Older people with amputations: Amputee Case Study


Original Editor - Mohamed Abdelmegeed

Title

Older people with amputations: Amputee Case Study

Abstract

Ahmed is s 65 years old, works in a bakery store for more than 20 years. He is a heavy smoker with history of hypertension, which is managed with beta blockers and ACE inhibitors. Two years ago, he had transfemoral amputation after a car accident while crossing the street. He indicated that he has problem seeing at night especially for far vision, he said that his doctor told him that he has glucoma and was on medication for that as well. He was referred to our rehabilitation center after the surgery for pre-prosthetic training and continued with us after his prosthesis was fabricated for him.

Key Words

Transfemoral, lower limb prosthetic, Physical Therapy, rehabilitation

Client Characteristics

  • Demographics: 65 years Old male, married with three children
  • Height: 5'8, Weight: 210 lb., Bakery store worker

  • Previous Medical Diagnosis: Hypertension, Glaucoma
  • Medication: Concord, Lisinopril
  • Co-morbidities: Inactivity, reluctance to remain active all day, prefer lying down, swollen stump, hypertension, weak vision

  • Previous care or treatment: Started physiotherapy in a low-resource clinic, 20 miles away from his residence place, did not continue for more than three session since he was not comfortable. He said that he started to find discharge around the incision site at that time and fell twice in the clinic. He lost hope to walk again.

Examination Findings

Subjective examination: rounded shoulder, forward head, belly abdomen, flattening of lumbar curvature, flexion, abduction, external rotation of the residual limb, toe out of the non-affected limb, atrophied quadriceps of the non-affected limb, pelvic drop on the non-affected side, dark coloration around the stump.

Patient's chief complaint: inability to walk efficiently with the prosthesis, pain and limping while walking.
Self-reported outcome measure: McGill Pain Questionnaire (SF-MPQ), Visual analogue scale (VAS), Short form (SF-36) questionnaire.

Objective exam: Hip flexion: 20-100, extension: -20, abduction: 35, adduction: 20. Hip flexor ms test: 3+, extensors: 3+, abduction, adduction: 3. Positive Thomas test for both limbs, more apparent on the affected limb.

International Classification of Functioning, Disability and health (ICF): Health condition: transfemoral amputation, Body structure/function: Involved anatomical body part is the right lower extremity, impairments category: pain strength, ROM. Activity limitation: difficulty donning/doffing the prosthesis, difficulty walking, difficulty negotiating stairs. Participation restriction: inability to go back to work to make his living, diminished social role, no recreational activity. Personal factors: problems with his wife. Environmental factors: decreased availability of finding appropriate, easily, handicapped transportation, and facilities. Patient's goals: walk independently, return to work.

Clinical Hypothesis

Insufficient rehabilitation received led to development of contractures, decreased ROM, decreased muscle power, decreased motivation and overweight. 
Patient should start structured physical therapy program addressing the above-mentioned problems, taking into consideration patient's goals, financial resources, availability of the patient for therapy, and home environment modification

Intervention

After the evaluation, we sent the patient to a prosthetist for prosthetic checkup and evaluation. We received a report that the socket was tight and was not fit to the girth of the residual limb. The problem was fixed
.

Non-weight bearing training included ROM exercises, stretching of tight hip flexors, abductors, external rotators, flexibility training for the affected hip joint, and we instructed the patient to sleep prone as tolerated. Strengthening exercises were performed for the gluts. and was progressed manually and by using thera-band with varying resistance. Strengthening of the non-affected limb as well Management of the stump was performed each session by measuring the stump circumference and was recorded on stump card. Elastic wrapping of the residual limb was performed whenever needed.


Pain was treated using trans-cutaneous electrical nerve stimulation (TENS) and desensitization techniques.
After the patient was comfortable with his prosthetic, we started gait training in the parallel bars and corrected gait deviations. Progression was performed by weaning from holding the bars and the use of gait belt to putting obstacles on the floor to walking independently inside the bars.

When the therapist found the patient ready for independent walking, gait training started outside the parallel bars and progressed as tolerated.
 Donning and doffing training was checked to make sure the patient understands the procedure and how to maintain the residual limb health.

Outcome

  • The patient was motivated all the time and his motive increased dramatically when he saw himself walking independently with no pain.
  • Gait improved dramatically with little or no pain and no limping
  • Stump restored a permanent non-swollen shape with no tenderness
  • The quadrilateral socket was comfortable with no complain of tightness

  • Patient walked independently and voiced his intention to go back to his work soon

Discussion

Treatment of above knee amputee is quiet challenging. In this case, we summarized the physical therapy plan of care and the outcome obtained. Treatment of amputee should involve a multidisciplinary team[1] [2] and the Physical Therapist plays the key role in coordination of rehabilitation[3][4].

Understanding of residual limb volume and its relationship to the socket fit is essential in rehabilitation[5]. Gait training should be established based on achieving energy-efficient gait pattern, restoring normal gait[6] [7][8]. Patient should be taught that the energy cost for the gait is dependent on the amputation level[9].

It is important to start gait training inside the parallel bars unless there are reasons to use alternative strategies and should be progressed from clinical setting to comfortable home environment[10]. Patients should be asked whether or not they have fear of falling and this should be addressed by incorporating balance training in the program [10]. According to Consensus opinion gained by the Delphi process, patient should be instructed on how to use his prosthesis, its function, limitation, proper fitting, footwear, proper use of any suspension device, how to manage phantom pain, and appropriate wound care.

[9]

References

  1. Linstone H, Turoff M (Eds)(1975) The Delphi Method: techniques and applications. Reading MA: Addison-Wesley.
  2. Thangaratinam S, Redman CW (2005) The Delphi Technique. The Obstetrician & Gynaecologist. 7: 120-125.
  3. Ham, RO (1985) Rehabilitation of the vascular amputee - one method evaluated. Physiotherapy Practice. 1: 6-13.
  4. Ham RO, Regan JM, Roberts VC (1987) Evaluation of Introducing the team approach to the care of the amputee: the Dulwich study. Prosthet & Orthot Int, 11, 25-30
  5. Levy, SW (1995) Amputees: skin problems and prostheses. Cutis,. 55(5): 297-301.
  6. Pinzur, MS, et al. (1995) The effect of prosthetic alignment on relative limb loading in persons with trans-tibial amputation: a preliminary report. J Rehabil Res Dev,. 32(4): 373-7.
  7. Powers, C, Rao, S, Perry, J (1998) Knee kinetics in transtibial gait. Gait & Posture. 8:1-7.
  8. Powers, CM, et al. (1996) The influence of lower-extremity muscle force on gait characteristics in individuals with belowknee amputations secondary to vascular disease. Phys Ther,. 76(4): 369-77; discussion 378-85.
  9. 9.0 9.1 Waters, R, et al. (1976) Energy cost of walking of amputees: the influence of level of amputation. The Journal of Bone & Joint Surgery, 58-A(1) (January): 42-46.
  10. 10.0 10.1 Consensus opinion gained by the Delphi process