Home Physical Therapy for a Complex Patient with Bilateral BKA: Amputee Case Study

Title

Home Physical Therapy for a Complex Patient with Bilateral BKA

Abstract

This case presentation describes the the partial course of home physical therapy (with mention of prosthetic, nursing and surgeon input) for a complex patient s/p new L BKA and old R TKA. After being cleared for prosthetic training, gait and transfer training were impeded by skin breakdown on the left residual limb. This paper explains the attempts to address this issue and many others. It also discusses the reasons why, despite the team's best efforts and intentions, this patient would not meet her goal of independent ambulation.

Key Words

Diabetes, transtibial amputation, bilateral, phantom pain, blistering.

Client Characteristics

The patient is a 65 year-old female, retired teacher, s/p left BKA January 2014 with multiple comorbidities including DMII s/p right BKA 2010. She is non-compliant with prescribed dietary recommendations and resumed smoking shortly after left BKA, despite warnings that this may result in poor outcome. Her right BKA healed slowly, but, after several months of rehab, she achieved independence with ADLs and ambulation with a cane on level surfaces. She used a walker for uneven surfaces or long distances. After her R BKA, this patient had a difficult time adjusting to the loss of her leg. She also had significant residual limb and phantom pains. She became increasingly depressed and sedentary. There was a question of opiode dependency. She had multiple falls, likely due to a  combination of pain, decreased strength and balance, decreased compliance, medication side effects, and multiple comorbidities. She later developed an ulcer on her left foot which resulted in BKA. After a month in the rehab hospital, she returned home, at wheelchair level, with help from her PCA. She had a brief course of home P.T. Once her HEP was established and she had made maximal progress at wheelchair level, P.T. was put on hold until prosthetic training was possible. Nursing continued due to issues with pain and wound management. Once the residual limb stabilized, the prosthetician fit, built, issued and began adjusting the prosthesis. P.T. was resumed (eval findings below).

Examination Findings

SUBJECTIVE:

HPI:

s/p L BKA 2014 due to non-healing foot ulcer

CC:

Residual limb & phantom limb pains

PMH:

DMII, s/p right BKA 2010, PVD, COPD, morbid obesity, severe shoulder OA, R RC tear, smoker 2 PPD x 30 yrs

Pain:

L stump 5/10. L phantom ""itch"" 6/10. B shoulders 8/10.

Social:

Retired; lives alone. PCA works 25 hrs/wk & is primary source of physical & emotional support. Unable to drive. Sedentary. Sits in w/c most of day.

Environment/Equipment:

One-story home; w/c ramp garage to kitchen. Grab bars in bathrooms. Master bath too small for w/c access. Low toilet. High bed.

Patient. goals: Indep gait w/ walker. Indep ADLs. Return to light gardening.


OBJECTIVE:

AROM: Shoulder Flex & Abd to 90 degrees B. Trunk grossly 50%. Hip Ext, IR & Add to ~25% bilaterally. L Hip Flexion to 95 degrees. Knee grossly -10 to 110 degrees B.

Strength: Shoulders 3/5 w/pain. Elbows WNL. Trunk grossly 4/5. Hips grossly 4-/5 B except L Hip Flexors.

Balance: TUG: Unable to assess. SLS: 2 secs max. AmpNoPro: 6/39

Transfers: MaxA sit<->stand from w/c or low surface; minA to pull self up to counter or // bars.

Gait: MaxA in // bars. Circumduction, B toe-out, poor foot clearance during swing phase; limited to 10 ft. by pain/fatigue. Unsafe w/ walker.

Integument: Stump warm, edematous. Scar healed. Skin red along tibial crest & distal stump after standing activities. After 2 wks of prosthetic training: several small, painful blisters noted on ant and inf L stump. L stump hypersensitive to LT.

Clinical Hypothesis

Our hypothesis was that the patient's main problem was decreased toleration for weight-bearing activities in the new prosthesis as demonstrated by skin breakdown and blistering on the distal left residual limb. The toughened right residual limb tolerated weight-bearing activities well, even with the increased demand on it. The hypothesis was that this patient's L>R lower extremity weakness was resulting in deviations during gait and transfers that placed increased shearing forces on the newer residual limb resulting in skin irritation.

Intervention

Based on this hypothesis, we decided to postpone gait training in favor of less dynamic weight-bearing activities such as weight shifting in static standing, single plane standing exercises, and prolonged static standing. We continued sit to stand transfers from the wheelchair to the kitchen counter using UE support, but postponed practicing stand-pivot transfers that might twist the prosthetic feet and place increased torque on the residual limbs. We also advised the patient to wear the prosthesis less during the day (with her knee extended to prevent contracture) and gradually increase wear time as tolerated. The patient continued seated LE strengthening exercises during P.T. sessions. The O.T. worked on UE strengthening (especially triceps and biceps since toleration of shoulder therex was so limited) and seated ADL training. Carryover with the assigned home exercise program was questionable.

