Post Prosthetic fitting rehabilitation of patient with trans tibial amputation, PVD and DM Type2: Amputee Case Study


Original Editor - Carolyn Wilson

Title

Post Prosthetic fitting rehabilitation of patient with trans tibial amputation, PVD and DM Type 2

Abstract

This case study follows the rehabilitation of a 62yr old male, transtibial amputee with PVD and Type 2 Diabetes. In Northern Ireland the number of adults diagnosed with diabetes has increased by 33% in 5 years. These issues are being addressed by a new strategy published by DHSSPS with an action and implementation plan from 2014. My aim was to evaluate the patient's assessment, treatment and outcome measurements with reference to the WHO ICF framework and current guidelines in the literature. This case supported current practice but also highlighted areas for improvement.

Key Words

Amputee, Diabetes, PVD, Northern Ireland, Recommendations, BACPAR

Client Characteristics

62-year-old man with a 8 week post-op following right transtibial amputation secondary to PVD and Type 2 Diabetes

Past medical History:


  • PVD
Type 2 DM but on Insulin - poor glycaemic control CKD- not on dialysis
  • 
Diabetic foot ulcers
  • 
Diabetic neuropathy bilateral feet - no retinopathy
  • Gout

  • no MI/COPD/CVA/OA/RA/#/other surgery

History of Present Condition:


  • Several months h/o non healing diabetic foot ulcers.

  • Seen regularly by podiatrist.
  • Referred to hospital for vascular opinion.
  • Failed attempt at revascularisation of foot.
  • Decision to do TT amputation.

  • Post op c/o phantom limb pain.
  • Commenced on Pregabalin.

  • Still has ulcer on right great toe. being dressed regularly by podiatrist.

  • Discharged 7 days postop from Acute hospital to home.

Social History:


  • Married with 2 sons aged 25 and 22 - not living at home.

  • Lives in 2 storey house. 2 steps to front door.
  • Ramped access back door.

  • Bedroom and bathroom with shower upstairs.

  • Currently sleeping in lounge, using basin to wash and borrowed commode downstairs.

  • Wife is main carer - no health issues at present.

  • Able to transfer independently bed to wheelchair to commode.
  • Wife assists lower half dressing.

  • Retired lorry driver.
  • No plans to return to work.

  • Smokes 20/day. 6 units of alcohol a week.
  • 
No assessment by OT at present.
  • Using W/C on loan from the Red Cross.

  • Hobbies- watching local football team.
  • Watching sport on TV
  • Driving- hopes to return to driving. Has not yet informed DVLA

Examination Findings

  • All UL full functional
  • ROM and Muscle power
Movement R ROM R Muscle Power L ROM L Muscle Power
Hip Flex 115 4 120 5
Hip Ext 0 4 5 4
Hip Abd 30 4 35 5
Hip Add 15 5 20 5
Hip Int Rot 20 4 25 5
Hip Ext Rot 15 5 20 5
Knee Flex 120 5 120 5
Knee Ext -10 4 full 5
Ankle D Flex 5 5 0 5
Ankle P Flex 50 5 55 5











  • Power Dexterity: good pincher grip but some reduction in fine dexterity
  • Balance: Pt tends to sit slouched but able to correct this when asked.
Able to achieve passive and active sitting balance.
  • Transfers: Independent transfers W/C to plinth using banana board without prosthesis.
 Sit to stand to zimmer frame with supervision.
  • Standing : Able to stand for several minutes using zimmer frame maintaining balance and no shortness of breath.
  • Residual Limb:
 wound condition -well healed med- lat scar line.
oedema - still some significant pitting oedema - fitted with new juzo shrinker
stump length -14cm
cut end of bone -slightly prominent tibia
skin perfusion -adequate
sensation -reduced sensation distally
 tenderness -some tenderness over end of tibia
stump shape -bulbous and oedematous distally
mobility of scar -mobile
pain -PLP 4/10

  • Contralateral limb: small area ulceration on left great toe 1cm x1cm.Ulcer photographed. Some granulation tissue at edges but central slough. Not on weight bearing area.
  • 
Psychological: patient reports that he is coping well with good family support.
  • 
Cognitive:MOCA score 24/30
BP 146/79 HR 72 SpO2 98%

Clinical Hypothesis

Problem List:

  • 
Right transtibial amputation - fitting with TT prosthesis.
  • Gait re-education.

