Older person with amputation: Amputee Case Study

Title

Older person with amputation: Amputee Case Study

Abstract

The impact of lower limb amputation on the geriatric patient can be complex. Taking into account all possible complications and post-operative goals is paramount for effective management of these patients. It is well documented that with age comes increased incidence of chronic disease. The numerous co-morbidities associated with chronic disease have several implications on the status of an elderly patient post amputation (Fried et al. 2004). This case study aims to discuss the examination and most appropriate rehabilitation process for an individual elderly patient with a lower limb amputation

Key Words

transtibial, elderly patient, PVD

Client Characteristics

  • 77 year old male

  • Underwent elective left transtibial amputation secondary to longstanding peripheral vascular disease due to diabetes. Goals of the surgery were pain control and improved quality of life. Unfortunately, there was slow healing of the incision related to a fall post-surgery. Fitting of the prosthesis was delayed by several months.

  • Social History: Lives with supportive wife in raised bungalow. Home has 5 front stairs.

  • Functional Hx: Previously independently mobile with 4WW, approximately 40m before requiring rest (limited by lower limb pain and shortness of breath on exertion).

  • Medical History:

    • PVD

    • Diabetes

    • Congestive heart failure (on supplemental oxygen) - Note: Patient is cognitively intact and aware of trip hazards associated with the oxygen tubing.
  • Previous care: Community nurses visit home weekly to attend to lower limb wound dressings (chronic ulcers). Also receives home assistance once per fortnight for cleaning/domestic duties. Community heart failure service physiotherapist sees patient once per fortnight - physiotherapist prescribed 4WW approximately 6 months prior to amputation.

Examination Findings

SUBJECTIVE: Patient consented to physio. C/O of left lower limb stump pain when dependent - eases with lower limb elevation. Denies any dizziness. Patient reports to be managing pivot transfers with 1x assist currently. Wishes to be more independent with this to facilitate return home from rehab facility.

  • Social Hx: Lives with supportive wife in raised bungalow. Home has 5 front stairs, with bilateral railings. Receives home assistance for domestic tasks/cleaning once per fortnight. Was also receiving community physiotherapy in home once per fortnight before hospital admission (through heart failure service).
  • Functional Hx: Previously independently mobile with 4WW, approximately 40m before requiring rest (limited by lower limb pain and shortness of breath on exertion).

  • Patient goals: To be independent with transfers to and from wheelchair and minimise burden on wife.

  • Self Report Outcome Measures

    • Pain VAS 2/10 at rest; 3/10 with movement

    • Shortness of breath - Modified BORG (at rest) =1; (with activity/transfers) =3-4

OBJECTIVE

  • LL Power: R)L)

    • Hip flexion3+/53/5
    • Hip extension3+/53/5
    • Knee extension3+/53/5
    • Knee flexion4/53+/5
    • Ankle DF4/5N/A
    • Ankle PF4/5N/A

  • LL ROM:
R)L)

    • Hip flex110 deg110 deg
    • Hip ext 20 deg10 deg
    • Knee ext0 deg-5 deg
    • Knee flex120 deg120 deg
    • Ankle DF10 degN/A
    • Ankle PF25 degN/A
  • Function:
    • Bed mob= independent

    • Sitting balance= independent
    • Pivot transfers (to right)= 1x assist

Clinical Hypothesis

Main problem: Inability to perform independent transfers to and from wheelchair due to general deconditioning and reduced strength.
 Ability to return home is also limited by environmental factors including stairs at front entrance and lack of rails throughout bathroom/toilet.

Intervention

Strength and ROM training
 Plinth exercises including:


  • Hip extension in sidelye (prone limited by heart failure)

  • Knee extension (incorporate contract-relax techniques to facilitate increased knee extension ROM)

  • Bridging
-Rolling

  • UL exercises using free weights (avoiding too much overhead activity given heart failure)


Transfers practice (and part-practice):


  • Sitting balance and trunk control exercises - reaching outside of base of support

  • Bottom lifts

  • Transferring plinth to fixed chair

  • Transferring plinth to wheelchair

  • Progressed to transferring mattress/bed to wheelchair (and back)
  • Altered heights and surfaces to challenge

  • Wheelchair to toilet/shower chair transfers

  • Car transfers

Environment factors: Liaised with occupational therapist to arrange for home visit to take place. This allowed for necessary home modifications to occur including ramp access to home and installation of grab rails throughout the bathroom and toilet.

Outcome

With rehabilitation and multi-disciplinary input, the patient was able to achieve his goal of independent transfers to facilitate returning home with his wife. Increased community services and supports were also instituted to assist. Outcome measures for strength and ROM also demonstrated improvement.

  • LL Power:
 Right Left
    • 
Hip flexion4/53+/5
    • 
Hip extension 4/53+/5
    • Knee extension 4/53+/5
    • Knee flexion 4+/53+/5
    • Ankle DF 4/5N/A

    • Ankle PF4/5N/A
  • LL ROM: Right Left
    • Hip flexion 110 deg110 deg
    • Hip extension 20 deg20 deg
    • Knee extension 0 deg0 deg
    • Knee flexion120 deg120 deg
    • Ankle DF10 degN/A
    • Ankle PF25 degN/A
  • Function:

    • Bed mobility = independent

    • Lie to sit = independent

    • Sitting balance = independent

    • Pivot transfers (towards right) = independent

Discussion

Depending on the past medical and functional history of the geriatric amputee patient, our goals and expectations of rehabilitation can be variable. In this case assignment, I felt that achieving safe transfers to/from wheelchair was the main priority, rather than achieving successful prosthetic use.

Even though a prosthesis could in fact aid the ability of the patient to transfer more effectively, the presence of wound break down and reduced hip and knee extension ROM made the process and applicability of a prosthesis less suitable. The patient's pre-existing health concerns including congestive cardiac failure and his functional limitations prior to amputation meant the goals of rehabilitation were more focussed on wheelchair transfers rather than pursuing the direction of prosthetic fitting and rehabilitation. Other factors that contributed to this decision process included the patient's falls history and risk of skin tears.

Literature supports this idea also. A study by Fleury et al. [1] describes the low prosthetic success rate in geriatric amputee patients, with only 36% being successfully fitted with a prosthesis. The overall management of the elderly person with an amputation should be an individualised process. It should take into consideration the pre-existing health and functional status of the patient in order to allow for optimal outcomes.

[2][3]

  1. Fleury A, Salih A, & Peel N (2013), 'Rehabilitation of the older vascular amputee: A review of the literature', Geriatric and Gerontology International, vol.13, pp. 264-273.
  2. Fried L, Ferrucci L, Darer J, Williamson J, & Anderson G (2004), 'Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care', Journal of Gerontology, Vol.59, No. 3, pp.255-263.
  3. Patrick L, Knoefel F, Gaskowski P, & Rexroth D (2001), 'Medical comorbidity and rehabilitation efficiency in geriatric inpatients', J Am Geriatr Soc., vol.49(11), pp.1471-7.