Inpatient rehabilitation challenges in a hip disarticulation amputee : Physiotherapy management: Amputee Case Study

 Title

Inpatient rehabilitation challenges in a hip disarticulation amputee : Physiotherapy management

Abstract

A 59 year old man with left hip disarticulation after left lower limb cellulitis/gangrene was admitted for inpatient rehabilitation after multiple operations over a period of 3 weeks. He required 2 additional weeks of bed rest to allow the healing of the allografts and developed deconditioning. Because of weight bearing precautions and other complications, he required the use of gait aids to ambulate, maintaining non weight bearing on the allografts. He progressed to walking 100 metres using axillary crutches at a modified independent level, crossing kerbs and climbing stairs independently.

Key Words

hip disarticulation, peripheral vascular disease, geriatric, wheelchair

Client Charactoristics

Patient is a 59 years old local male of Indian ethnicity.

Diagnosis : Left Total Hip Disarticulation secondary to left lower limb cellulitis complicated by gangrene (started with TTA and thereafter TFA followed by total hip disarticulation due to poor wound healing).

Co-morbidities : Peripheral vascular disease, hypertension, history of left lower limb cellulitis, smoker/drinks 2-3 cans of beer daily, undiagnosed type2 DM

Vocation / Occupation : Patient works as a part-time dishwasher/cleaner in a food centre.

Eaxamination Findings

Subjective :
Patient is pre-morbidly independent, community ambulant and works as a part-time cleaner. He is married and stays with his wife in a 1 bedroom public housing on a lift landing level. There is a 1 inch step up to entrance of the apartment and leading to the bath. The bath has a seated toilet but does not have any grab bars installed.

Patient’s wife is a home maker and is a diabetic with heart disease. Patient reports good family relations and is a carer to wife who needs help with daily insulin injections and house chores. Patient and wife currently receives social welfare support and enjoys subsidized medical care. He works from 10am to 3pm daily. He travels to work daily via public transport.

Patient's/family's goal :
Patient hopes to be able to continue to be independent and community ambulant with aid. He also hopes to be able to continue to care for his wife. Wife wants patient to be able to be independent as she is unable to care for him.

Self Report Outcome Measures
Pain : Numeric scale 0 to 10 - patient reports pain at residual limb 5/10 at rest. Pain 8/10 when residual limb is moved and when seated. Reports nil phantom limb sensation.

Physical Performance Measures
Chest - clear
Muscle strength : upper limbs - 5/5, right lower limb - 5/5, single leg bridging : 1/3 range limited by pain
Sensation : Hyperesthesia on ant. distal part
Mobility : 1 man assistance - min for bed, mod to max for sitting, max for standing with frame

Clinical Hypothesis

1. Decreased mobility secondary to pain and loss of left limb
- During the initial post op period, patient experienced significant amount of pain in the residual limb which greatly limited therapy and increased patient’s need for assistance during mobility
- The loss of the limb also meant that he could not

2. Deconditioning secondary to bed rest due multiple operation and poor wound healing
- Most patient who have undergone hip disarticulation have suffered a decline in their physical fitness[1]. Likewise, the patient required some assistance for functional mobility when he was referred for rehabilitation.
- To perform similar tasks meant that he will need to have higher physical fitness sufficient to meet the energy demands of walking required for practical success. [2]
3. Decreased balance
- No residual limb results in loss of balance and stability as there is no joint sense to allow for the body to position/stabilize itself. Post surgical pain/wound also results in decreased weight bearing/shifting on the amputated side[3] 

Intervention

1. Mobility practice

  • Bed mobility : rolling, moving up, sitting over edge of bed
  • Sitting : static sitting, dynamic sitting
  • Transfer practise : to and from chair / wheelchair
  • Sit to stand : with use of frame progress to axillary crutches
  • Floor transfer to and from floor

2. Physical conditioning

  • Aerobic training : stationary bike for UL, Buddha claps, ambulation with equipment
  • Strengthening : strengthening program was planned to strengthen the muscles that are important in three-point gait using crutches by a progressive resistive exercise regime after determining 1RM
  • upper limb (shoulder depressors, rotator cuffs, serratus and latissimus)
  • Lower limb : hip muscles gluteus
  • Stretches : Hamstrings, calf muscles
  • Standing tolerance : tilt tabling, progressing to standing with 4 point frame and parallel bars
  • Sit to stands
  • Ambulation with frame and crutches
  • Kerb/obstacle training with use of frame and progressing to crutches
  • Stairs training : ascending and descending with use of crutches

3. Balance training

  • Static and dynamic sitting tasks (after pain is controlled and the wound is healing well)
  • Static standing between parallel bars, progressing to standing without support between parallel bars
  • Dynamic standing activities between parallel bars : reaching tasks, throwing ball

Outcome

1. Ability to perform task and assistance and aid required

  • The patient initially required 1 man assistance for functional mobility and progressed to being modified independent

2. Ambulation with gait aid and level of assistance required

  • The patient initially started training with a 4 point forearm rollator frame and progressed to a 4 point walking frame and then to axillary crutches independently.

3. Ambulation distance

  • He initially could ambulate 5 metres and his RPE would be 13-14. He progressed to ambulating 100 metres by discharge with RPE of 11-12

4. Ability to negotiate stair and kerb crossing independently with axillary crutches.

Discussion

The patient factored his age when he made the decision to mobilize using wheelchair with limited ambulation using axillary crutches. D.G. Smith (2005) [4] wrote that age and the rigors of learning are important factors in recovery and rehabilitation especially with higher amputation level.

Psychosocial factors also affected his decision. The patient had a long hospital stay due to multiple operations and wound infection resulting in sepsis. He was not motivated to commit to longer inpatient rehabilitation stay to be fitted for prosthetics. While he was hospitalized, his wife had to be institutionalized and he wanted to be discharged home once he is fit and independent with equipment to continue to care for his wife.

Rehabilitation factored his specific home environment and that patient had to care for his wife. Despite not fitted with prosthesis, the patient was able to progress to being able to progressed to walking 100 metres using axillary crutches at a modified independent level, crossing kerbs and climbing stairs independently. Occupation therapists worked with him on his ADLs and wheelchair mobilisations.

A multidisciplinary approach involving team doctors, medical social worker, rehab doctors, occupational therapist and psychiatrist was key to his eventual successful discharge back to home.

[5]

References

  1. Chin T, Sawamura s, Shiba R, Oyabu H, Nagakura Y, Nakagawa A. Energy expenditure during walking in amputees after disarticulation of the hip. J Bon Joint Surg Br,. 2005: 87-B, 117-199
  2. Chin T, Sawamura s, Shiba R, Oyabu H, Nagakura Y, Nakagawa A. Energy expenditure during walking in amputees after disarticulation of the hip. J Bon Joint Surg Br,. 2005: 87-B, 117-199
  3. Smith DG. Higher Challenges: Amputations at the Hip and Pelvis Part 2. In Motion A Publication of the Amputee Coalition of America, 2005; 15(2)
  4. Smith DG. Higher Challenges: Amputations at the Hip and Pelvis Part 2. In Motion A Publication of the Amputee Coalition of America, 2005; 15(2)
  5. The Rehabilitation of People with Amputations. Philadalphia, MossRehab Hospital. 2004