Case study of a transfemoral amputee semi-professional cyclist: Amputatee Case Study

Title

Case study of a transfemoral amputee semi-professional cyclist

Abstract

This case presentation is a semi-professional cyclist who incurred a transfemoral amputation as a result of a road traffic accident. The case study documents from initial assessment until discharge and highlights the main problems encountered by the patient, the goals, the rehabilitation programme and the outcome.

Key Words

Transfemoral; grieving; cyclist; phantom limb pain; prosthesis; amputee

Client Characteristics

The patient is a 24 year old man who was previously very fit and well with no medical history. He was a semi-professional cyclist who also worked in a very physical job in a bicycle shop. Previously he would train for many months training for the race season and cycling was the centre of his life.
He was knocked off his bike whilst cycling by a truck driver who was drunk.
 He incurred an emergency transfemoral amputation three weeks prior to the initial assessment with the author.

Examination Findings

On examination, subjectively he spoke about the pain that he was experiencing. He explained the pain as shooting pain into the absent limb 7/10 on the VAS scale. This was intermittent pain during sleep and was affecting his rehabilitation and use of prosthesis. It also became apparent that he was working through the grieving process recognized as; denial, anger, bargaining, depression, and acceptance[1].He was very angry that the truck driver that had caused the accident had been drunk and he felt like his life would never be the same again.

He had been a highly functioning young man previously, a semi professional cyclist and worked in a bike shop which was a very physically demanding job. His main objective was to return to the life he had.
He was managing to independently clean, toilet and dress himself and was ambulating using crutches. He was not having any problems with transfers.


Objectively, his transfemoral stump and wound were in good condition. He had no contractures and he had full range of movement at the hip and trunk.
He had reduced strength of the hip, especially extension, adduction and internal rotation.
 His core muscles were weak and bridging was difficult.
 His sitting balance was very good, as were his pelvic movements but his standing balance was poor.
 He was able to transfer his weight side to side and forwards and backwards.
His gait was very assymetrical, with poor hip extension, hip hitching and trunk side flexion.

Clinical Hypothesis

A major problem that the patient faced during rehabilitation was phantom limb pain, a neuropathic pain perceived by the region of the body that is no longer present[2]. This was affecting his sleep and his rehabilitation programme and having negative psychological effects, adding to already altered psychological state as he was working through the grieving process[1]. The pain he described as tingling, cramping and shooting pains in the portion of the limb that was removed. He found this pain, not only disabling but also unnerving, as he could not understand why he would continue to get pain where he no longer had a limb.

Intervention

It was important to work with the consultant to prescribe the relevant medication to initially ease the symptoms but there were also other approaches that could help. It was important for the patient to understand that this pain was real and he was not imagining it. It was explained to him that although the limb is no longer there, the nerve endings at the site of the amputation continue to send pain signals to the brain that make the brain think the limb is still there. 


A TENS machine was initially used to try to ease the pain. 
It was also important to massage the stump, continue the rehabilitation programme and to wear an elastic stump sock to minimize the volume changes.
 It has also been shown that there is a significant reduction in the intensity of phantom limb pain using mental imagery[3] and mirror therapy can help to resolve the visual-proprioceptive disassociation in the brain[2]. 
Therefore mirror therapy was also initiated with graded motor imagery. This is where the patient views a reflection of the intact limb through a mirror positioned where the amputated limb would have been. Gradually, movements of the intact leg were introduced.

Outcome

The anti-neuropathic medication, amitriptyline, and TENS reduced the patient’s symptoms initially but the pain continued to impair function of the limb when doing exercises and gait re-education and was still affecting his sleep. The patient felt more in control of his pain, once he understood why it was occurring.
When the patient started massaging the stump he felt that the pain diminished more but did not stay away.

It was the mirror therapy that seemed to have the greatest effect. As the patient used the mirror therapy more and gradually introduced movements of the intact limb, he felt a decrease in the amount of pain he was experiencing. After a while, he was able to visualize the limb without the mirror, which he could do more regularly.

The pain went from a 7/10 on the Visual Analogue Scale to 2/10 and it no longer disturbed the patient's sleep.

Discussion

There are many cases, such as this, with previously healthy and very fit amputees who have suffered traumatic amputation and wish to return to high level competitive sports, especially since the increase of war conflicts in the past twenty years, considering there were 1,221 US Service members who sustained an amputation from 2001-2011[4].

It is therefore imperative that, as physiotherapists, we strive to rehabilitate all patients to the best of their ability. It is so important to have shared, realistic goals with the patient and to be aware not only of the physical issues, but also social, emotional, psychological and economic problems that they will encounter on the way[5]. It is imperative that at each step of rehabilitation the patient remains at the centre of the inter-disciplinary team. The rehabilitation is an ever-evolving situation with constantly revised training programmes and communication and education is key.

References

  1. 1.0 1.1 Spiess, K., McLemore, A., Zinyemba, P., Ortiz, N. and Meyr, A. (2014) Application of the five stages of grief to diabetic limb loss and amputation. Journal of Foot and Ankle Surgery, 53, 735-739.
  2. 2.0 2.1 Subedi, B. and Grossberg, G. (2011). Phantom limb pain: Mechanisms and treatment approaches. Pain Research and Treatment.
  3. MacIver, K., Lloyd, D., Kelly, S., Roberts, N. and Nurmikko, T. (2008) Phantom limb pain, cortical reorganization and the therapeutic effect of mental imagery. Brain, 131, 2181-2191.
  4. Krueger, C., Wenke, J. and Ficke, J. (2012) Ten years at war: comprehensive analysis of amputation trends. Journal of Trauma and Acute Care Surgery, 73(6 Suppl 5):S438-44.
  5. Belon, H. and Vigoda, D. (2014) Emotional adaptation to limb loss. Physical Medicine and Rehabilitation Clinics of North America, 25, 53-74.