Case study of a trans-femoral amputee’s rehabilitation journey: Amputee Case Study

Title

Case study of a trans-femoral amputee’s rehabilitation journey

Abstract

This case study concerns the pathway of a retired 70-year-old male elective trans-femoral amputee, from amputation through to current day encountering various psychological and medical barriers over a prolonged rehabilitation period. Stages include assessment from a community based therapy aspect incorporating regulated outcome measures and guidelines related to levels of function as well as patient focused goals relating to mobility and activities of daily living.

Key Words

Trans-femoral, diabetes mellitus, rehabilitation, peripheral artery disease.

Client Characteristics

Surgery was completed in March 2014 with the primary cause for amputation relating to peripheral artery disease (PAD) secondary to Diabetes Mellitus (DM). He is overweight with a sedentary lifestyle and has little community integration due to his limited function. Along with this and the geographical spread of his family he has little in the way of a close family/friends support network. He is currently supported by a package of care four times daily and living in supported authority housing. Various co-morbidities include ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), transient ischaemic attack (TIA), and asthma. The respiratory issues are relevant to his previous occupation as a coal miner and smoking heavily for many years - now a non-smoker.

Post amputation the patient received community Physiotherapy support prioritising posture, range of movement (specifically hip joints), strength and stamina alongside standing practice to enable him to stand sufficiently to be cast for prosthesis[1]. At times of low mood this patient disengaged with therapy and therefore made no progress-worsening mood further. Various medical issues including a TIA and continuing circulatory issues with the remaining limb lengthened progress significantly. The multidisciplinary team made a difficult decision as to whether this patient was a suitable candidate for prosthesis but agreed to trial him, as he appeared very keen. The importance of the commitment and high levels of effort required were discussed and the patient appeared to understand this information and wished to have the opportunity to walk again.

Examination Findings

  • Chief complaint relative to rehabilitation is the number of comorbidities and recurring medical issues that have arisen.
  • Progress has been slow and hindered on several occasions, including a TIA episode resulting in hospitalisation, day surgery for issues with remaining limb and PAD, and episodes of low mood due to circumstances/frustrations.
  • Post hospital discharge patient was homeless having lived in a different country prior to surgery, therefore housed temporarily in an available location.
  • The MDT supporting this patient is based in a different county and therefore after discharge care was primarily passed to community services (District Nurse, Occupational Therapy, Physiotherapy etc.). For this reason MDT working is more difficult. Original MDT is accessible for continued follow-up but clinics are limited to once a week and transport is often difficult.
  • As mentioned previously this patient has limited family/friend support.
  • His goal is to mobilise around his flat with the use of a wheeled Zimmer frame without physical support from anyone as he lives alone.
  • 
The self-report outcome measure' Patient Health Questionnaire'(PHQ-9)[2] was completed resulting in a consultation with the MDT and anti-depressant medication alongside further funding for care to assist with outings.
  • The situation was compounded by restrictions to participation, poor housing access and limited appropriate activities locally.


Clinical Hypothesis

This patient's goal is to mobilise around the home with the use of a prosthesis and wheeled Zimmer frame without physical support of another person.

From a clinical point, the main problem is the energy exertion required to safely become mobile on the prosthesis as a trans-femoral amputee[3]. Although the patient is very motivated his growing comorbidities continue to reduce the level of rehabilitation.

Intervention

Initially this patient was assessed for range of movement and strength throughout. Due to length of time sitting and lack of compliance with home exercise plan, patient began with limited hip movement, specifically hip extension bilaterally. He had good upper body strength but was extremely limited with upper limb activity due to shortness of breath, early onset of fatigue in relation to cardiac/respiratory comorbidities and reduced physical fitness.


Lack of appropriately sized equipment to PPAM Aid (Pneumatic Post Amputation Mobility)[4] patient with gradual increase in weight led him to be seen by an outpatient team in a different district with travel by pre-arranged medical transport. He was cast and provided with a trans-femoral prosthesis comprising of a Quadrilateral Socket with Silesian belt, a uniaxial knee and non-articulated foot with shoe to match remaining limb[5].

Plan to complete at home entailed stretches/exercises for active range of movement, specifically lower limbs, strengthening for upper/lower limbs and periods of lying in prone to encourage hip extension.

Carers assist patient donning prosthesis and gradually increase wear time until able to tolerate for longer. Advised and encouraged to monitor residual limb for areas of redness, swelling, marking, and heat. Patient taught the importance to care for his residual limb washing, drying and dressing appropriately. To wear stump shrinker when not wearing prosthesis and doff independently. Weight management.

Outcome

This patient requires assistance of one to don prosthesis but is able to doff independently. At present he is able to mobilise very short distances with verbal prompting of one and being followed by a wheelchair for safety due to limited exercise tolerance resulting in shortness of breath. With consideration of the length from surgery to prosthesis fitting this patient has achieved his initial goal in receiving a limb. He must commit to the hard work and be supported by the medical professionals involved to enable him to continue achieving personal goals.

Weight management and diet were discussed at length with offered professional help if patient wished to accept. Concerns regarding any further weight gain leading to prosthesis no longer fitting, prolonging progression whilst waiting for a new cast and socket to be made.

Realistic goal setting based on present function to avoid disappointment or return to low mood. Focus on positives and achievements of rehabilitation so far.

Discussion

This was a difficult and continuing case hindered throughout by many factors from acute medical issues, housing issues and low mood/lack of motivation by patient. It has been an extremely difficult and long journey for him and it was agreed to trial a prosthesis based on his keenness to return to walking and at times of commitment showing rehabilitation potential. With the outpatient therapy team flexed posture and stride length were addressed as well weight distribution. Now rehabilitation is continuing in the home priority is focusing on safe functional abilities and stride length with the wheeled Zimmer frame adjusting posture as able. They also include activities of daily living and more social/community integration to improve quality of life and mood.

References

  1. Esquenazi A (2004); Amputation Rehabilitation and Prosthetic Restoration:From Surgery to Community Reintegration. Disability and Rehabilitation; 26, (14/15); 831-6.
  2. Kroenke K, Spitzer RL, and Williams JB (2001); The PHQ-9:Validity of a Brief Depression Severity Measure. J Gen Intern Med.
  3. Carroll K, and Edelstein JE (2006); Prosthetics and Patient Management:A Comprehensive Clinical Approach; Slack Inc.; Pg. 11.
  4. Porter SB (2008); Tidy's Physiotherapy; Physiotherapy for People with Amputation; Churchill Livingstone, Elsevier; Pg. 612-613.
  5. Engstrom B, and Van de Van C (1999); Therapy for Amputees; Trans-Femoral Level of Amputation; Pg. 162-164.