Post Bilateral Transfemoral Amputation Phantom Pain, Phantom sensation and difficulty in IADL: Amputee Case Study

Title

Post Bilateral Transfemoral Amputation Phantom Pain, Phantom sensation and difficulty in IADL

Abstract

Sikander Vohra is a 51-year-old Indian man well-built coming for outpatient rehabilitation six-month post bilateral transfemoral amputation in a railway accident. Prior to that he was working in Sardar Patel University at a clerical post and had no significant medical complains except for acidity and low back pain but not disturbing. He has phantom limb pain and phantom limb sensation with burning pain, depression and functional limitation. Goals are to meet patient’s needs of becoming independent and back to work.

Key Words

bilateral transfemoral amputation, transfemoral amputation, vibration therapy, biofeedback

Client Characteristics

The patient has phantom limb pain and phantom limb sensation with burning pain, depression and functional limitation. He lives on ground floor house with two steps to climb; with his wife and three children, one is married and other two are working. Economically stable.

During his hospital stay he got Chest PT and on discharge what advice for PT. After a fortnight he was given compression garments in the form of elasticated socks. He isn't finding any relief for his itching even after application of topical lotion given by the physician. He does take proper nourishment for his skin.

He started PT after three months, as no one was available to carry him for PT. His sleep is disturbed because of phantom pain and hyperaesthesia of upper extremity on right arm and forearm. He is not even able to bear the weight of the blanket. He is a graduate with sound knowledge about his condition, maintains good interaction will all in socially appropriate manner and is independent in self-care activities with a goal to independently walk and go back to work.

The client had met with railway accident in February with no loss of consciousness, no history of vomiting or giddiness or headache. He was travelling by the train and stepped down on the wrong side and was walking along the tracks besides it. Out of sudden he felt a jerk on his left shoulder and he turned in order to see who was and mistakenly moved on to the tracks where an engine was coming back and lost both limbs.

Examination Findings

  • His vitals are normal and weighs 57 kg with residual height of 108 cm.
  • Posture assessment reveals upper extremities elevated and abducted bilaterally because of pain and also reduced lordosis.
  • The scar is healed and invaginated & nonadherent.
  • Phantom sensation present with hyperaesthesia over UE.
  • Grafts location on UE Rt. Arm and forearm. 5 rectangular grafts and Lt arm 4 grafts with reddish brown color.
  • The residual limb space is having bulbous end over the Rt. Stump and cylindrical end over the Lt. stump.
  • Adductor roll is present on the Lt. side. Vascularity is good B/L.
Pain is present which is lancinating and 5 on VAS scale for both limbs. PAF is exercise. Also over the donor area on UE there is itching and burning pain.
  • PAF is hot and humid climate, movement. PRF is cool air. No oedema,
  • ROM is full for B/L Hip, UE and lumbar spine.

  • Chest expansion is good at axilla, nipple and xiphsternum level and 2.5 cm, 3 cm and 2.5 cm respectively.
  • Passes the wheelchair skills test.
  • MMT reveals 4+ power for UE and spine.
  • On FIM independent in self care, 25% dependent for transfers up, locomotion independent by wheelchair, independent for Bowel and bladder, communication and social cognition. IDEAS score of disability is 40%
  • ICF Level - Current Status - Goals
, Body Structure and Function - Phantom sensations, phantom pain, neuropathic pain, UE Scar and hyperaesthesia - Control pain and increase ROM, UE Posture
Activity - Limited mobility in wheelchair & use of transport

Clinical Hypothesis

Impaired integumentary integrity with pain associated with scar formation, phantom sensations, phantom pain, impaired mobility and IADL

Intervention

The first approach was to develop a rapport of mutual trust and respect with the patient as a base for future negotiations and decision-making and to promote consistency of approach. The intervention was structured at an optimal level so that constructive stimulus is achieved without provoking fatigue related difficulties. It was more of a functional approach with each task to be carryover into real life tasks. Initially distributed practice with frequent rest periods was used to avoid risk of fatigue.

For reduction of pain, sensory integration with stress loading, desensitization, tapping, massaging and interferential therapy was used using 4KHz frequency for 20 min with 90 degree vector where base was kept 50 Hz and spectrum at 100 Hz over both the stump as well as over the UE graft region. Since mirror therapy is not an option for bilateral lower limb amputees, direct observation of another person's limbs was used to relieve phantom pain.


For correcting posture and maintenance, visual feedback with ergonomic posture analysis and correction was done. Use of NeuroTrac Simplex EMG Biofeedback was done for posture correction as well as for phantom pain at rest and during activity.

For Wheelchair training, transfers from mat to wheelchair was taught with pivoting activities promoting pelvic rotation was used. Wheelchair propulsion forward and backward on even and uneven surfaces was also practiced. For safety, trunk belt was used.

Outcome

For preparing the stump to be ready for weight bearing proper care was taken for the scar, wound and also proper nutritional advices were given for nourishment of skin. Sensory integration continued with above techniques with continued use of semi rigid dressing for shaping the stump in anticipation of fitting the prosthesis. Patient was advised to clean the stump at least one a day with water and not to put the bandaging in case of blisters.

The patient has turned very enthusiastic and has good control of pain 3/10 for B/L UE graft and 4/10 for B/L stump. Posture correction was achieved successful with use of EMG Biofeedback after nearly 12 sessions. Patient takes care of the stump as advised and is able to bear weight on first fitting of prosthesis with no pain. Patient tolerated standing for nearly 5 minutes under supervision with rails support. Patient is looking forward into the options of stem cell therapy for limb growth.

Discussion

For High Level Amputation patient, the rehabilitation process gets slow if phantom limb pain is there. In case of bilateral amputation, the option of graded motor imagery is not possible. A study done by Monica L Tung et al [4] studied the use of observation of limb movements of other person to reduce phantom limb pain and found statistically significant improvement in phantom limb pain reduction. In this case we could also use vibration therapy, hypnosis and acupuncture for relief of phantom limb pain.

References

  1. Belleggia G, Birbaumer N. Treatment of phantom limb pain with combined EMG and thermal biofeedback: a case report. Appl Psychophysiol Biofeedback. 2001 Jun;26(2):141-6.

  2. Trifiletti RJ. The psychological effectiveness of pain management procedures in the context of behavioral medicine and medical psychology. Genet Psychol Monogr. 1984 May;109(2D Half):251-78.
  3. Dougherty J. Relief of phantom limb pain after EMG biofeedback-assisted relaxation: a case report. Behav Res Ther. 1980;18(4):355-7.
  4. Monica L Tung et al; Observation of limb movements reduces phantom limb pain in bilateral amputees. Ann Clin Transl Neurol. 2014 Sep; 1(9): 633-638.
  5. 
Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch Phys Med Rehabil 2006;87(3 Suppl 1):S34-43.