Diabetic complications leading to amputation: Amputee Case Report


Original Editor - Eamie Bolger

Title

Diabetic complications leading to amputation: Amputee Case Report

Abstract

In 2014 an estimated 3.2 million people suffer from diabetes in the UK[1]. According to the national health and Care Excellence (NICE) guidelines there is an increase in the proportion of people undergoing annual checks. These checks are set out to prevent the occurrence of complications associated with diabetes such as peripheral vascular disease, sensory neuropathy and foot ulcers[2]. Detection and treatment is key to preventing amputation. While amputation is an extreme procedure it may in fact lead to a better quality of life for the patient versus man

Key Words

Transtibial, diabetes, independence, gait re-education, foot ulcers, multidisciplinary team.

Client Characteristics

The patient was a 68-year-old retired female from rural Ireland. She lives with her husband and has two grown up children that no longer live at home. She previously worked as a secretary in a school but retired 3 years ago and since retirement has become a keen gardener.

The patient was diagnosed with type-1 diabetes as a child and manages it with insulin injections. She is a very independent and active person. Her hobbies included walking, swimming and line dancing along with gardening and baking at home. As well as the type-1 diabetes the patient was also diagnosed with hyperlipidaemia and Raynaud's disease. She has been insulin dependent since childhood and finds that her diabetes is well managed with no major incidents reported as she is well educated regarding the do's and don't surrounding her condition. The patient controls her hyperlipidaemia with diet and remaining physically active.

The patient has been treated for foot ulcers however due to her love of walking the patient has neglected her skin integrity, which led to a deterioration of the foot ulcers. This resulted in a trans-tibial amputation on her left leg. It was a life changing operation for the patient, as she was previously an independent lady so she struggled to accept her new level of mobility. The residual limb has healed and due to appropriate nerve conduction and sensation, the patient is able to use crutches to mobilise short distances but relies on a wheelchair when outside her home.

Examination Findings

The patient was emotional initially on assessment but has learnt to accept her new circumstances. She has awareness of the issues surrounding diabetes and circulation she feels it is both necessary for her physical and mental health for her to be active and maintain as much independence as possible throughout her retirement.

She has been assessed for more appropriate footwear to prevent rubbing and friction of the skin of the contralateral limb, prevent complications and allow safe use of crutches. It was discussed with the patient about the risk of falling if she lacked upper limb strength while walking with crutches. However the patient has managed safely since her amputation and had appropriate upper limb strength, as she has always been physical active.

The patient did not experience any impairment's in mental, sensory, voice and speech, cardiovascular, haematological, immunological or respiratory functioning therefore is not deemed severely disabled according to the World Health Organisation[3] checklist regarding ICF.

In order to allow improvements to occur in the integrity of the skin, the patient had to decrease her level of activity from walking 4-5 times a week to cycling on a static bike. Also one of the key issues with skin integrity is keeping it clean and dry the patient had to reduce her swimming classes. A swimming pool is a haven for infection to spread and was deemed an inappropriate environment during her recovery.

Clinical Hypothesis

The patients main concern is the decrease in her level of activity and thus her independence. She is unable to go walking as she is on crutches for short distances such as mobilising around the house but relies on a wheelchair when mobilising outside of the house. She is unable to carry out the gardening or household chores as she previously would have. This lifestyle change has led her to become frustrated and resentful of her husband who she now realises heavily upon with daily tasks and gardening. Her reduced mobility is affecting all aspects of her life so when this is dealt with it will allow improvements in all other areas of well-being.

Intervention

It was discussed with the patient about how she would feel about the prospect of being assessed for a prosthetic limb. She was concerned that it would be cumbersome and be more of a hindrance than helpful. It was explained to her that the medical advances have allowed for the development of a range of prosthetic limbs to accommodate all amputees they are made to fit and are lightweight. It was also explained to her that she would also have the support of the multidisciplinary team to support with gait re-education, falls prevention, and education around transfers.

