Mrs L.S: XDR TB Below Knee Patient: Amputee Case Study

Title

Mrs L.S:XDR TB Below Knee Patient

Abstract

54 Year old female with Extreme Drug Resistant Tuberculosis (XDR TB) with and HIV positive status presents with a Right Below knee amputation due to Peripheral Vascular Disease and Type II Diabetes Mellitus.
Amputation done on December 2013 (19months post surgery) patient has been seeing physio once a month at the local clinic since then. She was then diagnosed with TB March 2015 and has been receiving physio once a week at the hospital. Patient shows signs of decreased (R) Hip Ext, balance issues and global weakness

Key Words

  • Below knee amputation
  • Diabetes
  • South africa
  • Tuberculosis
  • Hip ROM

Client Characteristics

Ms L.S is a 54 Year old female with Extreme Drug Resistant Tuberculosis (XDR TB) with and HIV positive status presents with a Right Below knee amputation due to Peripheral Vascular Disease and Type II Diabetes Mellitus.
She comes from Khayelitsha which is a disadvantaged area in Cape Town, South Africa.
She previously worked as a cleaning lady for 30 years and has 4 children and 3 grandchildren.
She lives in a shack with her 2 children and 3 grandchildren, her husband passed on 3 years ago from TB.
She receives a government disability grant every month.
She has a grade 7 education level.
She is a smoker (15 a day), non-drug user and drinks socially.

Amputation done on December 2013 (19months post surgery) when doctors noticed she had gangrene in her right lower limb. Patient has been seeing physio once a month at the local clinic since then.
She was then diagnosed with TB March 2015 and has been receiving physio once a week at the provincial TB hospital. Patient shows signs of decreased (R) Hip Ext, balance issues and global weakness.

Examination Findings

Active ROM:

  • Decreased (R) Hip Extension: 12degrees
  • (L) Hip ext: 30 degrees
  • All other joints normal
  • Passive ROM:
  • Decreased (R) Hip Extension: 15degrees (end feel muscle spasm of hip flexors)
  • (L) Hip ext: 32 degrees
  • All other joints normal

Muscle Power:

  • (R) Hip Extension: Grade 2
  • General muscle strength Grade 3 in upper limb and lower limb

Palpation:

  • Tightness of (R) hip flexors
  • Passive hip flexor stretch is uncomfortable for patient (4/10 VAS pain scale)

Able to mobilize 40m on crutches before fatigue sets in.

ICF DIAGRAM:[1]

1) IMPAIRMENT
Decreased (R) Hip Extension
Poor standing and dynamic balance in standing
Weakness of (R) Hip extensors (grade 2)
Generalised weakness of upper and lower limb muscles

2) ACTIVITY LIMITATION
Walking independently with crutches
Stair climbing

3) PARTICIPATION RESTRICTION
ADL's: interacting with friends and family
Working as a domestic cleaner.
Looking after grandchildren: carrying, cleaning, cooking.

4) ENVIRONMENTAL
Lives in a shack (small informal housing thats the equivalent of 1 bedroom/bachelors) with 2 of her children and 3 grandchildren

5) PERSONAL
Has some support from children, income mostly dependent on grant.
Husband passed away recently

PATIENTS GOAL:
Be able to mobilise independently and safely with crutches and strengthen enough to fit into the criteria in order to apply for a prosthesis at a tertiary government hospital, as well as to return to work some day.

Clinical Hypothesis

Main problem:

  • Balance and strength
  • Decreased (R) Hip Extension
  • Poor standing and dynamic balance in standing
  • Weakness of (R) Hip extensors (grade 2)
  • Generalised weakness of upper and lower limb muscles

Intervention

  • Crutch education
  • Gait re-education
  • Education on minimum of 20min prone lying daily
  • Soft tissue release on hip flexors (massage)
  • Dry needling of hip flexors
  • Hip flexor stretches 30x3 twice daily
  • Hip extensor with manual resistance 10x3
  • Triceps strengthening
  • Core strengthening to improve balance
  • Mobilizing in parallel bars
  • Sit to stand exercises
  • General endurance - increasing distance at every session
  • Education of importance of exercise.
  • Education on Tuberculosis, Diabetes, good eating habits, dangers of smoking.

Outcome

Patients strength of her hip extensors improved to a grade 3 after 4 weeks of physiotherapy and her general strength has improved to a grade 4.
She still has some hip flexor tightness but this will improve with time.
Her balance has improved and is now able to mobilise 100m before fatigue sets in.

Patient unfortunately is not very diligent with her home exercises, and there is only so much a therapist can do even with the a lot of persistent education.

Discussion

Mrs L.S would ideally like to return to work to support her family, but this is very difficult due to her occupation. She will not be able to work well as a domestic cleaner if she is on crutches. Additionally, prosthetics is very difficult to come across in South Africa; when applying for one there's a lot of difficult criteria that needs to be fulfilled before one is able to be issued with one. Mrs L.S is not diligent with her home exercises which means that she won't be strong enough to meet the criteria needed. Her age and co-morbidities also put her at a disadvantage because XDR TB is very difficult to treat.

Thus people that cannot afford to pay for their own prosthetic will most likely not be able to get one unless the criteria is fulfilled. Prosthetics are a luxury and many patients end up adapting and carrying on with their ADL's in wheelchairs or crutches.

References

  1. WHO ICF Model