Mr. W. A Bilateral Below Knee Diabetic Amputee: Amputee Case Study

Title

Mr. W. A Bilateral Below Knee Diabetic Amputee

Abstract

Mr. W. is a bilateral below knee amputee who developed Type II diabetes after his most recent amputation. The following is a case study of his journey through an outpatient physiotherapy setting and his reintegration into society.

Key Words

below knee amputee, diabetes, cardiac complications, bilateral

Client Characteristics

Demographics:


  • Mr. W: a 65 year old male retired from the pipefitting industry.
  • Previously a semi -pro football player in the Canadian Football League and body builder.


Medical Diagnosis:


  • Bilateral Below Knee Amputee

    • Left - 19 years ago

    • Right - October, 2014

  • Both prosthesis are partial surface bearing prosthesis with silicone sleeves and locking pins


Co-morbidities:


  • During his most recent hospital stay and amputation this patient was diagnosed with type II diabetes.

  • Also during his hospital stay he developed congestive heart failure post-operatively.

  • Otherwise this is a healthy man with no other co-morbidities.

Previous Care or Treatment:


  • This patient underwent rehabilitation 19 years ago for the Left BKA and successfully reintegrated into society and functional activities.

  • Most recently this patient stayed in an acute care hospital for approximately 4 weeks following his right BKA. His length of stay in acute care was extended secondary to developing congestive heart failure post-operatively to ensure he was medically stable.

  • He was then discharged home and referred to outpatient physiotherapy where I have currently been treating him.

Examination Findings

  • 19 years ago in an industrial accident shattered his left leg after a 30 ft fall. Developed osteomyelitis, and had left leg amputated below the knee.

  • In October of 2014 developed osteomyelitis and had to have right leg amputated BK.
  • Diabetic Education Sessions

  • Self Report Outcome Measures:

    • Numerical Pain Rating Scale (NPRS) right residual limb 0/10 at best and 3/10 at worst.

    • The Activity Specific Balance Confidence Scale - UK (ABC-UK) - 55%

Objective : Physical Examination Tests and Measures


  • Sensation: Reduced throughout the distal aspect of the right residual limb. Left residual limb was WNL

  • ROM/Muscle Length:
UE - WNL
, LE
,Left - WNL except mild contracture/shortening is noted in the hip flexor
, Right - Mild-mod contracture is noted in the hip flexor and hamstrings

  • LE Strength
: Left - all movements of hip and knee are 5/5 on manual muscle testing (MMT)
, Right - 4 to 4+/5 throughout
oUE Strength - all WNL bilaterally


Functional Mobility:


  • Bed Mobility - all independent - but slow and cautious

  • Sit - Stand and transfers- independent with use of hands

  • Gait Analysis
 With Rollator walker (RW) independent, the patient has very flexed trunk posture. The right LE is externally rotated,

  • Physical Performance Measures:

    • Amputee Mobility Predictor - bilateral: 26/47

    • Berg Balance Scale: 37/56

    • 2 min walk test : with RW 66m mild to moderate SOBOE is noted
    • 6 min walk test: unable to perform due to deconditioning

    • TUG: 18.5 s with RW

Clinical Hypothesis

This gentleman is learning to adjust both psychologically and physically to the fact that he now is a bilateral below knee amputee. He functioned very well for 19 years being a single limb amputee. He presents with some adjustment issues psychologically, as the process of undergoing the second amputation has been more difficult than he expected, and what he has been able to do physically has been much harder. He also now has to deal with other issues related to the development of diabetes.

Functionally the main goals are to reduce the contractures in the lower extremities, increase strength particularly in the gluteals bilaterally, improve his balance, improve confidence and ease of movement in bed mobility, become independent with ambulation with a single point cane for short to moderate distances, and with the rollator walker for longer distances, and to be able to be independent x 13 stairs with 1 railing and the single point cane. Because of the cardiac issues and deconditioning that he presents with, it is also a goal to improve his cardiac fitness and endurance.

Intervention

  • Education regarding limb inspection with mirror, reduced sensation, importance of bed exercises at home on a daily basis, peer support etc.

