Hotel Worker, Lady Q Undergoes Transtibial Amputation but 'Gears up' for Prothesis and Rehabilitation: Amputee Case Study


Original Editor - Pierann Brown

Title

Hotel Worker, Lady Q Undergoes Transtibial Amputation but 'Gears up' for Prothesis and Rehabilitation

Abstract

53 year old diabetic, Lady Q, a post-transtibial amputee, was gainfully employed in a hotel prior to amputation and is keen on returning to work. Post-op: she joined a smoking cessation, and an amputation support group, is compliant with medication, seeing a dietitian. She wishes to obtain prosthesis and is willing to work hard during post-amputation rehabilitation to ensure recovery.
Considerations of Lady Q's health issues, psychological status and family/social support will help guide the process of pre- and post- prosthetics rehabilitation and reintegration into work and social environs.

Key Words

diabetic, transtibial, phantom limb pain, contacrture, endurance, rehabilitation

Client Characteristics

Lady Q, known Type 2 diabetic with a long history of smoking. Diagnosis of peripheral artery disease (PAD) several months ago lead to arteriosclerosis obliterans in the dorsalis pedis artery of her right leg. She was subsequently hospitalized with a chronic Fontaine’s stage IV foot ulcer and critical limb ischemia. After a revascularization attempt via percutaneous transluminal angioplasty (PTA), circulation was only marginally improved and she underwent transtibial amputation.
Post-amputation she presents with: pain; phantom limb sensation; decreased strength, range of motion and balance; decreased skin integrity; decreased endurance and ability to walk and work and psychological issues.

Examination FIndings

Subjective findings are any information reported by Lady Q, such as phantom limb pain, feelings in regard to her current condition, matters pertaining to her health status, home and social life. Inclusive of her goals of getting fitted with a prosthesis, being able to walk,to return to work and active social life.
Objective findings are based on observation and measurements made by examiner/(PT).

ICF Model:
Body function/ structure

  • TT amputee – healing stump, decreased skin integrity – potential bruises- pressure relief not done often in WC
  • Pain residual limb
  • Phantom Limb sensation
  • Decrease strength ( B) LEs
  • Decreased ROM (R) LE, tight hamstrings/ developing Kn. flexn contracture- forgets Kn board
  • Decreased balance and endurance
  • Decrease ability to walk and work
  • WC and walker mobility

Personal factors

  • Quit smoking post-op
  • Family support
  • Eager to return to work
  • Joined support groups
  • Motivated to start and complete rehab
  • Gets visits from coworkers mostly on weekends but they call her daily
  • Restricted LE mobility – manages most ADLs needs assist to bathe
  • Unable to stand to prepare meal but can use microwave from WC
  • Lonely during the days when daughter and grandchildren are at work/school
  • Refuses to go to church (“to many questions”, “not going in WC”, ”don’t want pity”)

Environmental factors

  • Shared, small bathroom: transfers from WC to walker to enter
  • Unable to drive
  • Unable to work
  • Kitchen top cupboards challenging

Clinical Hypothesis

Client's main problems:

  • TT amputee - healing stump which needs shaping - decreased skin integrity
  • Pain / Phantom Limb sensation / increased risk of falls
  • Decrease strength(B) LEs
  • Decreased ROM (R) hip and Kn. - tight hamstrings/ possibility Kn. flexion contracture
  • Restricted mobility- WC and walker use - decreased independence
  • Decreased balance and endurance
  • Decrease ability to perform ADLs and work
  • Some difficulty adapting to present condition - loneliness - loss of self confidence - feeling of loss of worth in family and society

Intervention

Multidisciplinary approach - Physicians, PT, Prosthetist, Dietitian, psychologist, OT, social worker.

  • PT plans and executes post-amputation / pre-prosthesis/ post-prosthesis programme: 2-3 hrs. / daily for 5 days/week to safely promote mobility and recovery while protecting the (L) LE.
  • Patient and her family educated:- Support roles; DM; skin/stump care, shaping- bandaging/rigid and semi rigid dressings; socks; protecting contralateral limb; phantom pain; falls prevention; relieving pressure, don /doff prosthesis. Referral for social worker to work with family.
  • Pain mgt. - modalities and coping strategies - desensitizing techniques.
  • Strengthening exs for (B)U & LEs and stretching exs to prevent contractures[1]. Progressive resisted exs programme[2].
  • Transfers; balance and reaction training;
  • Fitted with TSB - total contact socket, SPSC suspension
  • Gait training pre- and post- prosthetics. Progressive training to advance activities.

Lady Q and family were provided with pamphlets, website info for support services; advice given on continued care; how to and when to get in touch with PT and/or other members of the multidisciplinary team in preparation for discharge

Outcome

  • Pain decreased - stump scar healed and desensitized.
  • Lessened Phantom limb sensation
  • Maintained (L)LE and increased AROM (R)LE
  • Maintained UEs and increased muscle strength (B)LEs
  • Improved balance and reaction to disturbance
  • Managed optimal weight bearing on the TSB prosthesis which offered extra medial/lateral and anterior/posterior stability, hence, increased gait control and is adaptable for amputees with sensitive skin [3] 
  • Successful gait training, hence reduced energy expenditure needed to walk.

Lady Q was determined to maximize rehab potential, she routinely did her stretching exs, prone lying daily and use of extension board (initially)to prevent knee flexion contracture.
She became competent in performing most daily operations like don/ doff prosthesis, sitt to st and vise versa, car and walking up and down stairs, walking >50m with load.
She is managing most ADLs, able to prepare meals and manages bathing and toileting independently

She regained self confidence - now volunteers / advocates at amputee support group, goes to church and exercises at park with family. Work/Studying/ job change - telephone operator / receptionist at hotel.

Lady Q is now compliant with medication management and diet, no worsening of vascular complications on contralateral limb developed. She has adapted to her condition, is cooperative and determined in advance gait training, cognizant of rehab goals and knowledgeable of her roles and responsibility on discharge.

Discussion

Lady Q was progressed safely and successfully through the nine phases of the rehabilitation process for amputees[4] [5]. It was a challenging yet diligent rehabilitation journey from her acute post-surgical treatment in hospital to pre-prosthetic rehabilitation phase, prosthetic prescription, prosthetic training, community integration, vocational rehabilitation, discharge and arrangements for follow-up.
In particular, vigilance to prevent falls, skin care, promote wound healing, ensure comfortably fitted prosthesis to minimize pressure on sensitive areas and prevention of blisters/ breakdown of residual limb.

Lady Q is happily reintegrated into work and social environment and is studying to enhance her skills at her new vocation.

References 

  1. Galley RS, Galley AM. Stretching and strengthening for lower extremity amputees. Miami, FL. Advanced Rehabilitation Therapy Inc. 1994
  2. International Committee of the Red Cross. Exercises for Lower-limb amputees. Geneva, Switzerland. 2008
  3. International Committee of the Red Cross. Exercises for Lower-limb amputees. Geneva, Switzerland. 2008
  4. Engstrom B, Van de Ven C. Therapy for Amputees. Churchill Livingstone, London. 1999
  5. Esquenazi A.Rehabilitation in Limb Deficiency. Arch Phys Med Rehabil. 1996; 77(3): S18-28.