Multiple Appendage Amputation in a 76 year-old Female: Amputee Case Study

Title

Multiple Appendage Amputation in a 76 year-old Female

Abstract

Amputations secondary to vascular disorders are the leading most cause of amputations. The elderly are the largest population that receive amputations; over 75% of all lower extremity amputations occur in the elderly[1]. Treating this population of elderly can cause difficulties not experienced in a younger population. This case study exams the physical therapy treatment of 76 year-old female with multiple upper and lower extremity amputations and her outcome.

Key Words

elderly, wound, depression, amputation, prosthesis, strength

Client Characteristics

The patient of interest is a 76-year-old female who presents to physical therapy (PT) for treatment of a recent left below knee amputation (BKA) secondary to peripheral vascular disease (PVD). Amputation was performed 1 year prior to entry into PT.

Pt has a complicated medical history including of R BKA 10 years ago. She has not worn her right (R) prosthesis for the past four years due to a MRSA infection at distal, inferior residual limb, which is healing. In addition, she has limited bilateral upper extremity (UE) use secondary to multiple finger amputations. at DIP joints on 2nd through 4th digits.

Other notable co-mordities and knee flexion contractors are HTN and hard of hearing and depression. The patient is retired ands lives at home with her husband. She has a full-time aide to help with activities of daily living (ADLs). She received multiple bouts of therapy for her right amputation, and was most recently at an inpatient facility for 3 months for her left amputation.

Examination Findings

  • The pt's chief complaint was inability to walk and pain. She was non-ambulatory since the L BKA. At home, she was independent with slide board transfers and used a chair lift to go upstairs.
  • Pt reported moderate to maximum to don/doff prostheses. L prosthesis is total contact with gel liner and pin suspension. Right prosthesis is a patellar tendon-bearing socket with external suspension via thigh cuff.
  • Pt presented with several L ROM impairments including -45 degree knee extension and -15 deg hip extension. Pt had -28 degrees right knee extension, and -8 degrees left hip extension.
  • Skin integrity was normal except a healing wound on R residual limb with dry scab. Strength for all B LE musculature was scored 3/5 or below. She needed mod to max assist for all bed mobility and maximum assistance to stance with platform walker and L prosthesis.
  • The only outcome measure performed was the AMP which was scored 4/47. No TUG or 50 ft TWT scores were recorded.
  • By ICF standards, her body structures and functions affected were skin, hands, knees, hips, and trunk musculature. Impairments were decreased strength, ROM, and sensation. Activity limitations are inability to ambulate, use stairs, move in bed, and getting out of a chair. Participation restriction includes: inability to don/doff prosthesis, driving, and ADLs. Environmental factors to consider are her 24-hour aides, 2-story house, and a high car. Personal factors are: depression and low motivation.

Clinical Hypothesis

The patient's main problem related to her goals for therapy is actually the wound on her older amputated leg, which is causing her not to be able to wear her R LE prosthesis as well as her age. Based on the patient's age, co-morbidities, and her emotional status, the hypothesis was that she would have difficulty achieving her ultimate goal of ambulating with B LE prostheses.

Intervention

The patient was treated for three months in the outpatient setting. She was treated twice a week for an hour each session. All aspects of treatment were covered working toward the main goal of the patient ambulating. Initially, a large focus was placed on wound management. The patient was immediately referred back to her vascular doctor for increased healing and clearance to wear R prosthesis again. Many mat exercises were given to strengthen her lower extremities, upper extremities, and core. She completed stretching and range of motion activities daily in PT sessions to maintain flexibility and in an attempt for better gait mechanics. Prone lying and prone exercises were stressed to improve flexibility.

After the patient progressed, standing activities were added. Since she did not have functional B grip, she utilized a platform walker to stand. She was still not able to wear her R prosthesis, so patient practiced sit to stands, static and dynamic standing, and hopping in all directions for transfers using L prosthesis only. Gait training was never attempted.

Pt education and caregiver training was greatly utilized throughout her treatment duration. All were given home exercise programs. All transfer training and standing was reviewed with her aides and husband so that it could be practiced at home to improved functional weight bearing strength.

Outcome

Throughout her 3 months of physical therapy, the patient made minimal gain in therapy. She had poor compliance with her home exercise program , and recommendations by this therapist throughout her treatment. She was very consistent with attendance and missed very few appointments. Her strength improved slightly. Bilateral hip abductor and hip extensor strength improved each by 1 muscle grade. Knee range of motion was unchanged, with significant contractors in both knees. The patient's wound status worsened throughout therapy. The scab re-opened which caused the patient to continue to not wear her prothesis.

The patient did show improvements in bed mobility. She became independent will all rolling, scooting, and sitting e up. She even was able to transition supine to prone without assistance.

The patient's discharge Amputee Mobility Predictor Index was 7/30. She was never able to walk secondary to inability to use R prosthesis, therefore no TUG or 50 foot timed walk test were performed at discharge. The patient met only 3/10 of her long and short-term goals. The patient discharged with plans to return to therapy once her wound was well managed.

Discussion

The pt's poor progress can be attributed to her age, emotional status, and presence of PVD with a wound.


Aging results in a gradual loss of muscle and joint flexibility. Also, an elderly's ability to regain muscle mass and strength is far less than a young adult. Her age could have contributed to her minimal gains in strength and ROM. Kirkendall and Garrett discuss how there are metabolic changes leading to decreased endurance. This may explain why the pt did not tolerate therapy as well. Resistive training is best to improve muscle strength[2], which is what the patient did in therapy, so all means were taken to improve her strength and ROM.

PVD can cause long lasting, difficult to heal wounds, which is what she had. The elderly are likely to have more post-op complications[3]. Her wound never healed on her R residual limb so she could never stand and practice walking on two legs.

Throughout therapy, the pt struggled with depression. This is very common in the amputee population. She was non-compliant with her exercises because she lacked the motivation and will to do them. It is greatly recommended that amputees reeceived some sort of counseling secondary to significant psychological effects[4]. She could have benefited from this to improve outcomes.

This can help a PT in the future if they treat an elderly pt, especially when formulating realistic goals. If a pt enters the clinic with depression, a wound, or or is elderly they may not achieve a PLOF.

References

  1. Fletcher DD, Andrews KL, Butters MA, Jacobsen SJ, Rowland CM, Hallett JW Jr. Rehabilitation of the geriatric vascular amputee patient: a population-based study. Arch Phys Med Rehabil 2001;82:776-779.
  2. Kirkendall DT, Garrett WE. The Effects of Aging and Training on Skeletal Muscle. Am Journ Sports Med 1998; 23:598-602.
  3. PREVENTING POSTOPERATIVE COMPLICATIONS IN THE ELDERLYfckLRFrederick E. Sieber, MDa,b and Sheila Ryan BarnettcfckLRhttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC30736 75/)
  4. Engstrom B. Therapy for Amputees. 3rd ed. Digital print. Edinburgh, Scotland. Catherine Van de Ven; 2003: 68-92.