Physiotherapy Management of Lower Limb Amputation Secondary to Diabetic Foot: Amputee Case Study


Original Editor - Afolabi Olakunle Olalekan

 Title

Physiotherapy Management of Lower Limb Amputation Secondary to Diabetic Foot

Abstract

The patient presented in this case presentation had left diabetic foot ulcer secondary to puncture wound which culminated into left transfemoral amputation. She had poor hyperglycaemc control and residual limb pain. She was deconditioned and had great challenge with exercise tolerance and body balance. She was hospitalized for 98 days. Eventually, the patient was able to ambulate on a pair of crutches and has no joint deformity. The stump has healed with conical shape ready for prosthetic fitting, but she is limited by the high cost of prosthesis.

Key Words

Transfemoral,diabetes, residual limb pain, balance,stump,prosthesis.

Client Characteristics

  • Demographic information: 51 years old Female civil servant
  • Medical diagnosis: Left diabetic foot secondary to a puncture wound in the left foot in a known diabetic patient. There was associated fever.
  • Co-morbidities: Nil
  • Previous care/Treatment: Patient was diagnosed as being diabetic (Type II) 3 years before presentation in a private hospital. She did not receive quality treatment there. She had stopped taking the prescribed medication 6 months prior to the incidence. Only anti-tetanus injection was given after she sustained the puncture wound.

Examination Findings

Subjective:

  • Foot swelling, tingling sensation in feet and fingers for 3 days and two days history of fever. There was discolouration of the left leg. The fasting blood sugar on admission was 19.3mmol/l. There was gangrene of her left lower limb up to distal left thigh.
  • Past Medical history: There is history of paraesthesia of the left foot 2 years before presentation and osteoarthritis of the right knee joint.
  • Patient/Family goals: That the patient would be able to walk independently.
  • Self Report Outcome Measures: Verbal rating scale 6/10 i.e. moderate pain
  • Physical Performance Measures: Patient could roll and sit up in bed but could not stand unsupported, there was impairment in the patient's balance.There was impairment in the patient's balance even with a walker and she got tired easily. She could not stand for more than a minute. She was having some of her daily activities like bathing, toileting and eating in bed.

Objective Examination:

A middle aged woman, conscious, febrile, not pale, anicteric, acyanosed and well oriented in time place and person.Vital signs: Respiratory rate: 46 cycles/ min Chest excursion is reduced.Fasting blood sugar on the first day of physiotherapy review was 15.3mmol/L.Patient's Psychological stage: Acceptance and hope stage[1].ICF Personal factors- The patient is a fifty-one year old, married woman with four children.ICF Environmental factors-The patient feels very well supported by her family members.ICF Struructure-L TF"

Clinical Hypothesis 

1.Left transfemoral amputation.

2.Dyspnoea
3. Upper and lower limbs muscular weakness
4. Residual limb pain
5. Stump oedema
6.Mobility problem
7. Balance problem
8.Hyperglycaemia
9.Wound infection

Intervention

The patient's management involved multidisciplinary team[2] comprising; endocrinologists, orthopaedic surgeons, physiotherapists, nurses and dieticians.PTs did;deep breathing exercise, Soft tissue massage of the stump and application of TENS to the residual limb,Teaching of transfer techniques,Enlightenment on deformity and ensuring prone lying for 30 minutes at least thrice daily. The stump must never be placed on the pillow and the stump must lie parallel to the sound limb and hip kept in neutral position in lying and sitting,Isotonic exercise of the upper, lower and residual limbs and later progressed to isometric exercise of a 10-second contraction followed by 10 seconds of relaxation for 10 repetitions for each of the muscle groups thrice daily,Isotonic exercise of the back extensors and retraining of balance in standing with parallel bars, walking frame, and eventually with a pair of axillary crutches, Physiotherapists were standing at the back of the patient most of the time to prevent fall. Reassessment of the patient's vital signs, blood glucose level, residual limb pain intensity, muscular strength, balance and exercise tolerance of the patient on each visit. Referral to prosthetist. The multidisciplinary management lasted ninety-eight (98) days and three weeks on outpatient basis."

Outcome

1. Patient's blood glucose was controlled to 9.7mmol/l upon discharge. She is on continuous medication.
2. Respiratory distress had resolved. There was good chest excursion and breathing was relaxed with respiratory rate at 12cycles/minute.
3. There was good stump healing with stump conical in shape.
4. Residual limb pain had resolved (Verbal rating scale score was 0).
5. The patient had regained maximal strength in her upper and lower limbs muscles.
6. There was neither hip contracture nor limitation in range of motion in any of the joints.
7. Patient could seamlessly transfer from bed to chair, from car to the crutches and could turn on the crutches to any direction.
8. Patient was stable on the axillary crutches and was eager to get prosthesis.

Discussion

" This case presentation shows how a trivial wound led to a limb loss due to an underlying pathology. People who suffer from Diabetes Mellitus often develop a foot ulcer[3] and associated complications[4] with 10 times higher risk of amputation[5].
|The loss of a lower limb affects a person's mobility, and ability to perform activities of daily living[6][7]. Residual limb pain precludes successful outcome following lower-limb amputation. This negatively impacts on their participation and integration into society.2 All of these sad turn of events played out in the case presented. The ultimate goal of rehabilitation after limb loss, is to ambulate successfully with the use of prosthesis and to return to a high level of social reintegration[8][9]. This involves multidisciplinary health professionals who bring to bear evidence based practice.The patient was rehabilitated to the pre-prosthetic stage, physically fit with conical shaped stump, static and dynamic balance re-established, residual limb pain abolished and neither hip contracture nor deformity. The patient was able to return to her job[10]. The outcome of this presentation lends credence to the importance of multidisciplinary approach and the key roles physiotherapists play in the rehabilitation of amputees[11],however, the prohibitive cost of prostheses is the limiting factor,preventing the the patient from getting a prosthetic leg. There should be increased awareness campaign on diabetes to stem increase in prevalence of amputation[12]."

References

  1. Morris S. The psychological aspects of amputation (2003) Amputee coalition.
  2. World Health Organisation (WHO). Int(WHO). Internatio
  3. Reiber, G. E., Vileikyte, L., Boyko, E.J., del Aguila, M., Smith, D.G. Lavery, L.A., Boulton, A.J. (1999). Causal Pathways for incident lower extremity ulcers in patients with diabetes from two settings. Diabetes Care 22: 157-162
  4. Dillingham TD , Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.
  5. Carmona GA, Hoffmeyer P, Herrmann FR, Vaucher J, Tschopp O, Lacraz A, Vischer UM. 2005, Major lower limb amputations in the elderly observed over ten years: the role of diabetes and peripheral arterial disease. Diabetes Metab. 2005 Nov;31(5)
  6. Dillingham TD , Pezzin LE. Rehabilitation setting and associated mortality and medical stability among persons with amputations. Archives of Physical and Medical Rehabilitation 2008; 89; 1038-1045.
  7. http://total-contact-casting.com/diabetic_foot_disorders/diabetic-foot-disorders.html
  8. Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594
  9. Falls Risk Assessment and Management Plan (FRAMP),Fall Risk Assessment
  10. Burger, H. Marincek, C. (2007). Return to work after lower limb amputation. Disability & Rehabilitation, 29(17), 1323-1329
  11. Ham RO, Regan JM, Roberts VC (1987) Evaluation Introducing the team approach to the care of the amputee: the Dulwich study. Prosthet & Orthotics Interational, 11, 25-30
  12. Amputee Coalition of America. 2010. ACA's Limb Loss Task Force warns of increasing limb loss in the U.S.P
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