Older Patient with Transfemoral Amputation: Amputee Case Study

Title

Older Patient with Transfemoral Amputation

Abstract

I am a rehabilitation therapist for the aged and neurology for all ages at a small community hospital in a large city of Australia. Recent restructuring of the health services means that my caseload will now also include patients with amputations. This case study is about my first patient with a transfemoral amputation due to an ischaemic foot due to arterial vascular disease. He was fitted with a transfemoral prosthesis with elastic suspens.He presented wheelchair bound and after rehabilitation is now mobilising independent with a walking aid. He is independent with all activities of living.

Key Words

Older patient,transfemoral amputation,

Client Characteristics

Mr G is a 77 year old male who underwent a transfemoral amputation due to an ischaemic foot. His past medical history includes Ischaemic heart disease, arterial vascular disease, hiatus hernia, diverticulitis and hypertension. He lives with his 86 year old wife who has complex medical problems. They live in a house without steps.He enjoys gardening and maintaining the house. He used to drive and this is an important goal for him.

He was fitted with a transfemoral prothesis with total elastic suspension belt. He received rehabilitation in the acute hospital and was discharged home and referred for further rehabilitation to our outpatient department. 

Examination Findings

Subjective:

  • Previously independent with activities of daily living, mobility and driving, no supportive services. He was doing most of housework as his 86 year old wife has complex medical issues and can't manage cleaning or shopping.
  • Currently spending days in self propelling wheelchair as he doesn't feel safe with the elbow crutches he was discharged with from hospital.
  • Patient reports high fear of falling. no pain
  • Patients' goal: Independent mobilisation with a walking aid, return to driving.

Objective examination:

  • Patient independent with donning and doffing prosthesis, stump in good condition
  • Transfers: independent
  • Sit to supine to sit: independent
  • Timed unsupported stand feet apart: 2 minutes with stand by assistance. Weight bearing Left more than right. Feet together 1 minute with stand by assistance
  • Timed up and go test: 2 elbow crutches and stand by assistance x1 1 minute and 43 seconds,4 wheeled walker 43.28 seconds independent
  • Mobility-needs assistance x1 with elbow crutches, doesn't have frame at home
  • Gait: reduced loading on prosthesis in stance, unable to fully extend Right hip due to old injury
  • Left lower limb range of motion and strength-within normal limits
  • Right hip joint flexion-normal, extension minus 15 degrees due to old injury-reports that he has had a limp for over 30 years
  • Unable to lie prone due to stomach discomfort-increases reflux
  • Difficulties with car transfers-using more expensive wheelchair taxis

Clinical Hypothesis

Mr G main problems are:

  • Unable to mobilise at home as he is not safe with elbow crutches and he doesn't have any other walking aids at home.
  • He doesn't have anybody at home who can practice with him which means he must be totally safe with his walking aid in order to mobilise. He was not able to practice with the elbow crutches at home as he was not safe
  • Decreased hip extension on the amputated leg means that he will have a compromised gait
  • Financial pressure means that he can only come to therapy once a week which in combination with limited ability to practice at home slowed down his progress.difficulties with car transfer means taking even more expensive wheelchair accessible taxis
  • Decreased lower limb strength due to inactivity.

Intervention

Initially provision of 4 wheeled walker to promote safe mobility indoors and reduce time sitting in wheelchair, balance exercises included-weight shifting onto right, putting left leg onto step, upper limb movements in standing feet apart and feet together, reaching for objects, side walking along support.

Strengthening exercises for left leg-stepping up small step, single leg squats. Strengthening exercises for right remaining leg -movements in standing with prosthesis.

After patient felt safe with the 4 wheeled walker indoors we started outdoor mobility practising on grass, slopes, curbs with the elbow crutches and 4 wheeled walker.We also practised stairs.Patient decided that he prefers 4 wheeled walker to elbow crutches.

Falls prevention education was provided looking at environment, managing health and medication, footwear, eye check-ups and physical activities.

We also discussed getting off the floor and the patient tried once where he was able to get up with the support off the chair. He found it very uncomfortable and didn't want to practise again so we discussed strategies for him to use to get assistance in case he would need to and he was aware what the best way was to get up.

Patient was referred to the occupational therapist for assessment of car transfers.

Outcome

Mr G achieved his goal of independent mobility with a walking aid.
He mobilises independently in and outdoors with a 4 wheeled walker. He is able to do all activities required at home .He is able to mobilises indoors with elbow crutches but only uses them in the living room as he fears bathroom or kitchen floors could be wet and slippery. He did not become independent with 2 elbow crutches outdoors. Given his age ,gait limitation due to decreased extension on amputation site and fear of falling I feel the 4 wheeled walker is the appropriate walking aid for him .If need arises he is able to manage stairs using one elbow crutch and rail. He is independent with all transfers

Mr G achieved independent car transfers and mobility with 4 wheeled walker in and outdoors and 2 elbow crutches indoors.
Timed unsupported stand feet apart and together: 2 minutes
Timed up and go test: 2 elbow Crutches: 34.75 seconds independent, 23.16 seconds with 4 wheeled walker independent.
Mr G was happy with the outcome and treatment was put on hold as he was fully independent and had no areas of concern. Treatment will resume once he will be fitted with his permanent prosthesis. He has a home exercise program to maintain strength and balance.
His goal of driving independently will be addressed by the occupational therapist and driving authority once he has been fitted with his permanent prosthesis.

Discussion

Mr G was my first patient with an amputation and this case study was retrospective looking at my notes. I feel that I was able to identify his main problems, set appropriate goals and implement effective functional treatment strategies. This fantastic on line course highlighted gaps in my knowledge about the initial stump care[1], different types of prosthesis and complexity of fitting[2]. I used timed up and go and timed unsupported stand as outcome measures. I will look at developing a specific amputee assessment form for our department[3]. I will also liaise with the multidisciplinary team at the acute hospital to learn more about the different roles and particularly about the different types of prosthesis. I am not sure which prosthesis my patient will be fitted. I gave my patient a home exercise program but could have included more exercises on the bed to maintain and improve strength.[4] 

References 

  1. Engstrom. B, Engstrom. C; Therapy for Amputees
  2. ICRC. Prothetic gait analysis for Physiotherapist. ICRC physiotherapy reference manual
  3. Hull & East Yorkshire Hospital NHS Trust Physiotherapy Department Amputee assessment form
  4. Gailey. R, Gailey A; Stretching and strengthening for lower extremity amputees.