It has been noted that in trans-tibial amputee's they normally reach out with the residual limb to support themselves when at risk of falling, thus falling onto the distal end of the residual limb leading to injury. She was excited about the prospect of being able to return to the activities she once enjoyed.

She patient was then assessed, measured and fitted with a prosthetic limb at the end of her residual limb. The physiotherapist was able to assess the patient with the prosthetic limb using the parallel bars for support. She was also assessed on different surfaces in order for her to gain confidence that she was able to walk on different terrains with her new limb.

The occupational therapist carried out a home visit to assess the environment and ensure there were no trip hazards or obstacles that would challenge her new found mobility.

Outcome

Prosthetic limb was extremely successful as the patient was able to see that it was comfortable at the residual limb and did not lead to any pain or discomfort, which was one of her concerns. She was worried she would not be able to adapt to mobilising with the prosthesis and that she would never be the active independent lady she once was.

Through intensive gait re-education in physiotherapy sessions the patient was able to gain the confidence she needed to mobilise independently. She struggled initially to take weight when stepping through with the contralateral leg causing her to limp. Over the number of weeks spent with her in physiotherapy her gait and confidence dramatically improved along with her independence and sense of well being. The patient was able to return walking 3-5 times a week as well as line dancing once she had time to learn the steps.

While the patient's residual limb had healed appropriately and there was an absence of foot ulcers on both feet, a second amputation can occur with the return of complications associated with diabetes. The patient was reminded that while her recovery from the amputation was successful, skin care was still an essential part of the management of her condition. However she insisted that this experience had made her determined to pay extra attention and take more care with her skin integrity and circulation.

Discussion

Despite the large body of evidence demonstrating that preventive foot-care programs can decrease the incidence of lower-extremity ulcers and amputations by 44 to 85 percent[4], may of those who suffer from diabetes are unaware of the serious complications for which they are associated.

According to Geertzen et al[5] further education is required from all members of the multidisciplinary team in order for amputee patients to comfortably be assessed and fitted for a prosthetics. Furthermore literature surrounding patient's responsiveness to intervention still lacks methodological rigor and has not been well established[6]. Thus further outcome measures are required in order for an accurate portrayal of a patient's level of mobility to be gained.

There are many people with diabetes, young and old, who have no access to preventive services for routine foot care or diabetes management making it more challenging to provide education to all those suffering from diabetes. However it has been reported that all individuals with diabetes should receive an annual foot examination to identify high-risk foot conditions[7]. This examination should include assessment of protective sensation, foot structure and biomechanics, vascular status and skin integrity.


From 9 to 20 percent of people with diabetes, who had already experienced an amputation, underwent a second amputation within 12 months of the first surgery[4]

[8]

References

  1. www.diabetes.org.uk 13-7-2015
  2. Adler A, Boyko E, Ahroni J, Smith D. Lower- extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers (1999) Diabetes Care 22; 7 p 1029-1035
  3. www.who.int/classifications/icf/en/ 14-7-2015
  4. 4.0 4.1 Reiber G.E, et al. (1995) Lower Extremity Foot Ulcers and Amputations in Diabetes. Diabetes in America, eds. 409-28 Bethesda, MD: National Institutes of Health publication
  5. Geertzen J, Rommers G, Dekker,R (2011) An ICF- Based education programme in amputation rehabilitation fro medical residents in the Netherlands. Prosthetics and Orthotics International. 35(3): 318-22
  6. Herbert JS, Wolfe DL, Miller WC, Deathe AB, Devlin M, Pallaveshi L (2009) Outcome measures in amputation rehabilitation: ICF body functions. Disability Rehabilitation. 31(19): 1541-54
  7. Bild D.E, et al, 1989 "Lower-Extremity Amputation in People with Diabetes. Epidemiology and Prevention," Diabetes Care 12 (1989): 24-31
  8. Puthoff ML, Celinda P. Evitt, (2011) Physical Therapist Practice in Geriatrics 2011, Issue 6, Diabetes Across the Physical Therapist Practice Patterns, Scarborough,P. APTA