Kyphotic Below Knee Amputee: Amputee Case Study

Title

Kyphotic Below Knee Amputee

Abstract

Patient underwent a right below knee amputee, due to critical limb ischemia and wet gangrene. Patient also has a significant kyphosis due to previous spinal fractures. Due to this both trunk, upper and lower limbs and the respiratory system where impaired. These impairments as well as numerous environmental factors considerably limited the patient in returning to both previous activities and social participation. A programme of education, stretching, strengthening and mobilisation was undertaken as well as referrals to other members of the MDT. Patient is now independently mobile.

Keywords

Trantibial, Kyphosis, Peripheral vascular disease.

Client Characteristics

David is a 70 year old retired computer specialist who lives in a 3 bedroom house with his wife. He underwent a right below knee amputation on 12th April 2015 for critical limb ischemia and wet gangrene of his right toes. He has a 20 year history of Peripheral Vascular Disease and sustained an ulcer to his right foot in June 2014 after dropping a pair of garden shears on his foot. He also had a fall backwards down the stairs in November 2014 resulting in multiple spinal fractures and a significant kyphosis. He reports he is no longer receiving treatment for this but feels his breathing has deteriorated with his change in posture. He has a history of previous angioplasty for PVD in 2000, High cholesterol, Hypertension and a Pulmonary Embolism in 2011 for which he takes Warfarin. He is an ex-smoker but stopped this 24 years ago. Prior to amputation David was limited by rest pain and was mobile for the 6 months prior to amputation with a walking frame indoors and a mobility scooter outdoors. Prior to this, he was mobile with one stick but limited how far he could walk by claudication, mainly in his right leg after approximately 150m.
After his initial inpatient stay he had been transferred to a Community hospital and then discharged home with community therapy input. This had since ceased but David was still performing his given exercise programme on assessment.

Examination Findings

David was self caring except with washing his back, shopping and preparing food. His wife assisted with these. He was unable to access the kitchen or get out of his property due to steps. He has a stairlift but was strip washing due to an inability to get in and out the bath. He had no history of falls post operatively. David was a keen gardener and reported his goals were:

  • To access the garden and return to gardening.
  • To get in a car and access friends and families houses.
  • To go on holiday and out for meals
  • To be able to walk up the steps into local shops from his mobility scooter


On examination he presented with a considerable kyphosis which limited ROM at shoulders and caused him to sit in posterior pelvic tilt with protracted shoulders and chin. David reported he was unable to lie supine or prone due to his posture and difficulties in breathing. He demonstrated weak core stability in his trunk. He had grade 5 Upper limb strength and grade 4 muscle strength in bilateral hips and knee. Left ankle grade 5. Lower limb range of movement was full except -10 left and -15 right hip extension. Residual limb was tender and swollen. Scarline was a posterior flap and although healed was very tethered laterally. Tenderness placed on NRS 4/10. No complaint of phantom limb pain. Perceived exertion on mobilising in the Ppam aid was 13 (Borg scale) and 2 minute timed walk test with a frame was 12m.

Clinical Hypothesis

Socially isolated with dependency on wife. Reduced independence has affected confidence, self esteem, mood and relationships.

  • Unable to re-engage with social activities and interactions.
  • Posture, reduced exercise tolerance and poor core control is impacting on breathing, function, movement patterns and reduced range of movement in upper and lower limbs.
  • Swollen and tender residual limb with scar tethering, likely to cause discomfort and prosthetic issues.
  • Reduced lower limb strength. As a current wheelchair user at risk of further reduction in strength and range of movement.
  • Remaining limb at risk and previous claudication likely to limit prosthetic mobility

