Prosthetic rehabilitation of a trans-tibial amputee because of arterio scleroses and diabetes mellitus: Amputee Case Report


Original Editor - Fred Smedes

Title

Prosthetic rehabilitation of a trans-tibial amputee because of arterio scleroses and diabetes mellitus: Amputee Case Report

Abstract

This case report describes a 56-year-old male, who underwent a trans-tibial amputation based upon circulation impairments. The management focused on treatment on all levels of the ICF. Impairments and disabilities where addressed with exercise therapy and patient education. The therapy was divided in 5 phases from postoperative phase to community integration. The progress of the patient was monitored with five functional tools. The patient improved on all functional and impairment outcomes. The presented therapy strategy and management as well as the used monitoring instruments are consistent

Key Words

transtibial, diabetes, PNF treatment, gait, Total ICF approach.

Client Characteristics

The patient described is a 56-year-old male, who suffered from extensive circulation impairments based upon arteriosclerosis processes and diabetes mellitus. His walking distance was decreased to +/- 50 meters (intermittent claudication signs). All together the situation led first to a Symes-amputation, but since the wound healing did not progress sufficiently a trans-tibial amputation followed with a stump of proximally 17 cm below the knee. Now the wound healing progressed as expected.

The patient suffered 4 year before the amputation a myocardial infarction which was treated with an angioplasty and a stent. The patient is an intense smoker, no signs of overweight.

Examination Findings

At Initial evaluation after trans-tibial amputation the patient is eager to improve his personal condition; he wants to be able to walk again. His views on physical improvement in terns of endurance might need further development. In general the patient is a strong man. He regained normal cardiac load ability after his infarction of 4 years ago. His general status on physical abilities is good. He scores on the Amputee Mobility Predictor Assessment Tool a score of 31 points. The affected right leg showed diminished ROM in the hip and knee joint, decreased muscle strength in Gluteus and Quadriceps. Oxford scale 3(+)

Intervention


The physical therapy treatment started at the 2nd day after the trans-tibial amputation.

The following stages in the rehabilitation process where defined:


  1. Post-operative: providing emotional support, promoting limbs hygiene and expediting wound healing, maximizing limbs shrinkage and stumps shaping, controlling phantom pain and alleviating phantom sensation

  2. Pre-prosthetic: reducing disabilities and impairments (facilitating independence)

  3. Prosthetic training: prosthetic management to increase wearing time and functional use

  4. Functional training: gait training and daily activities training

  5. Community reintegration: resuming life roles such as family and community roles, developing healthy coping strategies


1. Post-operative phase:


Providing emotional support
. The involved care providers established an ongoing supportive and trusting relationship with the patient. The emotional needs of the patient where sensitively addressed at all stages of the rehabilitation process. The patient was introduced to others who also underwent similar amputations resulting in similar disabilities[1]. 


Promoting limbs hygiene and expediting wound healing, maximizing limbs shrinkage and stumps shaping: The patient has been trained in daily care for his stump, washing with mild soap, careful and consistent drying has been emphasized. Shaping of the stump was managed with soft dressing / bandaging. [2].

Controlling phantom pain and alleviating phantom sensation. Managing the oedema could aid pain relief. The pain increased with stress. Therefore pain was assessed to determine its possible causes and allayed his fears to keep stress levels to a minimum. Effective pain-relieving techniques/modalities for phantom pain including relaxation, massage, percussion, compression, exercise. These interventions were also used to desensitize the residual limb. In this way the stump was prepared for suspension of the prosthesis.


  • Massage was used to desensitize and to prevent adhesions in the scar tissue

  • Tapping, rubbing and the use of a vibrator at the stump

  • Wrapping and bandaging the stump contributed to desensitization
  • The patient was instructed to put weight on the end of the limb against various surfaces. These surfaces varied from resilient, such as soft foam, to variously resistant harder materials, such as the treatment table. The patient was directed to push the limb down into the surface and to increase the contact time and pressure to train toleration.


2. Pre-prosthetic phase:


Reducing disabilities and impairments
. This phase focused on the abilities of bed transfers, bed - (wheel) chair transfers and ambulation with crutches. Secondary objectives where on impairments; strengthening of hip extensors and abductors, knee extensors and lengthening of hip flexors, knee flexors and hip adductors. Also training of the upper extremities and trunk was apart of the rehab.

