Encouraging Mobility Whilst Protecting the Residual Limb and Remaining Limb With Pre Prosthetic Rehabilitation of a Client with Type II Diabetes: Amputee Case Study

Original Editor ­ Vera Milligan

Title

Encouraging Mobility Whilst Protecting the Residual Limb and Remaining Limb With Pre Prosthetic Rehabilitation of a Client with Type II Diabetes

Abstract

Pre prosthetic rehabilitation of a 60-year-old female aboriginal client with type II diabetes who had a right transtibial amp. On initial assessment, she presented very weak with generalized pitting edema, required one person moderate assist to stand but able to crouch transfer independently with cueing slowly. She was independent with wheelchair and bed mobility but was unable to hop with the parallel bars. Upon discharge, edema had decreased, she was managing independent standing pivot transfers, able to hop with a 2 w/w 6 meters with one person stand by and get on/off the floor independently.

Key Words

pre prosthetic, transtibial, diabetes, protect, amputation , education

Client Characteristics

  • ID: 60 year old aboriginal female

  • HPI: Right TT amputation secondary to osteomyelitis and gangrene to right great toe and second toe. Debridement and closure 2 days later. Client transferred for early intervention amputee program at the Hospital and stayed for 2 weeks. Right foot issues began with a right foot ulcer under the great toe with gradual progression. Client was noncompliant with treatment for diabetes, osteomyelitis and gangrene progressed with amputation being the end result.

  • PMHx: hyperlipidemia, hypertension, type II diabetes
Soc.
  • Hx.: She worked as a researcher for the native band but has been on medical leave since March 2010 when her right foot problems began and is not planning on going back. The client lives in a bungalow with 6 steps with two railings and awaiting a ramp to be built. She has five children, 14 grandchildren and 2 great grandchildren. Client lives with 2 sons, daughter in law and 4 grandchildren in her home. Prior to her amputation she spent most of her time in a borrowed old wheelchair and her family had to carry her into her home and out in the wheelchair as she was unable to manage the stairs and therefore very deconditioned.

Examination Findings

  • Subjective:  The client's chief complaint was being very edematous to her lower extremities and abdomen since her TT amp. surgery. Also was constipated the first week and had nausea often. The client felt like the doctors following her did not have time for her and was giving up on letting them know her issues.
  • Objective:
  1. <span class="Apple-tab-span" style="white-space:pre" />Bed mobility: independent
  2. Sitting Balance: good
  3. Standing Balance: able to stand on left L/E holding parallel bars with one hand
  4. Transfers: one person min - mod assist for standing pivot, able to do crouch transfer with cueing slowly
  5. ROM: bilateral -5 degrees knee extension otherwise functional L/E ROM
  6. Strength: Note - client found she had difficulty with moving her left leg due to edema Hip Flex. R 3+ L 2+ Hip Ext: able to bridge lifting buttocks about 1 inch off mat Hip Abd./Add R 4 -/4 L 2+/3+ Knee Flex./Ext. R 5/too sore L 3+/3+ DF/PF R X L3+/4 Inv./Ev. R X L 3+/3+
  7. Ambulation: unable to hop with aids Palpation: pitting edema +++ to lower extremities, up into abdomen Foot Screen: 5/10 with callus L inferior D1 base, orthotics consult request
  8. ICF: The client's type II diabetes is her health condition. Her R TT amp. and pitting edema are changes to her body structure. Decrease strength and decrease standing balance are examples of impairments. Some activity limitations are being unable to standing pivot transfer and ambulate/hop. Stairs to her home are an environmental barrier but the ramp being built is an environmental facilitator.

Clinical Hypothesis

The client's main problem is decreased functional mobility due to deconditioning postoperative R TT amputation with pitting edema to lower body and legs. Post operatively, she was unable to transfer independently and tolerate any hopping. According to Douglas Smith "the ability to transfer is the key ingredient to self-sufficiency and independent living"[1]. Once independent in wheelchair to bed transfers, then toilet/ bath transfers can be worked on. All the while, the therapist must educate the client on protecting their residual limb while it heals and remaining limb from developing new open areas/injury as the client has type II diabetes.

