Established Below Knee Amputee Patient: Amputee Case Study

Title

Established Below Knee Amputee Patient: Amputee Case Study

Abstract

An elderly patient with an established below knee amputation on the right was transferred to our Older Person's and Rehabilitation service. She was admitted to hospital due to deconditioning and reduced independence with transfers and mobility secondary to Influenza A and a recent cerebellar stroke at the start of 2015. She had had a recent fall and her prosthetic limb wasn't fitting well. She underwent a period of rehabilitation focused on regaining independence with donning/doffing of her prosthesis and regaining independence with all transfers, toileting and mobility with her stroller.

Key Words

below knee, diabetes, over 65, established amputee

Client Characteristics

Presenting Complaint
:

  • 87 year old female presented to hospital with global weakness and fatigue with reduced independence with transfers and mobility. Recent fall whilst mobilising.

Medical Diagnosis:

  • Influenza A Past Medical History (Red = risk factors for amputation)
  • Peripheral Vascular Disease (most common cause of limb loss overall)[1]
  • Non-Insulin Dependent Diabetes Myelitis (people with diabetes mellitus have a 10 times higher risk of amputation)[2]
  • Right Below Knee Amputation (BKA) (advantages of this level of amputation include preservation of the knee joint and candidate for patella tendon bearing prosthesis)
  • Chronic Kidney Disease
  • Cerebellar infarct in Jan 2015 (another sign of atherosclerotic disease)

  • Non smoker (Of note risk of amputation is higher where peripheral vascular disease and diabetes coexist)

Social History: (The social situation, including available support, occupation, hobbies and home environment should be considered) [3]

  • Retired and lives in a rest home
  • Normally independent donning/doffing patellar tendon bearing below knee prosthesis with cuff suspension
  • Previously independently mobile with stroller and independent with all transfers and toileting
  • Minimal assistance required with showering
  • Hospital bed
•Has own wheelchair

  • No family nearby

Examination Findings

  • Full AROM in upper and lower limbs with no contracture e.g. full right hip and knee extension
  • Residual limb - well healed scar and nil International Classification of Functioning, Disability and Health (ICF)[4]
  • Impairments
- Mild residual R UL weakness (4/5)
- Mild residual R LL weakness (4/5)
- Decreased co-ordination in R UL and LL
- Decreased hand dexterity

  • Fatigue

  • Change in residual limb volume distally and prosthesis ill fitting
  • Pain in residual limb when weight bearing in prosthesis
  • Activity Limitations 
- Assistance of one to don/doff prosthesis however previously independent
- Distance able to self-propel WC limited by fatigue
- Currently only pivot transferring and hadn't been mobilising since recent stroke
- Assistance of one for all transfers however previously independent - Assistance of one for toileting whereas previously independent
  • Participation Restrictions
- Unable to attend social groups at rest home without being reliant on someone else to get her there
- Unable to access the community using her stroller as she did previously under supervision
  • Environmental Factors
 - Well set up in rest home level of care with assistance of 1 person available if required. Already has hospital bed, own WC, prosthesis and super stroller
  • Personal Factors
 - Very motivated and determined lady and was engaging well with goal setting process. No local family support. Patient already in the 'acceptance and hope' stage of grieving[5]

Clinical Hypothesis

Recent loss of independence with prosthetic don/doff technique, transfers and mobility secondary to deconditioning related to medical illness and recent stroke. Change in residual limb volume likely due to muscle wastage affecting prosthetic fit. Pain believed to be due to pistoning effect when mobilising with prosthesis and sitting too far into socket.

Decreased confidence to mobilise related to the recent fall and decreased strength and co-ordination in right side. Due to background of NIDDM and current pivot transfer technique combined with current poor prosthetic fit concerns regarding potential increased risk of requiring reamputation of residual and/or contralateral limb.Good cognition, motivated and showing good signs of rehabilitation potential to return to baseline function.

Patient Led Goals As was emphasised in week 1 for an effective and efficient service for the individual with amputation it is important that the health care team work together towards goals agreed with the patient[6][7][8]

Short Term
:

  • To obtain a good prosthetic fit within 4/7

  • To regain independence with don/doff of prosthesis in 1/52
  • To be able to walk to/from bathroom with walking frame and supervision in 1/52

  • To take self to bathroom, transfer and toilet independently in 2/52

Long Term
:

  • To return to RH and maintain independence with all transfers and to be able to mobilise increasing distances with own stroller and supervision initially but eventually independently

Intervention

Based around the BACPAR Guidelines for Prevention of Falls in Lower Limb Amputees[9]

Risk Assessment
•Hendricks's Assessment (Nursing staff)