  • Muscle weakness -right hip Gd4 Quads Gd 4 - strengthening program

  • Right knee ext -10 - stretches, encourage use of stump board and positioning

  • Right hip ext to neutral - prone lying and stretches

  • Oedematous bulbous stump - stump board and juzo
  • 
Flexed posture - core stability exs and posture exs
Ulceration on left great toe - monitor closely and liaise with podiatrist.

  • Poor glycaemic control - diabetic education
H/o falls - falls awareness, balance exs, proprioception exs.
  • 
Poor self care of feet - education re care of contralateral foot. PLP - r/v dose of pregabalin, mirror therapy

  • Smoking - cessation program

Intervention

Patient admitted for limb fitting rehab 8 weeks post-op.


Day 1- fitted with polyprop PTB socket with multiflex foot.
Regular skin checks and contralateral foot checks day 1 to D/C and liaison with nursing staff on ward. 
Fit with new juzo shrinker. 
OT referral for W/C with stump board/ W/C skills. 
Continue strength and stretch program for IRQ/hip/abdominals and core.
 R/V previous goal setting.

Day 2-5 - posture/balance exs/proprioception exs/resisted exs in parallel bars
Lat/AP/stride stance weight transferrance. 
Gait re-ed in parallel bars. 
Regular alignment checks and adjustments by prosthestist. Ongoing patient education re care of stump/oedema control/use of socks


Day 6-10 - Increase advanced balance and resisted exs. 
Progress to elbow crutches then sticks with assistance/supervision/independence
. Gait analysis & re-ed
Outcomes measured
. Practice - stairs/slope/outdoors/grass/rough ground/pavements/on-off floor/car transfers
. OT- kitchen/bathroom activities/mirror therapy attempted/referral to community services for home assess. 
Patient education-glycaemic control/care of contra lateral foot/smoking cessation/falls clinic.
Introduce to peer support group/sports/hobbies/social integration. Final check/torque/cosmetic finish by prosthestist


Day 11-15 Discharge and goals meeting. 
OT-Shopping trip. Driving assessment
. Temp D/C with prosthesis overnight. 
Final outcomes measured
Full D/C with info leaflet
. R/V in 6 wks and 6 wk outcome measures

Outcome

Gait Analysis and Re-education: [1][2][3][4]

  • 
Reduced balance due to lack of sensation in prosthesis and decreased sensation on contra-lat foot. This improved with balance exs and Bob Gailey resisted exs.

  • Flexed posture due to long periods of sitting. Corrected using visual feedback using mirrors and core strengthening exs. 

  • Side flexion of trunk- corrected using Bob Gailey strengthening exs
  • Decreased base of support- visual and verbal cues
Long prosthetic step - taught 4 point gait with E/C
  • Final gait was aesthetically pleasing, symmetrical 4 point gait with 2 sticks. Pain free, smooth and efficient.
  • Outcome measure:[3]
Outcome Measures Day 7 D/C 6wk R/V
CIGAM Cb Db Db
LC15 30 35 37
TUG 30 22 17
2MWT 56 69 79
ABC-UK 55 70 73
SCS 7 7 5
  • Patient Goals:
Patient Goal Date Set Date Met Comments
Reduce PLP 22.04.15 01.05.15 Not improved with Mirror Therapy
Walk with 2 E/C 22.04.15 01.05.15 Now progressed to 2 sticks at D/C
Go up 2 steps 23.04.15 03.05.15 Safe and independent, OT to arrange hand rail

Get into/out of car 22.04.15 01.05.15 Independent
Walk over grass 24.04.15 03.05.15 Needs supervision for confidence
Go shopping 23.04.15 06.05.15 Supervision still required
Climb stairs to bed 22.04.15 05.05.15 Independent using 1 EC and 1 rail


Discussion

Evidence to support current practice and change of practice using ICF Framework.


