Mr C: Amputee Case Study


Original Editor - Terri Nuccio-Youngs

Title

Mr C: Amputee Case Study

Abstract

Mr. C is a 56-year-old Caucasian male who underwent a left TTA. He sustained an anterior myocardial infarction (MI) while in recovery after the amputation and was also newly diagnosed with Factor V clotting disorder. His amputation occurred in another facility and he was transferred to our hospital for rehabilitation. Mr. C worked very diligently in physical therapy both pre prosthetic and during prosthetic gait training. Mr. C also had very strong emotional issues with the loss of his limb but in the end he was able to accept his amputation and was a successful prosthetic user.

Key Words

Trans-tibial, cardiovascular, grief, instability, crutches, prone lying

Client Characteristics

Demographic Information: Mr. C is a 56-year-old Caucasian male who is newly widowed, his wife expired one month ago from an MI. He was married for 33 years. He has two children, twin sons who are 29 years of age. His parents are deceased and he has two brothers and a sister. He is a Methodist and is very involved in his church. Primary language is English. He is unemployed and is a retired Private Investigator. He graduated from Virginia Tech and has a Bachelors degree in Business Administration. Co-morbidities/Medical history: DM, PVD, osteoarthritis and HTN, knee surgery for cartilage repair, with chronic instability right knee, LBP, left ulnar nerve transposition in 2001, Hyperlipidemia, CAD with ejection fraction of 25-30%, cardiac catheterization and stent placement. Previous functional status and treatment: Mr. C was independent in all self-care activities prior to his amputation. He ambulated without an assistive device and used his knee brace. He was seen previously for Low Back Pain (LBP) with a successful treatment series.

Examination Findings

  • He stated he is worried about not being able to perform the same activities after his amputation, like helping out with the Boy Scouts.
  • Long term goal: Independent using a prosthesis with forearm crutches 500' in 12 weeks.
  • Short term goals: Independent ace wrapping, transfers in 1 wk. Prone lying for 2 hours/day, amputee exercise program x 30 reps, improve lower extremity MMT by one half grade, ambulate 25' with standard walker with contact guard assist in 2 wks.
  • Self Report Outcome Measure: Houghton Scale of Prosthetic Use-Initial score 0 and discharge a 7 [1]
  • Physical Performance Measure: Functional Independence Measure-initial score 81 discharge score 105
  • Body Functions: Cardiovascular Blood pressure 117/78 Pulse 67 Pain residual limb pain-2 occ phantom sensations. Integumentary Residual limb healing, staples intact, bilateral dog ears.
  • Sensation intact residual limb, Right leg to Semmes Weinstein monofilament.
  • Musculoskeletal Height 5'11" Weight 204lbs BMI is 28.5-overweight.
  • Manual muscle test NL except:Left shoulder abd 4+,Right wrist ext 4+ Bilat Hip flx 4- Left knee ext 4+ ROM NL including Thomas Test.
  • Neuromuscular Sitting balance good Standing balance poor.
  • Stand pivot transfers,contact guard assist.
  • Bed mobility independent.Gait not tested.
  • Impairments-Motor Function,Locomotion and Balance Associated W/Amputation.[2]
  • Activity Limitations- Right knee instability,recent MI Participation Restriction- none Environmental Factors-2 story home,bath,bedroom on 2nd floor,steps to enter

Clinical Hypothesis

Mr. C is a 56-year-old diabetic with a recent left TTA (trans-tibial amputee) with a newly diagnosed clotting disorder. He presents as an excellent rehabilitation and prosthetic candidate. He is cooperative and motivated despite his very recent loss of his wife of 33 years. In general he is overweight, doesn't exercise regularly but has good glucose control. He needs to improve overall strength and endurance, heal and shape his residual limb to prepare for the prosthetic fitting. Due to his recent MI, he will need blood pressure and pulse monitoring while performing pre-prosthetic and prosthetic activities.

Intervention

Treatment began with amputee exercises as Mr. C did not have his right knee brace and was unable to ambulate. Prone lying, gradually increasing the time. Upper body strengthening and UBE for aerobic conditioning. Ace wrapping his residual limb. Progression by adding repetitions, weights or time to the activity. Patient education in: glucose control, weight loss and aerobic exercise. An intervention that is not commonly performed by physical therapists but was crucial to Mr. C, was talking about his losses. He was a very verbal person and more than one session was spent listening to him and actually letting him cry. Losing his limb, his wife and discovering that he has a clotting disorder was very stressful and venting was an important intervention for this particular patient. A fellow amputee provided additional support by visiting him during therapy.
Prosthetic training began as an outpatient. He was fitted with a Triple S (silicone suction suspension) total contact socket with audible locking pin and a College Park Tribute foot. He quickly mastered the balance, weight shifting and step in place preliminary exercises with the prosthesis. Gait began in the parallel bars, using a three-point gait pattern and progressing to a four-point and then two point pattern. He used forearm crutches in a two-point gait pattern outside the parallel bars. He achieved independence on ramps and stairs and floor transfers.

Outcome

Mr. C achieved all of the established goals and after intensive gait training was seen every two weeks for follow up sessions for 3 additional visits. Gait training on uneven terrain was accomplished and he then progressed to a single crutch. Currently he is a community ambulatory and wears his prosthesis all day, but continues to ambulate with a straight cane due to his knee instability on his contralateral limb. He can walk short distances or in his home, without the cane. He has had no skin break down on his residual limb. Mr. C continues to volunteer with the boy scouts and participates in weekend camping trips.

Discussion

Mr. C was a very motivated patient and despite all his medical issues conquered his impairments, worked through the grieving process and is a functional community prosthetic wearer. I think the most notable difference as compared to all my other amputee patients was his need to discuss his amputation and actually cry and show his feelings while in physical therapy. This was difficult for me as I had never had such an expressive patient and I learned to work on my listening skills! In the literature the Amputee Coalition has the most in depth discussions, services and education about grieving after limb loss. They offer support groups throughout the country and provide an excellent magazine with helpful articles.[3] The impact on clinical practice would be to draw awareness to be sensitive to the loss that all our amputees experience but to provide hope and encouragement that they can improve and function in the community.

References

  1. Mary Jane Cole,Jane Cumming,Nancy Golland,Sue Hayes,Chantal Ostler, Judy Scopes ,Louise Tisdale. BRITISH ASSOCIATION OF CHARTERED PHYSIOTHERAPISTS IN AMPUTEE REHABILITATION. BACPAR TOOLBOX OF OUTCOME MEASURES. Version 2. Found at: http://apfisio.pt/gifpa/wp-content/uploads/bsk-pdf-manager/9_TO OLBOX_OUTCOME_MEASURES_-_BACPAR_2014.PDF
  2. Guide to Physical Therapist Practice/Second Edition. Revised June 2003. American Physical Therapy Association.
  3. Saul Morris, The Psychological Aspects of Amputation. Found at: www.amputee-coalition.org/first.../psychological-aspects-amputation.