Physical exercises and educated was provided to perform strengthening and stretching. A PNF based therapy, in which techniques such as Rhythmic Initiation, Combination of Isotonics was used to teach the patient coordinated movements in synergies imitating functional movements (Shimura 2002, Mc Mullen 2000). Repeated Stretch through Range and Dynamic Reversals where used to promote muscle strength[3] and Hold Relax techniques aimed at increasing AROM [4] (Sahrmann 2006).

As soon as the wound healing allowed to use a IPOP a PPAM-aid was used. Functional balance and gait training was started [5] (Ross 2009). In this phase balance and weight bearing was facilitated with PNF procedures and principles mainly approximation and resistance stimulated proprioception, weight bearing and equilibrium[6] (Yigiter 2002).

3. Prosthetic training phase:

The prosthesis provided was a Patella tendon bearing prosthesis. The patient has been trained in donning and doffing of the prosthesis and how to determine the appropriate socks also how to adjust them.

4. Functional training phase:

Gait training started in the pre-prostatic phase with the use of the PPAM-aid. Even before that weight shifting, balancing and stepping was integrated in the rehab by standing with the knee on the treatment table. Based upon improved balance endurance and velocity on flat surfaces was trained [7] (Sansam 2009). Elevations, stairs, curbs and ramps followed (Vrieling 2009).

Outcome

The progress of physical abilities was monitored throughout the rehabilitation phase.

Instruments that where used are:

  • Timed up and go test (TUGT) for assessing the risk of falling (Shumway-Cook 2000).
  • Functional reach test to assess standing balance (Duncan 1990).
  • 10 meter gait test was used to assess average speed and step length[8].
  • Endurance was evaluated with the 6 minute walk test (Lipkin 1986).
  • Total indecency was assessed with the Amputee Mobility Predictor Assessment Tool. Measurements where taken at the moment of using the PPAM-aid, at the start of using the final prosthesis and after 10 weeks of training with the final prosthesis.

TUGT improved from 33 over 26 to 12 seconds. Functional reach test improved from 10 over 16 to 24 cm. Ten meter gait test developed from 37 steps over 32 to 18 steps, so step length with the unaffected leg from 5 over 19 to 43 cm and the effected leg from 49 over 43 to 66 cm.

The 6 minutes walk test was stopped after 2 min.+ 11 sec. after 40 meters with the PPAM. At the start with the prosthesis the test was stopped at 2 min.+ 47 sec. after 67 meters a the end the full 6 min. resulted in 259 meters. The AMP-AT improved from 32 over 32 to 39 points.

The impaired ROM of the HIP improved extension by 10 degrees abduction by 5. Knee ROM improved by 15 degrees for flexion, The muscle strength of the quadriceps and gluteus both improved from 3+ to 5- on the oxford scale. The patient was independent and participated in the family.

Discussion

The patient presented improved on his impairments and disabilities, this is consistent with outcomes of review studies on patients with amputation based upon circulation impairments[9]. In spite of his pre-amputation condition, the patient progressed enormous during his rehabilitation phase. Possibly his local leg condition was the main limiting factor for his diminished gait distance.

Reflecting from his initial results on the Amputee Mobility Predictor Assessment Tool (32 points) it was clear that the patient had good qualities to improve. This tool mainly assesses the abilities with a load of short duration. The main initial problem for the presented patient gait endurance. Local test showed relative good pre-conditions, only the Gluteus and the Quadriceps showed relative severe diminished strength. This explained the initial problems in standing and gait.

That balance and gait has improved might be explained by increased strength of these muscle groups(Perry 1992). Also the ROM of hip extension has improved. The total improvement is can also be explained by motor learning effects. (Wulf 2010) In all stages of physical rehabilitation varies principles of motor learning have been implemented, such as part task training and whole task training[10]. The chosen PNF based exercise strategy is aiming for motor learning in relation to sensation of joint positioning, which is mainly depending on muscle sensation (Marks 1997). The patient still smokes, so at risk

References

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  3. KofotolisN, Vrabas IS, Vamvakoudis E, Papanikolaou A, Mandroukas K: Proprioceptive neuromuscular facilitation training induced alterations in muscle fiber type and cross sectional area. British Journal of Sports Medicine 2005 (3):e11.
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