  • Timed up and go = 1 minute 45 seconds (> 30 seconds indicates maybe prone to falls)

  • Tinetti assessment indicated high falls risk

  • Advised to step round transfer with a front wheeled walking frame and assistance of 1

  • Medical staff review of medications to identify contributory factors to falls risk and treated for medical condition

Exercise Program (idea's taken from Gailey's Stretching and Strengthening for lower limb amputee book)


  • Issued with exercises to do with therapy assistants to target right upper and lower limb strength and exercise tolerance
  • Don/doff practice Gait assessment and education

  • Issued with front wheeled walker as main advantage was that it allowed for maximal stability for ambulation

  • Gait re-education focused on decreasing stride length to prevent exaggerated fast terminal extension of right knee during initial contact due to quads weakness and decreased co-ordination

Achieving Good Prosthetic Fit


  • PT trialled adjusting socks but good prosthetic fit still not achieved

  • Instigated a joint review with the Prosthetist

  • Trialled with sleeve suspension instead of cuff but discontinued as it took away independence to be able to don and doff due decreased hand dexterity

  • Instead cuff suspension tightened and lateral paratibial pad added

  • Joint gait analysis and education

Outcome

Post review with the Prosthetist a good prosthetic fit was achieved and as a result the pain in the residual limb when mobilising resolved. With practice the patient regained independence with being able to don/doff her prosthesis independently. She is still currently an inpatient but she is now mobilising short distances with the front wheeled walker and supervision only. She is also able to independently self-propel to the bathroom and then stand and step round transfer with supervision only but should progress back to independence shortly.

She still presents with a residual mild weakness in her right upper and lower limb with decreased co-ordination but subjectively reports that she feels an improvement with the exercises and is keen to continue these post discharge. She has had no further falls and her exercise tolerance is slowly improving as her medical condition improves and with a graded exposure to increasing her activity levels. Her Tinetti score now indicates a moderate falls risk and her timed up and go has improved to 1minute 10 seconds.

She is due to remain in rehab for another week with the goals focused around regaining independence with toileting and being able to mobilise with the front wheeled walker independently. Post discharge long term she wants to return to mobilising independently with her stroller and so the team will liaise with her care home to arrange follow up Physiotherapy.

Discussion

In my current rehab setting we utilise an IDT approach where the team including the patient discuss goal setting and co-ordinate and manage discharge plans. I find this model of working extremely beneficial as it's a co-ordinated approach which is patient centred and it minimises conflicting advice received.

Based on the earlier course learning I had a good understanding of what would have caused her original amputation, why that level of amputation was chosen and had a good basic awareness of the type of prosthesis she had and the suspension method.

My initial assessment was based around what I had learnt in week 2 and included appropriate outcome measures. I could then summarise the information gathered utilising the ICF model which I find extremely beneficial. I feel that the ICF model really gets me to think about the patient holistically not just as a condition and considers things like psychological impact and social supports that might affect the rehab process.

Although through previous clinical experience I have a good understanding of exercise prescription I feel that the Gailey books have increased my repertoire of exercises that can be used specifically with amputee patients and is great for future reference.

I really enjoyed working alongside the Prosthetist to try and problem solve round what was caused the residual limb pain and how it could be resolved through both strengthening exercises and adjustment to the actual prosthesis.

References

  1. Stewart and Jain. Cause of death of lower limb amputees. Prosthetics and Orthotics International, 1992,16,129-132
  2. Carmona GA, Hoffmeyer P, Herrmann FR, Vaucher J, Tschopp O, Lacraz A, Vischer UM. 2005, Major lower limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease. Diabetes Metab. 2005 Nov; 31(5):449-54.
  3. Clinical Guidelines for the pre and post-operative physiotherapy management of adults with lower limb amputation. BACPAR (2006) http://bacpar.csp.org.uk/publications/clinical-guidelines-pre-post-o perative-physiotherapy-management-adults-lower-li
  4. International Classification of Functioning, Disability and Health (ICF) by World Health Assembly (2001)
  5. The psychological aspects of amputation. First Step (2003) http://www.amputee-coalition.org/first_step_2003/psychological-a spects-amputation.html
  6. Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation. Department of Veterans Affairs, Department of Defence. 2007
  7. Government of South Australia, Statewide Rehabilitation Clinical Network. Model of Amputee Rehabilitation in South Australia. 2012
  8. Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert, A., Quinlivan, D., Randell, T., Shepherd, R., Withpetersen, J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses, 2nd Edition, Chartered Society of Physiotherapy: London
  9. BACPAR guidelines for prevention of falls in Lower Limb Amputees (2011) http://bacpar.csp.org.uk/publications/guidance-falls-prevention-low er-limb-amputees