate the increased volume. He was taught to monitor for stump volume changes and change the number of socks accordingly.

Post fitting gait training commenced, starting from walking within the parallel bars. He also underwent balance training. However, due to the reduced hip range and reduced balance, it decided that he would be walking with a walking frame. Walking with a walking frame also reduces his energy expenditure during walking. Although he was able to complete 30 mins of cycling, he still felt tired after walking for about 20 metres. This is not a functional distance for outdoor walking, and thus would remain a K1 walker and continue to use motorized scooter outdoors.

Discussion

Mr. L is a geriatric amputee who presents with the challenges of multiple co-morbidities. It is known that an elderly amputee has a reduced chance of prosthetic success, some reported as low as one third of geriatric amputee population.[1] Cardiac disease is quoted as one of the top reasons for prosthetic failure.[2] Mr. L has IHD, which affects his cardiovascular fitness. The increase in energy expenditure of prosthetic gait will increase the strain on the cardiovascular system. Thus, we decided to reduce the impact by the using of a walking frame, and alternative mobility for outdoors.

Geriatric amputees are at high risk of falls with risks factors such as neuromuscular weakness, medication side-effects, postural blood pressure changes, cognitive disorders, loss of vision, changes to sensation and proprioception as well as phantom sensations.[2] Mr. L presents with some of the above factors and thus at higher risk of falls. Care has to be taken with prosthetic mobility and transfers. It would be helpful to teach Mr. L fall recovery before discharge. It is well documented that improving joint mobility, muscle strength is important in the amputee.

Patients should have a personalized exercise program targeting the problem areas.[3] Mr. L had an exercise program drawn that that targeted his impairments. Mr. L also had practice with the PPAM, which helps to increase cardiovascular fitness, improve balance, reduce stump oedema and provides a psychological boost. [4]

References


  1. Fletcher, D., Andrews, K., Butters, M., Jacobsen, S., Rowland, C. and Hallett, J. (2001). Rehabilitation of the geriatric vascular amputee patient: A population-based study. Archives of Physical Medicine and Rehabilitation, 82(6), pp.776-779.
  2. 2.0 2.1 Fleury, A., Salih, S. and Peel, N. (2012). Rehabilitation of the older vascular amputee: A review of the literature. Geriatrics & Gerontology International, 13(2), pp.264-273.
  3. Broomhead P, Clark K, Dawes D, Hale C, Lambert A, Quinlivan D, Randell T, Shepherd R, Withpetersen J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses, 2nd Edition. Chartered Society of Physiotherapy: London.
  4. Scottish Physiotherapy Amputee Research Group, National Centre for Training and Education in Prosthetics and Orthotics, PPAM Aid Clinical Guidelines for Physiotherapists