  • ROM/Stretches - prone on stomach, up on elbows, with pillow underneath leg; hamstring stretches, Hip adductor stretches
  • Strengthening exercises - supine SLR, QOR, bridge, Sidelying hip abd/add, prone hip ext, standing hip abd/ext, all weighted depending on tolerance
  • Gait Training
oIn parallel bars working on forward, backward, sideways, tandem walking, over rolls, mats

    • With RW working on pattern of gait and correcting deviations mentioned above and building up endurance progressing to around obstacles and ramps.

    • With SPC working on building confidence and independence with the SPC and progressing to ambulating on uneven surfaces, around/over obstacles, curbs, ramps

  • Stair Training with single point cane and one rail, as well as training in and outside of parallel bars for 4, 6, 8" step heights with only the SPC.

Outcome

Subjective:


  • NPRS 0/10 at best, 1/10 at worst for the right residual limb

  • ABC - UK 90%

  • Mr. W reports a much improved confidence in his abilities and is happy that he has been able to resume the activities functionally that he wanted to be able to perform even though it took him longer than he hoped it would.


Objective:


  • Sensation: still reduced but Mr. W. shows good understanding of the importance of daily visual inspection with a mirror for this reason.

  • ROM/Muscle length: LE - left WNL, right very slight increased tone in hip flexor only, hamstring is WNL

  • Muscle Strength: Bilateral LE 5/5 throughout
•Functional Mobility:
oBed mobility - all independent and demonstrates confidence and ease of movement

    • Sit - stand - independent with no hands

    • Transfers - independent with minimal use of hands without gait aid

  • Gait analysis: with RW or SPC independent, Mr. W demonstrates a normalized gait pattern. He is much more extended through the trunk. Occasionally with fatigue he still externally rotates the Right LE but otherwise demonstrates a good pattern.

  • Stairs: performs 15 stairs with 1 rail and SPC independent minimal SOBOE evident.

  • Physical performance Measures:

    • Amputee Moblitiy Predictor - bilateral; 42/47

    • Berg Balance Scale: 49/56
    • 
2 min walk test: 150 m with SPC no SOBOE observed

    • 6 min walk test: 415 m with RW mild SOBOE observed

    • TUG: 11s with SPC

Discussion

Mr. W's case is a somewhat unique one in the fact that he had both legs amputated and then found out that he was diagnosed with diabetes. However, given the fact that his right leg did develop a small sore on it that developed into osteomyelitis, it makes me wonder if he was an undiagnosed diabetic prior to the actual event that caused amputation of his remaining limb.

As Pecoraro et al have found in most cases an episode involving minor trauma caused cutaneous injury, and preceded 69-80% of amputations in diabetics.[1] Mr. W. did have some adjustment issues initially as he struggled with the loss of his second leg, and the difficulties he experienced through this process.

Initially when I first started working with Mr. W. he was probably in the "depression" phase of grieving for his limb. However, the fact that he was very motivated, and had a strong work ethic allowed him to overcome this and move into the "acceptance and hope" stage as written in the article by Saul Morris.[2]

Mr. W. made significant improvements in all aspects of outcome measures both subjective and objective. Objectively, the fact that he improved from a score of 26/47 to 42/47 on the Amputee Mobility Predictor-bilateral (AMP-B) is quite significant. This outcome measure was selected given the fact that Mr. W is a bilateral amputee and there has been work to show that the AMP-B provides a more accurate assessment of the functional capabilities of Service Members with bilateral lower limb amputation.[3]

References

  1. Pecoraro RE, Reiber GE, Burgess EM., 1990, Pathways to diabetic limb amputation. Basis for prevention., Diabetes Care. 1990 May;13(5):513-21.
  2. Morris, Saul, 2003 The psychological aspects of amputation. Taken from http://www.amputee-coalition.org/first_step_2003/psychological-a spects-amputation.html July 12, 2015.
  3. Raya MA, Gailey RS, Gaunaurd IA, Ganyard H, Knapp-Wood J, McDonough K, Palmisano T. 2013 Amputee Mobility Predictor-Bilateral: A performance-based measure of mobility for people with bilateral lower-limb loss., Journal of Rehabilitation Research and Development. 2013; 50 (7): 961-968.