Physical Therapy Treatment for a Traumatic Below Knee Amputation and an Above Elbow Amputation: Amputee Case Report

Title

Physical Therapy Treatment for a Traumatic Below Knee Amputation and an Above Elbow Amputation: Amputee Case Report

Abstract

This is a case report on a 23-year-old male who presented to outpatient therapy with traumatic left transtibial and transhumeral amputations after a motorcycle accident. The patient presented with decreased range of motion in his left lower extremity residual limb, decreased strength in bilateral lower extremities, decreased balance in standing and an inability to walk. Intervention consisted of pre-prosthetic and prosthetic training to increase strength, range of motion, perform gait training and other functional activities related to his job. At discharge from therapy the patient was walking without an assistive device but sometimes with use of a SPC.

Key Words

Transtibial, transhumeral, traumatic, amputation, treatment, rehabilitation,

Client Characteristics

The patient was a twenty-three year old male who presented to inpatient and outpatient rehabilitation after sustaining a traumatic injury from a motorcycle injury. His injury resulted in a below the knee transtibial amputation to his left lower extremity and an above the elbow transhumeral amputation on the left upper extremity.

In addition, the patient also presented with a minor traumatic brain injury. No other significant co-morbidities existed. Before coming to outpatient therapy rehabilitation the patient spent time in inpatient rehabilitation. There he worked on tolerance to vertical position, dressing changes for swelling control in his lower and upper extremity, transfer training, wheelchair negotiation, bed mobility, range of motion of hip and knee flexors on residual limb, sitting to and from standing and activities of daily living with occupational therapy[1]. The patient was also given speech therapy for cognitive evaluation and training. Prior to his accident the patient was training to be a paramedic and was close to graduation.

Examination Findings

Prior to seeing the patient, his history and current physical status were discussed with his inpatient therapist to ensure an accurate evaluation was established so therapy could continue where inpatient therapy left off. Upon initial evaluation to outpatient therapy the patient's goals were to prepare himself physically for a prosthetic, learn to walk with a prosthesis and return to his previous functional independence status as much as possible which included work.

After the history and examination were taken the patient presented with the following information based off of the WHO International Functional Classification model.

  • Body Structure and Functions: Decreased hip flexion and knee flexion ROM in residual LE limb, decreased strength to hip and knee musculature in residual and sound limb, decreased strength and ROM in upper limb, decreased standing balance, pain in his residual limb, decreased incisional mobility

  • Activity: Unable to walk, decreased ability to transfer independently
  • 
Participation: Unable to work, unable to participate in recreational activities

  • Personal Factors: 23 year old male, living with his girlfriend, supporting family to be of assistance 24 hours/day

  • Environmental Factors: 1 story home with no steps to enter home, transportation provided by patient's girlfriend
  • Outcome measures taken included: Pain, manual muscle testing, range of motion, static balance testing. Dynamic Gait Index was performed later.

Clinical Hypothesis

After taking a history and examination of the patient, major impairments included decreased strength in his lower extremities, decreased range of motion in his lower residual limb, decreased balance and inability to walk secondary the patient had not yet received his prosthesis. Therefore, the goal of therapy was towards correction of his impairments while developing his functional mobility and returning the patient back to his goal of working.

Intervention

Intervention consisted of two phases.

The first phase, pre-prosthetic training, emphasized range of motion stretching, especially hip and knee flexion stretching, secondary that these two ranges are crucial for proper prosthetic training[1][2][3].  Strength training was also performed for his residual limb and sound limb, particularly with hip abduction strength on his residual limb to assist with maintaining proper stability in gait.

Scar and soft tissue mobility were performed on the patient's residual limb to sensitize the lower extremity for gait training and weight bearing in the prosthesis, ensure proper mobility of the skin on the residual limb stump and to help with decreasing pain[4]. In addition, transfer training, wheelchair negotiation training and standing balance training were performed.

In the second phase of therapy, donning and doffing training of the patient's LE prosthesis, socks and liner were performed. Weight shift training was practiced while standing in the prosthesis in a lateral and diagonal fashion with progressively more challenging exercises performed to increase the patient's single leg stance ability[5].

Gait training was initiated within a Lite Gait assisted device for safety, then within the parallel bars, the rolling walker, cane and then no assistive device. Stairs, curbs, ramps, outdoor gait and functional training was added such as lifting heavy items off the floor, using his upper extremity prosthesis to prepare for work.

Outcome

At the beginning of therapy the patient was negotiating via a wheelchair with assistance from his girlfriend. By D/C from therapy the patient was walking without an assistive device but sometimes with use of a SPC.

He continued to demonstrate a lateral lean in stance phase over his prosthetic side during gait but this was most likely due to his decreased upper extremity weight on his left upper extremity, residual hip abduction weakness but also due to a patient developed habit. This habit was created as the patient was originally scared that his prosthesis would not hold his weight. Unfortunately this was not able to be discontinued but when he walked with his cane this would go away. T

he patient was using his upper extremity prosthesis with functional related tasks that pertained to his job of a paramedic. He was able to lift heavier items off the floor, which included dummy transfers with assist from the therapist. Currently the patient is back working as an intake coordinator at an emergency department and he is back to his passion of weight lifting. He is still working towards becoming a paramedic.

Discussion

Overall, although the patient had some remaining impairments at the conclusion of therapy, the outcomes were successful. The patient was able to return to work and was able to return back to physical fitness. The greatest challenges occurred in this case report were to progress with knee flexion range of motion and to decrease lateral lean in stance phase of gait. Knee extension range was able to be achieved, however, knee flexion was diminished secondary that the patient had heterotopic ossification in his proximal quadriceps and hip adductors near the inguinal crease area. This decreased knee flexion secondary his quadriceps musculature would not stretch effectively. According to research, after a patient sustains a head injury, heterotopic ossification is at greater risk to occur[6].

The patient's lateral lean was also challenging to work towards correcting but in accordance with research stating that hip abduction strength needs to be progressed he was able to achieve a more normal gait pattern[7]. Communication was also critical with the patient's prosthetist to ensure that the patient's prosthesis was in proper mechanical alignment in conjunction with the patient's impairments.

Many items can be taken from this case to learn from to influence decisions for future patients. Incorporating current education and research along with experience will be the key to continuously developing as a clinician to help patients achieve a higher level of functional mobility.

References


  1. 1.0 1.1 Engstrom, B. & Van de ven, C., (1999), "Therapy for Amputees", 3rd edition, 93-102.
  2. Gailey, R. & Gailey, A. (1994), "Stretching and Strengthening for Lower Extremity Amputees", 2-5.
  3. Munin, M., et al. (2001), "Predictive Factors for Successful Early Prosthetic Ambulation Amoung Lower-Limb Amputees", 382.
  4. Lusardi MM., (2013) "Orthotics and Prosthetics in Rehabilitation"3rd edition, Postoperative and preprosthetic care. Missouri: Elsevier, 532-594
  5. Gailey R,S & Curtis R, C. "Physical Therapy Management of Adult Lower-Limb Amputees. Atlas of Limb Prosthetics"; Surgical Prosthetic and Rehabilitation Principles. Chapter 23. Abridged version. O and P Virtual Library http://www.oandplibrary.org/alp/chap23-01.asp
  6. Haran, M., et al. (2010) "Pharmacological interventions for treating acute heterotopic ossification", Cochrane Database of Systematic Reviews, Issue 5
  7. ICRC Physiotherapy Reference Manual, (2014), "Prosthetic Gait Analysis for Physiotherapists", Gait Analysis and Gait Deviations, 84.