Lower Limb Amputation: Diabetic Case Presentation: Amputee Case Study

Original Editor ­ Catrin John

 Title

Lower Limb Amputation: Diabetic Case Presentation

Abstract

A case presentation summarising the 21 day acute in-patient journey of a diabetic below knee amputee through to discharge to a community setting.

Key Words

Transtibial, diabetes, peripheral artery disease, phantom limb sensation, acute, in-patient

Client Characteristics

50 year old teaching assistant
History of presenting condition:
Peripheral artery disease leading to arteriosclerosis obliterans in the dorsalis pedis artery of the right leg
Subsequently hospitalised with an advanced diabetic foot ulcer and critical limb ischaemia
Revascularisation attempt via percutaneous transluminal angioplasty – an operation for enlarging a narrowed vascular lumen by inflating and withdrawing a balloon on the tip of an angiographic catheter through the stenotic region +/- positioning of an intravascular endoluminal stent
Marginal improvement therefore transtibial amputation

Past medical history:
Smoking
Type 2 diabetes
Peripheral artery disease: results in a restriction in the lumen of the arteries causing stenosis and restricted blood flow to an area
Arteriosclerosis: generalised degeneration of the elastic tissue and muscles composing the arterial system causing them to become hard and tortuous

Examination Findings

Subjective assessment:
Day 7 post right elective below knee amputation resulting from diabetic complications
Moderate post-amputation pain: reduced with analgesia
Phantom limb sensations (PLS): a normal experience for the majority of amputees. It is not a noxious sensation, but often described as a light tingling sensation and re-assurance is key
Depression: decreased mood and thoughts about not being able to walk and return to work
Objective assessment:
Decreased strength: full 5/5 on L. On R, 4/5 hip flexion and hip extension, 4+/5 hip abduction and hip adduction, and 4-/5 knee flexion and knee extension
Decreased range of movement: full range on L. on R, 90 degrees hip flexion, neutral hip extension, 20 degrees hip abduction, neutral hip adduction, 70 degrees knee flexion and -20 degrees from full knee extension
Decreased balance
Decreased endurance
Decreased skin integrity limiting opportunities to use PPAM aid
Independent wheelchair mobility and transfer to/from wheelchair with arm out
Decreased ability to walk, secondary to 2 and 5, and therefore return to work (long term goal)

Clinical Hypothesis

Main problem = decreased range of movement at the hip and knee (neutral position of hip extension and -20° from achieving full knee extension)
Decreased knee extension results in:
Decreased ability for through range strengthening
Reduced opportunity to use PPAM aid and ultimately a prosthesis
Decrease hip extension results in:
Decreased ability for through range strengthening
Altered gait pattern in stance phase on the right
Ultimately, reduced potential success with future prosthetic function

Intervention

Decreased Rom:
Reduced hip extension:

  • Prone lying +/- pillow under leg to increase passive stretch +/- active hip extension, 
  • Standing in parallel bars +/- active hip extension
  • Advice re: lying flat throughout the day

Reduced knee extension:

  • Advice re: avoiding resting with pillow under knee
  • Posterior capsule stretch with pillow under end of stump +/- over pressure
  • Static quads exercise

Decreased strength:

  • Range of static and through range strengthening exercises on a plinth, in a chair and in standing, including static quads, static gluets, inner range quads, straight leg raise, bridging, hip abduction, hip extension, hip flexion, knee extension and hip hitching, and mini squats and sit to stands for the non-affected leg

Decreased balance:

  • Sitting balance activities – reducing base of support (BOS), reaching outside BOS and across body, duel tasking, altering surface, etc
  • Standing in the parallel bars

Progression:

  • Reduced arm support +/- reaching outside BOS and across the body
  • Duel tasking activities – standing with head turns, conversation and games

Decreased endurance:

  • Gradual increase of repetitions/sets of exercises, length of stands, amount of transfers, distance of wheelchair mobility

Decreased ability to walk:

  • Unable to address problem or trial with PPAM aid due to decreased skin integrity. Will be addressed in a community/outpatient setting when appropriate

Phantom limb sensation:

  • Education, advice and re-assurance to de-threaten this

Outcome

Minor global increase in strength and endurance of the amputated lower limb. Unable to determine significance of an improvement using the oxford grading scale due to changes being small and subjective nature of the grading system.
Full range of extension at the knee and a 5-10° increase in hip extension on the right side. Would allow for greater functional application when appropriate to trial with a PPAM aid and eventually a prosthesis.
Improved postural correction to aid with balance, and ability to stand safely and independently within parallel bars. Ability to stand unsupported with supervision for

Discussion

Unlikely to see a drastic increase in strength in such a short time frame as muscle strength takes 6-12 weeks to improve [1]. It may have been more beneficial to obtain an objective outcome measure, such as the number of repetitions of exercises +/- weights used.
The loss of range at the knee post-amputation was an acute change, likely caused by swelling and pain from the trauma of amputation, therefore, soft tissue changes were easier to correct as swelling and pain were controlled.
Balance is required to reduce the risk of falls and maximise safety. This is of particular importance in diabetic patients as they are more susceptible to injury and tissue failure.[2] 
Vascular transtibial amputees expend 40% more energy in gait and therefore require greater endurance to cope with these demands.
PPAM aids may only be used from 5 days post-amputation following a satisfactory wound check. As the wound was not of satisfactory healing, this was avoided, in keeping with guidance [3]

References

  1. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee I-M, Nieman DC, Swain DP. Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy Adults: Guidance for Prescribing Exercise. Medicine & Science in Sports & Exercise [online]. 2011; 43(7):1334-1359 [Accessed 17 July 2015].
  2. Lowe T, Khadir SA, Lowe R. The Diabetic Amputee. 2015 Accessed 17 July 2015. http://www.physio-pedia.com/The_Diabetic_Amputee [Accessed 17 July 2015].
  3. Bouch E, Burns K, Geer E, Fuller M, Rose A. Guidance for the Multi Disciplinary Team on the Management of Post-Operative Residuum Oedema in Lower Limb Amputees. 2015. Accessed 17 July 2015 http://bacpar.csp.org.uk/publications/guidance-multi-disciplinary-team-management-post-operative-residuum-oedema-lowe
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