Interdisciplinary care of a 84-year-old patient, following a trans-femoral amputation: Amputee Case Study


Original Editor - Orianne Augris

Title

Interdisciplinary care of an 84-year-old patient, following a trans-femoral amputation.

Abstract

This clinical case concerns the rehabilitation of Mr. D, 84-year-old, hospitalized further to a trans-femoral amputation due to a sepsis on a prosthesis of knee. His wishes were to be able to re-walk with crutches inside his apartment, and be able to drive again. The objectives of rehabilitation were: the prosthesis, learning to walk, and the patient's independence. Phantom limb pain and fatigue somewhat disrupted the rehabilitation. However, after 16 weeks of rehabilitation, Mr. D returned home having achieved some of his objectives. The care started on September 29th, 2014.

Key Words

Trans femoral amputation; re-education; prosthesis; physiotherapy

Client Characteristics

Mr. D is 84 years old. He is retired from the Air Force where he worked as a helicopter pilot. He is married, father of three children whom he sees regularly. He lives in an apartment on the first floor, with a lift. He has no particular hobby. 
Mr. D was first operated on for a complete prosthesis of his right knee in 2001; after his prosthesis went loose he was operated on again twice, in 2003 and 2007. In the year 2014 his knee began to ache, Mr. D delayed before consulting his doctor.

When he eventually visited his surgeon, Mr. D could hardly walk, the infection was already too large and amputation could not be avoided. It took place on September 16th, 2014. 
Among Mr. D's risk factors it is necessary to note hyper blood pressure, overweight (BMI 26.9), a former smoking, sleep apnea and multiple operations including one for coronary artery disease.
Mr. D's background is a coronary artery disease for which he was operated on in 2009, with 4 stents inserted; and surgery to remove several tumors (kidney in 1982, prostate and rectum in 2003 and 2010).

Examination Findings

  • Mr. D arrived at the center on September 29, 2014. During his initial examination he indicated his desire to drive again and re-walk, "as before".
  • Several assessments were made, such as:
 Pain with E.V.A. : We could notice a phantom limb pain in addition to a 6/10 pain of the stump.
  • Cognitive status: Mr. D uses hearing aids and glasses, but does not suffer from disorders of understanding, and expresses himself without difficulty.

  • The skin-Trophic: the stump is clean, slightly red and hot. Some places aren't still closed up. The measurement of the perimeter of the thigh shows an edema.
  • Psychic: Mr. D accepted his amputation, though he thinks he will be able to walk again without difficulty with crutches and is in denial with regard to his actual skills.

  • Articular, with Kapendji references : we note a slight flexum of right hip of 10 °.
  • Muscular, with Held and Pierrot-Deseilligny scale : we note an imbalance and weakness of muscles of the right leg. The left lower limb and upper limbs are evaluated at 4.

  • Functional : transfers need training(chair-chair and sit-stand transfers).
  • I.C.F
 - organic function: Musculoskeletal problems, and movement problems
? structural deficiency: absence of the right lower limb (amputation) - activity limitations: transfer, walking
? function restriction: standing, grooming, driving
 - Environmental factors: well supported by his family

Clinical Hypothesis

Following various tests we chose with Mr. D. to work on his phantom limb pain in order to reduce it; we also decided his swelling needed to get reduced so as to stabilize the stump. Pre-prosthetic rehabilitation was also focused on the reduction of the right hip flexum, and work to strengthen the right leg. The muscles of the upper limbs, the left lower limb and trunk were all the same maintained for the walk with crutches. The work on transfer and balance made the patient more independent. We also reviewed the situation with Mr. D on therapeutic education and his actual skills. Once the patient was paired, we worked on walking, balance, support transfer.

Intervention

  • To counter pain we chose to use the mirror therapy and electrotherapy TENS type[1] (the electrodes are placed on the painful course).
  • Massages have been made to decrease swelling, and Mr. D wears a compression sleeve as much as possible.
  • To reduce the right hip flexum we performed hip flexor stretching, postures of this joint as well as a strengthening of hip extensors.
  • Strengthening the muscles of the right lower limb, trunk and upper limbs is performed in order to enable the fit of a prosthetic device, and walking: the gluteus and quadriceps are trained to be as strong as those on the left side, as well as IJ to avoid hip flexum, the dorsal and abdominal muscles to prevent back pain and upper limbs (push up) to help with crutches.
  • The unipodal balance is critical for transfers and walking.
  • So we worked with Mr. D on his standing position in the parallel bars on the left leg, then on moving on that same leg between the bars.

  • Mr. D could use his prosthesis when his wound was healed.
  • Then we worked on how to get the prosthesis on and off, on the loading, on how to transfer the support from a member onto the other, balance, and of course walking in the three planes of the space.

Outcome

  • Functional : Thanks to rehabilitation (reduction of hip flexum, muscle building ...) and a good healing of the stump Mr. D's prosthetic device could be fitted. The full team (prosthetist, doctor, physio, occupational therapist) chose a fixed knee for Mr. D as his level of activity was classified K1 (12/39 to AmpPro). Mr. D had no difficulty in getting his prosthesis on and off. Using the Gait rite, we were able to see Mr. D's limp. We could see a residual whip and that the patient did not sufficiently transfer his weight onto the prosthesis.
  • The TUG was 48 sec, and walking was not possible more than a few minutes because the patient got tired very quickly, and the phantom limb pain was being felt sharply over this time lapse.
  • The scale of Barthel gave a score of 75/100, which shows good functional independence. Mr D could not take driving up again, but he can walk at home with two crutches. He was given a wheelchair for long distances and outside.
  • Emotional: It has been a long process for Mr. D to understand that his life with a prosthesis would not be as he had imagined it would.

Discussion

Mr. D's rehabilitation lasted 16 weeks. The first part of pre-fitting rehabilitation went well, and Mr. D qualified for all the requirements, including a joint mobility and adequate muscle strength, allowing the fitting of a prosthesis.

The second phase of his rehabilitation was more complicated. Indeed, the phantom limb pain never disappeared. The use of mirror therapy and TENS reduced it but it reappeared upon weight bearing and walking, which prevented Mr. D from walking on long distances. The "graded motor imagery" [2]might be able to be tested. This problem largely deteriorated his morale, and a psychologist reviewed the subject with him. Fatigue was also detrimental to the recovery of walking on long distances.

Indeed, a trans-femoral amputee spends much more energy than a normal person to walk (+ 68%) [3], and given Mr. D's age, this expenditure was difficult to manage. These two elements hampered the patient in achieving some of his objectives: he can move in his apartment with his crutches, but over short distances. Mr. D is still independent on his daily trips because he was given a wheelchair.

Thanks to the operation of the interdisciplinary team, the management of Mr. D's case was focused on the patient's interests and goals. [4]

References


  1. Bryant G. Stump Care. The American Journal of Nursing 2001; 101(2); 67-71
  2. Rothgangel,S, Braun,S, Beurskens,A, Seitz,R, Wade,D, The clinical aspects of mirror therapy in rehabilitation: a systematic review of the literature, Journal of Rehabilitation Research, 34:1-13,2011
  3. Waters RL, Perry J, Antonelli D, Hislop H. Energy cost of walking of amputees: the influence of level of amputation. J Bone Joint Surg 1976;58:42-6
  4. Körner, M. (2010) Interprofessional teamwork in medical rehabilition: a comparison of multidisciplinary and interdisciplinary team approach, Clinical Rehabilitation, 24 (8)745-755