Intervention

David was referred to the Occupational therapist for review of environmental and personal care issues. Car transfers were practised to allow community access and re-engagement in social activities with his wife. Information regarding counselling and returning to driving was supplied. David was prescribed a core stability and stretching programme[1](15,3&4). Hip flexor stretches were taught in standing and side lying and his wife educated in how to assist (8). Positional advise was given and breathing exercises taught. An upper and lower limb strengthening programme was prescribed both though a home exercise programme and within therapy time (4&3). Patient was taught scar and residual limb massage techniques (5&12) and a silicon liner was prescribed. Patient was educated in swelling management and a stump shrinker sock provided (13&15). Patient was also mobilised twice weekly in the Ppam aid prior to casting for a prosthesis[2] (11&15) A graduated fitness programme using a static arm and leg bike and a seated exercise programme was also prescribed, to increase his exercise tolerance and cardio-vascular fitness.
Patient was educated in remaining limb care (10,16&1) and a referral made to both podiatry and also orthotics for provision of specialist footwear(10&16). Patient underwent a graduated prosthetic rehabilitation programme working on correct weight transfer and prosthetic use (6&16).
Functional tasks (2&7) were also practised relevant to the patient."

Outcome

David is now independently mobile with a PTB socket, Super-SACH foot, sleeve suspension and 2 sticks. He was unable to master 2 point reciprocal gait due to confusion in replicating this pattern and also limited right hip extension. He is therefore mobile with 3 point gait. David now reports there is no tenderness on palpation of his residual limb with NRS of 0/10. Initial difficulty of donning suspension sleeve were solved by changing type of suspension sleeve and patient is able to don and doff independently. David is now able to walk out of his house alone and get into a car although he has yet to return to driving. He has re-engaged with desired social activities and OT is currently involved regarding vocational rehab re: gardening. Exercise tolerance is improving. 2 minute walk test was 35m on last review. David reports he has noticed a benefit to his breathing and BORG score of exertion on walking is now reported to be 9. Current mobility is limited to 80m due to fatigue but exercise tolerance is still improving. Lower limb strength has increased to 5 but remains 4 in his left hip extensors, and quads. Ongoing strengthening as well as fitness programme is still in place.

Discussion

Older amputees have an increase likelihood of multiple pathologies[3] and these will affected the approach and nature of their rehabilitation. Wheelchair mobility post amputation was encouraged due to falls risk and risks to remaining limb[4] [5]. Taking warfarin increases the risks of serious injury in falls and this was considered throughout rehabilitation in consideration of prosthesis prescription as well as mobility aids. The benefit of walking frames for the older amputee has been highlighted [6] but these need to be assessed with functional use and goals. This patient demonstrated good dynamic and static standing balance and walking sticks allow him to manoeuvre easier around his house as well as to achieve his goal to mobilise into shops etc from his mobility scooter.


Falls prevention and management advise was given and on and off the floor practised[7][8] [9] both with and without the prosthesis in situ. Due to his kyphosis and posture, David's limitation in shoulder ROM meant he found utilising 4 and two point kneeling easiest and was able to get up independently using furniture for support. He was prescribed a super SACH foot due to his restricted outdoor mobility and therefore preference for stability. A PTB socket was used due to the ease of donning and likely residual limb volume changes expected in a primary amputee.[10]

References

  1. BACPAR, Clinical Guidelines for the Pre and Post operative Management of Adults with lower limb amputation; Recommendation 6. 2006
  2. BACPAR, Clinical Guidelines for the Pre and Post operative Management of Adults with lower limb amputation: Recommendation 6. 2006
  3. Physiopedia - Older persons with Amputation. http://www.physio-pedia.com/Older_people_with_amputations
  4. BACPAR, Clinical Guidelines for the Pre and Post operative Management of Adults with lower limb amputation: Recommendation 6.2006
  5. Therapy for Amputees (3rd ed.), Engstrom and Van de Van 1999 p.151
  6. Physiopedia - Older persons with Amputation. http://www.physio-pedia.com/Older_people_with_amputations
  7. BACPAR, Clinical Guidelines for the Pre and Post operative Management of Adults with lower limb amputation: Recommendation 6.2006
  8. BACPAR, Evidence Based Clinical Guidelines for the Physiotherapy Management of Adults with Lower Limb Prostheses; Recommendation 5. 2012
  9. Department of Defence, Clinical Practise Guidelines for Rehabilitation of Lower limb Amputation. Department of Veterans Affairs: Guideline 8. 2007
  10. Physiopedia - Prosthetics. http://www.physio-pedia.com/Prosthetics