Mr. A- an older amputee: Amputee Case Study
Mr. A- an older amputee: Amputee Case Study
Management of lower limb amputees of any age is a challenging task for physiotherapists around the world. This is due to the many compounding physical, medical, psychological and social factors. It is especially so when it comes to managing a geriatric amputee, as they not only tend to have a larger number of medical co-morbidities to be considered, but their baseline functional level tends to be lower. Coincidentally, these abovementioned factors have also been found to be an indicator of prosthetic success.
transtibial, pistoning, knee flexion, family, arabic
Mr. A is an 85 year old retired gentleman from Lebanon who speaks mainly Arabic. He had a left transtibial amputation in 2007 (patellar tendon bearing supracondylar socket) secondary to longstanding peripheral vascular disease as a result of diabetes. This was on a background of multiple medical co-morbidities, which include chronic obstructive pulmonary disease (COPD-100 pack year smoker previously), congestive cardiac failure (CCF), atrial flutter and multi nodular goiter. His most recent hospital admission was due to an exacerbation of CCF and likely new diagnosis of left lower lobe lung carcinoma.
He was admitted to the rehabilitation unit from the general medicine unit for optimization of mobility and prosthesis assessment post fall. Mr. A lived in a single story house, with two large steps in the front, with his wife and two daughters (13 year and 15 year old). His wife was his primary carer and assisted with all his activities of daily living (ADLs).
It was reported that Mr. A had been having an increased number of falls since about seven months ago. This was caused by a loosening of his prosthesis from a steady loss of weight. Due to the increased number of falls, Mr. A was more reluctant to put his prosthesis on to mobilize around the house and go out with the family. He was walking 5m to the living room and back to the bedroom twice a day with moderate assistance. Mr. A's steady physical decline was also impacted by his developing shortness of breath at rest and exertion.
The prosthetist reported that Mr. A was last seen a month prior to admission. She explained that Mr. A presented with a stump, which had shrunk due to weight loss and had multiple falls. It was observed that Mr. A had a pistoning gait while walking with a 4WF. Thus she had organized for Mr. A to get a new prosthesis, and provided him with thicker socks for use in the meantime.
Mr. A explained that his goal was to be able to enjoy social activities with the family. It was the family's goal that Mr. A returned home and was to be able to mobilize independently indoors. Mr. A's wife indicated that her role was to assist him, and she was happy to continue doing so. However, she would not be able to pick him up if he falls.
Mr. A was unable to complete a generic lower limb mobility outcome measure due to his limited functional mobility. He was a moderate assistance of one to stand and was unable to walk. Hence the outcome measure used, with the assistance of an Arabic interpreter, was the Locomotor Capabilities Index (LCI). Mr. A scored 6/42 on the LCI (basic activities 5/21 and advanced activities 1/21).
Objectively, Mr. A was also found to have a reduced active and passive knee extension of -20degs, and a loss of hip extension bilaterally (L>R) of about -10degrees. He had a global loss of muscle mass in both limbs and scored 3/5 in his antigravity muscles bilaterally. Mr. A's oxygen saturations were regularly in the low 70s on room air (ABG 36pO2). He required 4L O2 via nasal prongs.
From the above assessment, it can be hypothesized that Mr. A had three main problems.
First was his poorly fitting old prosthesis which has caused him to have an altered gait pattern, increased his number of falls, instilled a fear of falling, and thus resulting in his reluctance to mobilize independently or more frequently. Furthermore, this caused him to develop a knee flexion contracture.
Second was his reduced exercise tolerance. This was caused by a number of factors including his cardiac co-morbidities- CCF (and recent exacerbation) and atrial flutter, his respiratory co-morbidities- COPD, severe emphysema, pulmonary HT, pulmonary oedema, and his current his newly diagnosed lung cancer which has further worsened his respiratory function.
Lastly was his reduced mobility which was caused by his reduced exercise tolerance, his lack of confidence in mobilizing, his lack of motivation to mobilize, his altered gait mechanics (from the prosthesis and knee contracture) and reduced muscle strength.
