Mr N's journey to meaningful recovery: Amputee Case Study

 Title

Mr N's journey to meaningful recovery

Abstract

Mr N was an independent elderly gentleman who enjoyed preparing a cup of tea for his wife each morning and walking unaided a short distance from his seaside cottage to take in the view of the ocean. He had peripheral vascular disease (PVD) and non-healing ulcers on his left lower limb which led to him having a transfemoral amputation. Mr N was a motivated patient who worked diligently throughout his course of rehabilitation. Mr N achieved prosthetic success, he not only regained the ability to prepare a cup of tea for his wife, he also returned to walking with his prothetic limb.

Key Words

geriatric, transtibial, peripheral vascular disease, prosthetic, rehabilitation

Client Characteristics

Mr N's an 82 year old male retiree who was admitted to hospital with increasing difficulties with bilateral leg ulcers on background of PVD. On the 13/6/15 he had a L) transfemoral amputation.
His past medical history included PVD, vasculitis, leg ulcers, IHD, hypertension and osteoarthritis.
His past surgical history included debridement of leg ulcers in 2014; left and right fem pop bypasses 2012; a right leg split skin graft in 2012; a AAA 2011 and a coronary artery bypass graft 2011.
Mr N lived with his wife in their own home with a single threshold step and no rail.
He was previously independent mobile without an aid up to 100m he was limited by L) calf pain. Mr N was independent with all his activities of daily living (ADLs). He enjoyed pulling weeds in his rose garden and watering three times a week. He also enjoyed playing lawn bowls once a fortnight.
Mr N denied having had any falls prior to his hospital admission. Prior to his hospital admission he was receiving Anglicare three times a week for ulcer care and dressings.

Examination Findings

Subjective:

Goals-Short term: Independent transfers + self-propel WC- 1 week post-op
Long term: Independently make a cup of tea in standing + Independently mobilise 100m including uneven terrain with his prosthetic limb, on discharge from rehab.
Pain: moderate to severe in residual limb for 2 days post-op, minimal pain since then. Nil phantom sensation/pain
Dizziness/ lightheadedness on transferring from lying to sitting for 2 days post-op, nil further episodes. According to Rutan et al (1992)[1] there is a higher prevalence of orthostatic hypotension associated with aging.
Perceived exertion: regularly monitored using the Borg scale of perceived breathlessness. He didn't exceed ""somewhat hard"" level of intensity throughout his therapy.

Objective:
Respiratory assessment pre+ post-op unremarkable
Skin: wound was healing well initially. Four weeks post-op wound became infected and 2 courses of antibiotics were required.
Functional ability: transfers + bed mob + WC mobility Ax regularly
Strength- 4s + 5s ROM- fair
Also regularly monitored blood pressure, heart rate, respiration rate, and gait speed e.g. the 2 minute walk test
Activity Limitations- inability to weed the garden
Participation Restrictions-inability to do lawn bowls (for the first 9 months post-op) Returned to lawn bowls with an assistive device thereafter.
Environmental Factors included inability to access non-wheelchair accessible area. With the ramp installed at his home he was able to access his home"

Clinical Hypothesis

Initially it was unclear whether Mr N would be a good prosthetic candidate. He was motivated and had good strength and ROM however his past medication history, exercise tolerance and condition of his right lower limb required careful consideration. He was reviewed at the Amputee multi-disciplinary clinic to decide if he was medically safe to use a prosthesis. It was decided that a light weight prosthesis would be trialed to decrease the energy demand required to mobilise. His wound infection delayed the initial phase of his recovery somewhat however Mr N used that time to further improve his strength and exericise tolerance.

Intervention

  • Education re: wound management; rehab process; pain management; stump care, oedema management, prevention of contractures
  • Immediate post-op management- positioning, breathing + A/PROM exercises, bed mobility and transfer training

Outcome

Mr N is among a small percentage of the geriatric amputee population who achieved prosthetic success (Fleury et al., 2013)[2]. Mr N had a comfortable fit in his prosthetic limb. He not only regained the ability to prepare a cup of tea for his wife independently in standing, he also returned to walking independently with his prothetic limb and a walking stick 100m, so he was able to take in the ocean view each day once more. He returned to bowling with an assistive device called a "bowling arm" and although he wasn't able to return to getting down to weed his rose garden he was able to access the garden in his wheelchair via the ramp access from his home. He enjoyed spending time with his wife sitting in the garden area and watering the roses.

Discussion

Mr N was a geriatric amputee and as is often the case with the geratric population he had a number of co-morbidities effecting the health and function after his amputation. Considering the increased energy expenditure for an amputee walking with a unilateral prosthesis is at least 120% greater for a transfemoral amputee as compared to normal gait, Mr N managed a remarkable outcomes as detailed above (Fleury et al 2013)[3]
In light of this, geriatric amputees with multiple co-morbidities should not be overlooked as prosthetic candidates. Certainly factors such as motivation, cognition and exercise tolerance need to be carefully considered. Case by case evaluation of geriatric amputees by a multidisciplinary amputee team is certainly imperative to ensure patients are medically safe and they are able to return to meaningful activities and optimise function.         [4]

References

  1. Rutan G.H, Hermanson B, Bild D.E, Kittner S.J, LaBaw F, Tell G.S. Orthostatic hypotension in older adults. The Cardiovascular Health Study. CHS Collaborative Research Group.1992; Jun;19:508-19.
  2. Fleury A.M, Salih A, Peel, N.M. Rehabilitation of the older vascular amputee: A review of the literature. Geriatr Gerontol Int. 2013; 13: 264-273
  3. Fleury A.M, Salih A, Peel, N.M. Rehabilitation of the older vascular amputee: A review of the literature. Geriatr Gerontol Int. 2013; 13: 264-273
  4. Fried, L.P, Ferrucci, L, Darer, J, Williamson, J.D, Anderson G. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care. Journal of Gerontology. 2004; Vol. 59, No. 3, 255-263