PATHOLOGY
Pt has PVD, Diabetes, foot ulcers, poor glycaemic control and foot care. Diagnosed diabetes has risen in NI by 33% in 5 yrs. 1 in14 has had a foot ulcer. 1in10 foot ulcers result in 2 amputations/week here. Foot ulcers result from diabetic neuropathy and PVD.[4] After 1-5 years, 26-53% of dysvascular amputees in the UK require a 2nd amputation. BACPAR guidance recommends that prosthetic stability and gait should prevent abnormal loading of the contralateral limb. [5][6]

BODY FUNCTION AND STRUCTURE
: No referral made for W/C, stump board, community OT. No EWA used and minimal advice on ex. Pt did not wear juzo. This resulted in oedematous stump,FFD at knee,weak hip & core muscles. Guidelines recommend use of a stump board, EWA and juzo shrinker.[7][8][9]Pt had fallen when transferring. BACPAR guidance recommends balance exs to reduce falls risk. [10]Rehab was based on BACPAR guidelines,Engstrom,the Prosthetic Gait Analysis for Physiotherapists & Bob Gailey[1][2][3][4]

ACTIVITIES: 
Pt will always be W/C user and may become bilateral[5]. BACPAR guidance on the contralateral foot recommends education re risk factors and foot care.[5]


PARTICIPATION
: Diet,smoking,glycaemic control & foot care- discussed[5]. 80% Type 2 diabetes cases could be prevented by diet and exercise. Diabetes and smoking increases heart disease & stroke[6]. NICE recommend structured diabetes education[7].

References

  1. 1.0 1.1 Evidence Based Clinical Guidelines or the Physiotherapy Management of Adults with Lower Limb Prostheses. P Broomhead, K Clark, D Dawes, C Hale, A Lambert, D Quinlivan, T Randell, Ro Shepherd, J Withpetersen. BACPAR 2012
  2. 2.0 2.1 Therapy for Amputees Engstrom,B and Van de Ven C 19991
  3. 3.0 3.1 3.2 Prosthetic Gait Analysis for Physiotherapists. ICRC Physiotherapy reference Manual.Geneva, 2008
  4. 4.0 4.1 4.2 Prosthetic Gait Training for Lower Extremity Amputees. R Gailey, A Gailey. An Advanced Rehabilitation Therapy Incorporated Publication.19891
  5. 5.0 5.1 5.2 5.3 Risks to the Contralateral Foot of Unilateral Lower Limb Amputees: Guidance.F Brett, C Burton, M Brown, K Clarke, M Duguid, T Randell, D Thomas.BACPAR 2012
  6. 6.0 6.1 Fate of the contralateral limb after lower extremity amputation. Glaser JD1, Bensley RP, Hurks R, Dahlberg S, Hamdan AD, Wyers MC, Chaikof EL, Schermerhorn ML. Journal of Vasc Surg. 2013 Dec;58(6):1571-1577
  7. 7.0 7.1 White, E. (1992) Wheelchair stump boards and their use with lower limb amputees.British Journal of Occupational Therapy, 55(5),pp.174-178.
  8. Broomhead, P., Dawes, D., Hancock, A., Unia, P., Blundell, A. and Davies, V. (2006) Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. London: Chartered Society of Physiotherapy
  9. Oedema guidelines Guidance for the multi disciplinary team on the management of postoperative residuum oedema in lower limb amputees. E Bouch, K Burns, E Geer, M Fuller, A Rose. BACPAR 2012
  10. Guidance for falls prevention in Lower Limb Amputees. R Blundell, D Bow,J Donald, S Drury,L Hirst. BACPAR 2011