Intervention

The client was seen daily in the PT gym with writer, attended the upper extremity (U/E) group strengthening class and the lower extremity (L/E) group strengthening class daily Monday to Friday for two weeks. The U/E class consists of weighted pulley exercises, arm bicycle and bicep curls with weights lasting about half an hour. The L/E class consists of weighted mat exercises or Theraband for the lower extremity lasting about thirty minutes.During her last week, a half hour with the therapy assistant for one on one work in the parallel bars was added as well.

My time would focus on transfer practice; sit to stand in the parallel bars, standing balance and residual limb standing exercises in the parallel bars. The second week, the kneel board was introduced for some weight bearing through the client's R knee protecting the stump. Her left foot had a runner on for weight bearing, was monitored daily and the client reminded throughout therapy to take care of her remaining leg and protect from any trauma.

The importance of taking care of the residual limb needs to be stressed and a shoe must be worn on the remaining foot to protect from further trauma when teaching mobility[2]. She refused to consider a DARCO shoe during the orthotics consult for weight bearing and preferred to use the ill fitting (due to edema) runner. As the edema decreased, her strength and conditioning improved, she was able to hop short distances with a 2 w/w.

Outcome

Over the two weeks, the client's edema decreased significantly and she began to feel heard by the doctors and health care professionals. She was allowed to make the decision not to wear the DARCO shoe after hearing the reasons it would be best. Initially in a private room, then moved to a semi - private room. Her new roommate came for the early intervention program already able to transfer independently in/ out of bed and on/off the toilet. This motivated my client that she too, could get there.

She attended daily even when she felt nauseous and worked hard at the various tasks. After two weeks, she too can independently standing pivot transfer safely like her roommate who she says is her inspiration.

My client is now able to get up from the floor independently if she were to fall at home, something I did not think would be possible on initial assessment and her slow progress. She is able to hop 6 meters with a 2 w/w and one person stand by assist. Education was given throughout her therapy regarding protecting both residual limb and remaining limb. A 2 w/w has been arranged and bathroom equipment and wheelchair for discharge by the OT. The ramp is still not built but the client stated family can lift her into her home until ramp completion. Overall, she improved with her L/E strength in all areas except left hip add. and right plantarflexors remained the same.

Discussion

Informal peer support played a key role in my client's rehab. Her move out of a private room to a semi private and seeing how independent her roommate was, who was also a diabetic with a TT amp, like herself, was huge motivation.Her decrease in generalized edema was another factor influencing a positive rehabilitation outcome. Looking more generally at the amputee population and diabetes, the statistic for L/E amputation in Alberta "that people with diabetes were 15 times more likely to have a lower limb amputation than those without diabetes"[3] is staggering.Add to that for my client, "Diabetes is twice as common among the Aboriginal population." [4] 

What does this mean?As physiotherapists,we need to educate our clients with diabetes to prevent further trauma to their remaining limb and residual limb. The importance of daily foot checks, using care with toenail trimming, good footwear and changing socks daily[5] to name a few need to be stressed. Working with our clients who are diabetic, transfers need practice while making the client aware to always protect their residual limb and continue to do so upon discharge.

Ensuring clients are aware of potential hazards so protecting the remaining limb becomes automatic and always having a good shoe for weight bearing. Teaching protection is so important.In closing, "all diabetic amputees have a high rate of secondary amputation(30-50% at 3 years)" post operatively.[6] My hope is that we can help decrease the likelihood of a 2nd amputation.

References


  1. Smith, Douglas. 2005. Notes From The Medical Director Special Report Senior Health Prosthetic Rehabilitation and Technology Options and Advances for Seniors. inMotion 15:issue 6
  2. O'Sullivan et al. 2014. Physical Rehabilitation. p.1006-7. F.A. Davis Company, Philadelphia
  3. Alberta Diabetes Atlas 2011. Chapter 7. Alberta Diabetes Surveillance System
  4. website www.physiotherapyalberta.ca/files/fact_sheet_diabetes. pdf accessed on July 9, 2015
  5. McCulloch, David. website article www.uptodate.com/contents/foot-care-in-diabetes-mellitus-beyon d-the-basics accessed on July 9, 2015
  6. Engstrom, B and C. Van de Ven (eds). 1999. Therapy for Amputees: Third Edition. p.23. Harcourt Brace and Company Limited, London