Majority of the physiotherapy sessions were in conjunction with the prosthetist for fitting and adjusting the new prosthesis. The new prosthesis incorporated a slightly angulated socket to assist with fitting the flexed stump.
Sit to stand practice between parallel bars were completed to increase weight bearing through the stump/new prosthesis, learning how to adjust weight bearing appropriately and to improve standing balance. This slowly progressed to taking steps along the bars, where physiotherapist assisted from behind with weight transference onto the stance leg, whilst prosthetist assisted from the front with encouraging adequate swing through the opposite leg.
As Mr. A had not been walking much prior to his admission, he had a weakening of his hip extensor muscles and tightening of his hip flexor muscles. Independent physiotherapy sessions included exercises to strengthen hip extensors, abductors and knee extensors. All exercises were completed with assistance as Mr. A could not remember each exercise.
Passive stretching of the flexed knee and hip flexors were completed by Mr. A's wife as well as the therapists. Once able to ambulate in the parallel bars, he progressed to a 4WF on the ward and to the gym.
When able to ambulate with supervision, he completed a walking program with nursing staff and family when they visited. Mr. A was also taught how to go up and down stairs safely, get on and off the floor through the assistance his 4WF and maneuvering around on the floor.
Mr. A was in rehabilitation for a total of a month. Through rehabilitation, he was able to wean himself to using 2L of O2 via nasal prongs at rest and with exertion, and was able to independently transfer himself from bed to chair and in the bathroom, walk independently with his 4WF at least 60m without rest, and go up and down two steps with a rail and supervision or a single step with his 4WF.
Mr. A was also able to safely don on and off his new prosthesis with the supervision of his wife. It was obvious that Mr. A was unable to retain new information regarding the management of his new prosthesis (his wife had been assisting him). Thus, a large proportion of therapy time was devoted to educating his wife on how to assist him.
Despite having no significant change in his knee extension range of movement, he improved in terms of global lower limb muscle strength to a 4/5. On reassessment, Mr. A scored 22/42 on the LCI (basic activities score of 16/21 and advanced activities score of 6/21).
Three months after his discharge from rehabilitation, Mr. A was reviewed in the amputee clinic, which had the rehabilitation consultant, physiotherapist and prosthetist in attendance. He was able to walk into the clinic independently and it appeared that the prosthesis was still fitting well and was well maintained. It was reported that he did not have any more falls post discharge and was happily participating in market days with the family (overseeing the business, not helping out physically).
There are a few points of discussion relevant.
- For a successful discharge, it is important that the patient and family members are involved from admission to discharge. They should assist with goal setting, taught exercises and how to recognise signs that indicate escalation to a health professional and take part education sessions. This is important as they come in contact with the patient more regularly and are the ones who will be able to monitor his progress/deterioration closely.
- Energy expenditure for an amputee using a unilateral prosthesis is at least 62% greater for a transtibial amputee compared to someone without an amputation. This increase is further increased with a geriatric amputee. This fact is often easily overlooked due to the drive to push recovery and mobility post amputation. In Mr. A's case, this energy expenditure was further impacted by his physical deconditioning, respiratory and cardiac co-morbidities.
- Cognitive decline should be taken into consideration when dealing with the geriatric population. It is noted that cognitive decline is a limiting factor in prosthetic fitting/use, and strategies need to be put in place to address this. An effective strategy is assistance provided by carers and family members; this reinforces the importance of the inclusion of the family unit into the rehabilitation process of an amputee. The patient must be assessed and treated holistically to ensure the best outcome possible.
- Patrick L1, Knoefel F, Gaskowski P, Rexroth D. J Am Geriatr Soc. 2001 Nov;49(11):1471-7. Medical co-morbidity and rehabilitation efficiency in geriatric inpatients.
- Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation. Department of Veterans Affairs, Department of Defence. 2007.
- Aisling M Fleury, Salih A Salih and Nancye M Peel Rehabilitation of the older vascular amputee: A review of the literature Geriatr Gerontol Int 2013; 13: 264-273.
- Lower- Limb Prosthetics and Orthotics: Clinical Concepts- Aging with an amputation. Joan E. Edelstein, Alex Moroz M.D. Slack Incorporated. 2010, page 109.