Diabetic Patient with Bilateral Amputations : Amputee Case Study

Title

Diabetic Patient with Bilateral Amputations

Abstract

The patient described below is a patient I treated for 1 week in my second clinical experience during my doctorate of physical therapy program. This patient has bilateral amputations secondary to diabetic foot ulcers and morbid obesity. The setting was an outpatient clinic that treated high-level athletes, and lacked lower level equipment such as parallel bars. My clinical instructor and I initiated skin care treatments, exercise protocols, and functional mobility for endurance with the equipment we had available. The patient continues to progress to meet his goals in therapy.

Key Words

diabetes, bilateral amputation, trans-tibial, ankle disarticulation

Client Characteristics

This patient is a retired 56-year-old man with current medical issues of type II diabetes, hypertension, and morbid obesity as well as a history of cardiovascular disease currently managed with beta-blockers. This patient had a previous ankle disarticulation of the RLE with current prosthetic. No gait training was previously completed with R prosthesis secondary to fear of developing wounds on LLE. LLE trans-tibial amputation occurred 4 weeks prior to current outpatient physical therapy appointment.

Examination Findings

History of RLE ankle disarticulation secondary to diabetic foot ulcer with fitting of prosthetic
4 weeks post LLE trans-tibial amputation

PMH: type 2 diabetes, cardiovascular disease, hypertension, and obesity
No complaints of pain in the LE but does have L shoulder pain.
Pt currently uses power wheelchair for primary mode of transportation in home and community.

  • Family owns wheelchair accessible van with power lift to transport patient to and from appointments. Lives in single level home with wife. 2 children willing to give social support but in other states
  • Patient goals are to lose weight in order to better control diabetes and decrease risk of further wounds, and to ambulate household distances.
  • AMPPro- K0 score
  • Vitals: BP: 125/85mmHg, HR: 70, RR: 15brpm
  • Posture: pt sits in power wheelchair with both LEs externally rotated and abducted and knees flexed. Rounded shoulders apparent.
  • Sensation: intact bilaterally UE and LE
  • Integumentary: LLE staples present, wound is clean and healing, RLE no areas of increased pressure
  • AROM Bilateral UE: WFL, RLE WFL, LLE: WFL except knee extension: -10°
  • L LE strength: knee extensors: 5/5, knee flexors: 5/5, hip extensors: 5/5, hip flexors 5/5, hip abductors 5/5, hip adductors 5/5
  • RLE strength: same as tested above 5/5
  • Sitting balance: can maintain sitting balance with perturbation
  • Transfers: independent lateral transfers to and from treatment table and independent bed mobility

Clinical Hypothesis

The 56-year-old male patient presents with bilateral amputations secondary to uncontrolled diabetes leading to diabetic foot ulcers that remained unhealed. Currently the pt has difficulty with ambulation secondary to fear of creating more wound and waiting for his second prosthetic. Pt is unable to find means of exercising to lose weight due to his inability to currently use BLEs. Pt is unable to participate in areas of the community that cannot accommodate a power wheelchair.

Intervention

  • Prone L knee extension stretching with weight on lower residual limb
  • Soft tissue mobilization and joint mobilization to increased L knee extension
  • Education on laying prone as often as possible to stretch hip flexors
  • Supine bilateral hip flexor stretches
  • Isometric bridges with foam roll under distal residual limbs- cues for TA and glute contraction
  • Progressed to adductor squeeze on ball + bridge
  • Resisted sitting balance with reactive balance and end range (suddenly letting go)
  • Scapular strengthening exercises: weighted rows, scapular retractions, press ups on chair, catching/throwing 6 lb medicine ball without posterior chair support, rope drills for endurance with scapular stabilization, ER/IR against resistance, serratus presses against resistance
  • Alternative hip and shoulder flexion in supine for aerobic exercise
  • UE ergometry for aerobic exercise
  • Standing tolerance on RLE with prosthesis and bariatric walker (2ww)
  • Progressed to attempted hopping/holding weight in arms versus legs
  • When L prosthetic fitted, double leg balance and weight shifting between arms and legs→ walking with BUE support on walker→ standing with no support→ current
  • Education on wound management, stump shrinking, checking for wounds regularly, and ways to lose weight without LE exercise
  • Taught patient skin desensitizing techniques to prepare residual limb for prosthesis

Outcome

As mentioned before, I treated this patient when I was on a clinical rotation. I know that he continues to be treated by my clinical instructor to this day and am receiving updates regularly. At the end of the 2 weeks I was treating this patient, his staples had been removed, his residual limb was well shaped, and we had started working on his standing tolerance on 1 leg (about 15 seconds CGA) as well as sit to stand (modA of 2). We had been stressing the need for full knee extension on his residual limb, and were able to decrease his deficit to 0° of knee extension before being fitted with the prosthetic. No further breakdown of skin occurred on either LEs throughout therapy. His shoulder pain decreased and he was able to increase his overall upper extremity strength.
My clinical instructor has sent me updates that the prosthesis has been fitted to his L leg and now he is working on standing without UE support and ambulation with a 4ww. I believe he can now ambulate ~20 feet. Therapy is ongoing and the patient is motivated to continue to make gains to meet his goals of household ambulation and weight loss.

Discussion

This patient was the first and only patient I had ever treated that had an amputation. Previously, I had very little knowledge about how to treat patients with amputations, so this experience involved a large learning curve. In searching for how to treat this patient, I found a standard of care for LE amputees from Brigham and Women’s Hospital that aided my treatment greatly[1]. Through this protocol I was bale to understand appropriate treatment methods, such as avoiding contractures and treating them as a big priority[2], ideas of exercises after the amputation[3], and introducing me to an appropriate functional outcome measure to document the patient’s progress[4].
I believe that as the first patient with an amputation that my CI or I has treated, we have been successful and helping him through the rehabilitation process. However, after taking this course, I feel we could have done many more things to ensure better outcomes. For instance, I believe we, as therapists, should have been more directly connected to the prosthetist. This was difficult in this situation because the patient chose a prosthetist that was an hour and a half away. We did not communicate with him regarding the patient’s needs. This would be important with this case especially because the patient wished to lose weight. I learned so much from treating this patient and taking this course, and I want to thank you for opening it up to everyone!

References

  1. Cogden, Wes. Services BaWsHDoR. Standard of Care: Lower Extremity Amputations. The Brigham and Women's Hospital, Inc. March 2011
  2. Knetsche RP, Leopold SS, Brage ME. Inpatient management of lower extremity amputations. Foot Ankle Clin. 2001;6(2):229-241
  3. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):13-22
  4. Gailey RS, Roach KE, Applegate EB, et al. The amputee mobility predictor: an instrument to assess determinants of the lower-limb amputee's ability to ambulate. Arch Phys Med Rehabil. 2002;83(5):613-627