Mr. T. (right BKA): Amputee Case Study


Original Editor - Connie Routhier

Title

Mr. T. (right BKA)

Abstract

Mr. T. is a 64 year old male who attended 2.5 months of intensive rehabilitation to learn to walk again after being immobile for more than a year. Mr. T. was a diabetic whose right foot became infected after having a wound on his fifth toe. Mr. T. as a result had a below knee amputation which resulted in poor wound healing and another infection in his residual limb. He required debridement of the wound and 3 months after his surgery his incision site had healed so that he could begin walking again.

Key Words

Transtibial amputation, diabetes, multiple co-morbidities, poor functional mobility prior to surgery

Client Characteristics

  • Mr. T. is a 64 years old male who is on long-term disability.
  • He was previously a heavy machine operator.
  • He lives in a two storey house with his wife and has no intention of moving.
  • Mr. T's wife works full-time and is not at home during the day.
  • For the last year Mr. T. has been house bound and falling several time a day. He was mostly sitting in his lazy boy chair at home on the main level and even sleeping in it as he was too afraid to do stairs. Essentially he has been non-ambulatory for about a year previous to his admission to hospital.
  • In February 2015 Mr. T. was admitted to hospital for a diabetic foot, which then became gangrene and as a result he had a right below knee amputation at the beginning of March 2015.
  • Mr. T. also has the following co-morbidities:
  1. Diabetes

  2. Chronic Kidney disease (pre-dialysis)

  3. Obesity

  4. Hypertension

  5. Hypertensive nephrosclerosis

  6. Peripheral vascular disease

  7. BPH

  8. Recurrent falls

  9. CHF

  10. COPD

  11. Peripheral neuropathy

  12. Strokes (2008, 2014)

  13. Ex-smoker (50 pack year history)

  14. Left rotator cuff tear (as a result of his falls at home)
  • Previous to Mr. T's admission to hospital he was receiving home care nursing to address his leg wounds including the ones on his right foot. When he became febrile and the wound was becoming worse the home care nurse suggested he go to hospital.

Examination Findings

As a result of one year of immobility and a right BKA it took 3 people and a hoyer to transfer MR. T. Patient was totally dependent on nursing staff for his self-care. The patient reported that his goal was to be able to independently toilet himself, independent bed mobility, ambulate with a rollator, be able to go up and down his stairs and to get onto his deck so that he could BBQ.

  1. No contracture of his knees

  2. Decreased active range of motion of his left shoulder
  3. Unable to sit unsupported

  4. Ax4 to stand with High Wheel walker, initially able to stand 10 seconds. Patient was not able to hop on his unaffected leg.
  5. Poor healing of wound. The prosthetist provided the patient with a gel liner that he was able to tolerate and it helped to shape his residual limb)

  6. Strength testing demonstrated upper and lower extremity strength as a 3/5

ICF Findings[1]: Body Function and Structures

  1. Primary: Lower limb below knee
  2. Decrease strength and mobility

Activity Limitations:

  1. Decreased bed mobility

  2. Decreased ability to transfer bed to wheelchair
  3. Unable to ambulate

  4. Unable to perform basic self care activities

  5. Unable to get in/out of house, unable to perform stairs

Participation Restrictions


  1. Unable to BBQ on outdoor deck in backyard

  2. Unable to get out of home to visit friends in neighborhood

Environmental Factors/Personal Factors

The patient wanted to return home asap. Not working.

Clinical Hypothesis

The patient had multiple co-morbidities decreased mobility function prior to his amputation. Although the patient according to the guidelines[2] is not a prosthetic candidate his motivation and his realistic goals were worth pursing the possibility of him becoming an indoor ambulatory. Therefore the team including the patient despite the difficulty of re-learning to ambulate would proceed with have the patient fitted for a prosthesis.

Intervention

Mr. T. 1 to 2 hours of physiotherapy daily (5x/week) which consisted of:

  1. Wheelchair with amp board.
  2. Transfer training
  3. Unable to lie prone due to his obesity.
  4. Exercises. Upper and lower extremity and trunk strengthening,
  5. Stand with a high wheeled walker. Initially he could not extend his hips and had a flexed posture and mainly was weight bearing through his arms with the walker. Eventually he was able to maintain an upright posture and stand for 5 minutes.

  6. Prosthetic and stair training,[3]
  7. Mr. T. he didn't want to practice ambulating outside He said his balance was poor after his 2 strokes and was going to rely on his scooter, he was happy that he could walk indoors and did not want to progress his ability to ambulate outdoors.

  8. Education including taking care of his prosthesis and socks, don/doffing his prosthesis, home exercise program, residual limb care and proper foot care of his left foot.

  9. Mr. T was morbidly obese and as a result education on getting up from the floor was not attempted. It was felt that due to left shoulder injury and the patient being overweight that he would not be able pull himself up to sit or stand should he fall. It was suggested that he get a life line however the patient was only willing to carry a cell phone on himself when he was home alone so that he could call 911 should he fall.

Outcome

  1. Mr. T. was able to get in/out of bed independently without assistance

  2. He learned to don/doff his prosthesis independently, including understanding when to add socks.
  3. He is still learning to take care of his prosthesis and socks (his wife has taken over this duty)

  4. He was able to sit to stand independently

  5. He was able to ambulate 20 meters with a 2 wheeled walker and 10 meters with a rollator. He has a 2 WW on the second floor of his home and a rollator on the main level so he can use the seat as a tray to carry drinks/food for himself when he is home alone.
  6. Indpendent going up and down stairs using two handrails (13 steps)
  7. Mr. T was discharged home July 10, 2015 with CCAC supports: Personal support worker (PSW) 2x/day (maximum service provided) OT for home safety and home PT to progress mobility, strength and balance.
  8. His lower and upper extremity strength increased to 4/5 and his left shoulder range of motion for flexion and abduction was 110 degrees.

Discussion

Mr. T had a total of 4.75 month stay in the hospital, 2.5 months of which were spent in intensive rehabilitation. If the guidelines were followed for determining if Mr. T were a candidate for a prosthesis then Mr. T would have gone home is a wheelchair and would have become depressed.

His main goal was to get outside onto his back deck and BBQ. I was not able to ascertain this however, in my discharge note to the CCAC PT I communicated the patient's goal so that they could ensure that the patient was indeed able to BBQ. Instead Mr. T was able to transfer independently and ambulate short household distances which was his main goal. During the patient's stay in hospital he became quite angry and combative with the therapist.

Mr. T was also saying that he would not be able to get back home and was depressed by this notion. Once a discharge date was set concrete goals made his mood became better. It was requested by the team for Mr. T to see a psychologist [4] while in hospital, however the doctor did not feel this was necessary and since the referral can only be made by the doctor Mr. T did not receive this service.

In reviewing the literature it was certainly evident that a rigid or semi-rigid dressing is the best evidence for reducing edema after surgery. [5]Our vascular surgeons currently use tensor bandaging or compression bandages. Our prothetist uses the gel line to help with the shaping process. I am currently unsure how to go about changing this.

References

  1. Assessment of the Amputee; "Assessment for Suitability for a prosthesis". Physio-Pedia.com
  2. Assessment of the Amputee; "Assessment for Suitability for a prosthesis". Physio-Pedia.com
  3. Therapy for amputees, 3rd Edition, Edited by Barbara Engstrom and Catherine Van de Ven
  4. The rehabilitation of people with amputations. Psychological adjustment. Who textbook Chapter 2.3 (pg 19-21)
  5. Guidance for the multi disciplinary team on the management of post- operative residuum oedema in lower limb amputees.