Diabetic patient amputation: Amputee Case Study

Title

Diabetic patient amputation: Amputee Case Study

Abstract

Lower limb disease especially linked to diabetes causes a significant number of amputations yearly. Thorough knowledge of risk factors like ulceration, infection and neuropathy can make the management of the diabetic foot much easier. A large number of amputations can be prevented through early detection by the patient and proper management by a multidisciplinary team. The functional impairments and disability of amputees can be described and assessed through a globally accepted framework provided by the International Classification of Functioning. Strong focus should be placed on psychological

Key Words

Type 2 Diabetes, diabetic ulcers, amputation, transtibial, prosthesis, rehabilitation

Client Characteristics

Jumbo is a 56 year old self supportive male that has been referred to Physiotherapy for prosthetic prescription and rehabilitation. He has his own construction company where both his sons are involved.

A Trans Tibial (TT) amputation was done on his right leg to save his life after serious infection and gangrene.
 Jumbo initially suffered from peripheral neuropathy associated with uncontrolled diabetes. With the decreased sensation he unknowingly stepped up on hot coals that burned through the sole of his shoe. Poor blood supply in his leg and foot hindered wound healing, the blisters got infected and turned into foot ulcers and later severe gangrene. Numerous courses of antibiotics and specialized wound care could not stop the deterioration of the tissue.

Jumbo had a very inactive lifestyle and gained excessive weight. Multiple medical conditions that co-exist include: Type 2 Diabetes, hypertension, obesity, peripheral artery disease and persistent peripheral oedema.

Currently his diabetes and hypertension is under control with medication.
 His chief complaint is the difficulty he has to transfer that causes limitations to his mobility. He wants to be able to walk independently again.

Examination Findings

  • The past medical history includes Type 2 Diabetes, hypertension together with decreased exercise tolerance and endurance.
  • Currently his diabetes is under control and he uses anti-hypertensives for his elevated blood pressure.
  • Jumbo had a Trans Tibial amputation due to infection and gangrene from neglected foot ulcers on his right leg. Due to poor blood supply and decreased wound healing the wound on the stump took longer to heal, but has healed completely with a functional scar. Inactivity due to immobility led to excessive weight gain.
  • The skin condition of the stump presents with good perfusion, good sensation adjacent to the scar. Phantom limb sensations is mostly experienced at night.

  • Currently his functional ability includes self-transfer, but with great effort. He uses an electrical driven wheelchair. He has an automatic car that is well adapted for his needs and he can drive around independently.
  • On social level, he is well supported. Jumbo's home environment is well adapted and wheel chair friendly. 

  • As owner of his construction company was greatly affected by the amputation, since he can no longer access the building sites himself.
  • The prosthesis evaluation questionnaire was completed as well as the Barthel ADL index.
  • Physical examination revealed hip flexor tightness, full knee extension. Muscle weakness of Quadriceps, Hamstrings, hip abductors and Gluteus muscles were found in left and right leg. The patient had a good sitting balance, standing was poor. 

Clinical Hypothesis

Jumbo has Type 2 Diabetes together with Hypertension. As a measure to save his life, a Trans Tibial amputation was done on his right leg. Minor foot ulcers turned into severe infectious wounds with gangrene. Contributing factors from diabetes such as poor blood supply and slow wound healing played a major role.
 Being inactive together with unhealthy eating and prolonged wheelchair use, Jumbo presents with upper and lower limb muscle weakness. The excessive weight gain makes transfers very difficult. His greatest obstacle currently is the fact that he cannot walk on the building sites where his company are involved.

Intervention

  • Jumbo was evaluated by the multidisciplinary team.
  • It was decided to use a Total Bearing Socket (SSS) since it provided weight distribution over the entire limb, produced minimal skin pressure and has 100% surface contact during the gait cycle.
  • Together with the dietician and biokinetics, Jumbo was put on a diabetic diet a comprehensive cardiovascular fitness program.
  • The main problem area, which was muscle weakness, was addressed through a comprehensive strengthening program. Basic training skills were implemented including upper and lower limb strengthening. Mat work, Pilates, weights and hydrotherapy formed part of the program.
  • Stretching formed part of the exercise routine and the importance of stretching was emphasized.
  • Since Jumbo had difficulty with transfers and a fear of falling, transfers were practiced in a save environment to give him self-confidence to move around safely.

  • Education was given on evaluation, examination of the stump and care in general. The patient was shown how to massage and desensitization techniques. The rehabilitation process was explained as well as the prevention of complications.
  • With the first fitting the patient was shown how to don/doff the prosthesis as well as to how the prosthesis work.
  • Pre-gait training included single limb standing, orientation with regards to base of support and center of gravity.
  • 
Once the prosthesis was fitted we progressed to gait training in parallel bars with weight transfer and even weight distribution. 

Outcome

After 16 weeks of diligent exercise, hard work and family support, Jumbo regained his cardiovascular fitness and muscle strength to such an extent that he is no longer using a wheelchair.
He is now able to walk with crutches, using his prosthesis all day long. Jumbo has no more difficulty with transfers and moving around in turn makes life of his family much easier. With improved core stability, balance and weight loss, the patient overcame his fear of falling.


Since his strength and confidence improved he is much less house bound. He is now able to contribute actively in his construction company again by visiting the building sites himself.

He had a second rehabilitation prosthesis manufactured as his residuum dad changed in size and shape. He is managing the stump well and has very little phantom sensations of pain these days. Awareness of the possible complications are emphasized and he is still on the lookout for possible risks especially for the sound limb.

Functional tasks and activities of daily living are easy to perform and it contributed majorly to his improved psychological status as well as quality of life. 
Integration into the social community was also managed and he is now attending a diabetic small group twice a week.

Discussion

The patient in this case presented with a Trans Tibial amputation after serious infection and gangrene due to neglected diabetic foot ulcers.
 Being very over weight and inactive his biggest problem was the difficulty in transfers due to decreased muscle strength and confidence. A comprehensive exercise program was implemented together with a diabetic diet. The patient regained cardiovascular fitness and muscle strength and lost 11.2 kilograms.


He was fitted with a Silicon Suction Socket where after post prosthetic rehabilitation was done to enable the patient to walk independently and being integrated in his family role and society. Macro vascular complications due to diabetes include ulceration and amputation.

In the literature, it was concluded that although patients had a well-functioning social background their standard of living was reduced due to diabetic foot[1]
. Fortunately results have also shown that better self-care behavior and diabetes control were found in people that attended diabetes support groups compared to non-attenders[2].

Considering the high population of people with diabetes worldwide, the responsibility lies with health care practitioners and institutions on educating society about the impact of diabetes on quality of living, social impact and inevitably the immense burden on health structures. Clinical practices should focus more on education and prevention rather than management and cure.

[3][4]

References

  1. Fehfarova V, Jirkovska A, Dreagmirecka E. Does the Diabetic Foot Have a Significant Impact on Selected Psychological or Social Characteristics of Patients with Diabetes Mellitus? Journal of Diabetes Research http://dx.doi.org/10.1155/2014/371938
  2. Journal of Nursing research
Chiou, Chii-Jun
2014;22(4):231-241
  3. Therapy for amputees Third Edition Barbara Engstorm and Catherine van de Ven
  4. Prosthetic Gait Analysis for Physiotherapists ICRC Physiotherapy Reference Manual 5.Physiopedia Course notes