The hope was to progress the patient's LE and UE strength through gentler ""pre-gait"" activities while allowing proper healing, thanks to the reduced stress on the left residual limb. Once the breakdown healed, the patient would be in a better position to tolerate gait and transfer training with the walker or parallel bars.

Outcome

After putting the higher-level gait and transfer training on hold, we initially noticed a slight improvement in skin integrity. However, new blisters continued to arise, just at a slower rate. The prosthetician continued to make adjustments in hopes of addressing this issue from his perspective. The adjustments did not seem to make a significant difference.

It was also discovered that, due to the increased perspiration in the left residual limb when wearing the silicone liner, the patient had begun wearing her socks directly against the skin. This was done with the intention of reducing blisters by reducing moisture, but likely resulted in greater irritation due to an unsteady, pistoning socket. This error was corrected quickly though and, therefore, could not be isolated as the primary source of breakdown.

After consulting with the surgeon, it was decided to avoid weight-bearing all together until the skin healed completely. This took about two weeks. Unfortunately, this was enough time to result in LE strength losses. This led to increased shoulder pain due to greater demand on the UEs and increased difficulty with bed mobility and toilet transfers.

Discussion

In this case, multiple factors should have guided the IDT away from prosthetic issuance. These factors include her diabetes, age, continued smoking, severe RC damage, and limited family support. This discussion will focus on the diabetes and shoulder pain.

Diabetes is a primary cause of LE amputation worldwide[1]. Diabetic amputees have an 8-fold mortality rate at one year compared to non-diabetic amputees[2]. Complications from diabetes include compromised vascular supply, peripheral neuropathy, retinopathy and autonomic dysfunction[3][4][5]. Neuropathy results in impaired sensory feedback, crucial for patients suffering proprioception losses after amputation[6]. The retinopathy affects visual acuity so our amputee, already at a high risk for falling, would have greater difficulty identifying obstacles or walking in low-light situations[7]. Due to autonomic dysfunction/poor thermoregulation, the ICRC recommends a gradual increase in the time spent wearing the prosthesis due to the risk of developing blistering[8]. Despite following this recommendation, the patient continued to experience skin breakdown.

The patient's shoulder damage was also detrimental. Without it, she could achieve greater independence with transfers & ADLs, if not gait. Bilateral amputees use 200% more energy & rely heavily on UE strength[9]. It was unrealistic to expect her damaged cuff to tolerate these increased demands.

Resources would have been better spent maximizing safe, independence at the w/c level.

[10]

References 

  1. ICRC. ""Normal Gait and Prosthetic Gait."" Prosthetic Gait Analysis for Physiotherapists: ICRC Physiotherapy Reference Manual. Geneva: ICRC, 2014.
  2. Engstrom, Barbara, and Catherine Van De Ven. Therapy for Amputees. 3rd ed. Edinburgh: Churchill Livingstone, 1999
  3. ICRC. ""Normal Gait and Prosthetic Gait."" Prosthetic Gait Analysis for Physiotherapists: ICRC Physiotherapy Reference Manual. Geneva: ICRC, 2014.
  4. Engstrom, Barbara, and Catherine Van De Ven. Therapy for Amputees. 3rd ed. Edinburgh: Churchill Livingstone, 1999
  5. Peppa, M., Uribarri, J., and Vlassara, H. Glucose, Advanced Glycation End Products, and Diabetes Complications: What Is New and What Works, Clinical Diabetes, October 2003; 21(4):186-187
  6. Engstrom, Barbara, and Catherine Van De Ven. Therapy for Amputees. 3rd ed. Edinburgh: Churchill Livingstone, 1999
  7. Engstrom, Barbara, and Catherine Van De Ven. Therapy for Amputees. 3rd ed. Edinburgh: Churchill Livingstone, 1999
  8. ICRC. ""Normal Gait and Prosthetic Gait."" Prosthetic Gait Analysis for Physiotherapists: ICRC Physiotherapy Reference Manual. Geneva: ICRC, 2014.
  9. ICRC. ""Normal Gait and Prosthetic Gait."" Prosthetic Gait Analysis for Physiotherapists: ICRC Physiotherapy Reference Manual. Geneva: ICRC, 2014.
  10. Esquenazi A, DiGiacomo R. Rehabilitation after amputation. J Am Podiatr Med Assoc. 2001;91(1):13-22