Mr. H: Amputee Case Study

Title

Mr. H: Amputee Case Study

Abstract

This case study will focus on an elderly gentleman Mr. H, a 92yo man admitted for inpatient rehab post left AKA for critical ischaemia of the left foot. Mr. H initially was not for prosthetic rehab but during the course of his admission he made significant gains in strength and functional independence and broached the topic with the team. When considering the factors necessary for prosthetic rehab as detailed in the Physiopedia 'Assessment of the amputee' [1]resource, Mr. H met the criteria and despite the opposing factors of age and comorbidity went forward with prosthetic fitting.

Key Words

Transfemoral, elderly, pre-prosthetic, cardiac, comorbidities, equal-opportunity

Client Characteristics

Mr. H is a 92 year old retiree.

Medical diagnosis: L trans-femoral amputation due to critical ischaemia with distal tissue loss. Previous 4th and 5th toe amputations 3 months earlier with slow wound healing.

Comorbidities: Previous L 4th and 5th toe amputations, L popliteal bypass and femoral endocardectomy, hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, ex smoker, aortic stenosis.

Previous care/treatment: Mr. H presented to the emergency department of one of the large acute hospitals in our region with a painful, reddened L foot that he was unable to weight bear on. He was assessed by medical staff and was admitted for surgical review. Due to the acute nature of Mr. H's limb deficiency the decision to amputate was made quickly with little chance to prepare Mr. H for the reality of the amputation. Post-operatively Mr. H received standard care and his wound healed well with no complications.

Examination Findings

  • Prior to his admission to hospital, Mr. H was living alone in a unit he owned. Retiree, Scottish migrant and widower, he had 3 supportive sons. He was independent with all PADLs and received cleaning assistance and meals on wheels (meal delivery service).
  • He was independent with shopping.
  • Despite his functional independence prior to his most recent hospital admission, Mr. H had made the decision to enter residential aged care.
  • Mr. H reported his current issues to be difficulties in transferring, moving around in bed and managing daily tasks. He did not complain of any pain in his stump, phantom pain or stump sensitivity.
  • He did however report phantom sensation of his amputated foot.
  • From a psychological perspective Mr. H scored low for depressive symptoms on the patient reported health questionnaire.
  • Main goals were for independent tfs and ADLs.
  • Outcome measures DEMMI 27/100 (non-amp specific), AMPnoPro 14/43.
  • Function: all bed mobility independent, SBA for lie to sit using overhead bar, MA bed chair T/f to R, L=unable. Sit-stand 1xLA at rail. OE: Mr. H had full AROM with 5/5 power bilaterally in his UL'S AND remaining limb. In the amputated L limb Mr. H had 95° hip F, 30° Abd, 0° E, 10° Add.
  • Distal his stump was observed to be slightly bulbous but did not measure >5 cm increase in circumference. There was no tenderness to palp of the scar which was fully healed and he was able to tolerate end pressure without pain. There was some adhesion of the scar to the distal femur.

Clinical Hypothesis

At the time of my initial assessment Mr. H presented quite well. My main concerns were functional ones as Mr. H learned to rely on his remaining limb for transfers and standing. His comorbidities were stable and he appeared to be dealing well psychologically from the loss of his leg. When prosthetic rehab was broached I was initially concerned with the increased energy expenditure for a man in his 90s with a history of hypertension and vascular disease. My next thought was how we were going to be able to prepare the stump to be able to fit a prosthesis.

Intervention

  1. Mr. H was started with a general strengthening program similar to those detailed in Engstrom [2]. He attended 2 hour long therapy sessions a day completing a mix of bed and functional exercises including at least 15 mins of prone time.
  2. Mr. H commenced transfer training particularly sit to stand and bed to chair. Initially Mr. H struggled with the anterior weight shift necessary to complete a successful bed to chair pivot.
  3. Sitting and standing balance training. After a few days of this Mr. H could complete 54 seconds standing without upper limb support.
  4. After it was decided that Mr. H would be for prosthetic rehab he was commenced with a stump bandaging routine then fitted with a shrink er (limited supplies initially).
  5. We did not have access to an early walking aid but if I did this would have been something I would have tried at this point to get an idea of Mr. H's ability to tolerate weight through his residual limb.
  6. Throughout the whole process Mr. H was very receptive and engaged in learning how to manage his stump. He was careful to wash his stump daily and was diligent at checking his wound site especially once the shrinker was applied

Outcome

I am currently still working with Mr. H and he will soon be discharged to a residential care facility and will continue his prosthetic rehab in the outpatient setting Mr. H is now able to complete all bed mobility, lie to sit, sit to stand and bed to chair transfers independently. He is able to complete a full stand and pivot to the left and right when moving from surface to surface and is able to get in and out of a car. Mr. H is hopeful of returning to driving when he discharges however at this point he will need someone to help get his wheelchair in and out of the car as he is unable to manage this independently.

Mr. H is happy with his discharge destination and feels that at his age that having support around him is prudent. His family is very supportive of this decision as well as that to explore prosthetic options. Mr. H did not have any falls or complications as an inpatient. Mr. H has currently just been fitted by our prosthetist as is awaiting first fit

Discussion

Mr. H's case is a relatively uncommon presentation in our rehab ward. Most of the patients we have coming through with amputations are over 65 but most are trans-tibial and not as physically able as Mr. H. Referring to the Physiopedia page 'Assessment of the amputee'[1], most of these patients are fitted with prostheses purely to assist with transfers.

Mr. H was a difficult case as the drive for prosthetic fitting was patient centered and would have significantly increased energy expenditure and overall physical demand rather than lessened it. Keeping in mind the poor success rate of prosthesis use in older amputees, 36% as reported by Ferry et Al 2013 via the 'Older people with amputations' page on Physiopedia[3], the decision to support Mr. H in prosthetic rehab was even more difficult.

Coletta. E[4] also provides a good summary of the specific challenges of prosthetic rehab for the elderly patient as well as detailing each stage of amputee rehabilitation. Mr. H's case has highlighted the need for the use of more standardized protocols and procedures in our rehabilitation unit.As a new service, documents and guidelines are still being developed and as such each individual case has been considered in isolation from others. It would be more beneficial to draw on the wealth of resources out there to create a standardized approach so that each patient is given equal opportunity

References

  1. 1.0 1.1 'Assessment of the amputee' edited Julie Earle, http://www.physio-pedia.com/Assessment_of_the_amputee
  2. Engstrom, B and Van De Ven, C 1999, 'Therapy for Amputees', Churchill Livingstone. Gailey et al. 2002 , p120-149
  3. 'Older people with amputations' edited Rachel Walton-Mouw, http://physiopedia.com/Older_people_with_amputations
  4. Coletta, E 2000 'care of the elderly patient with lower extremity amputation', The Journal of the American Board of Family Practice, vol 13, no 1, Pp.23- 34.