Regaining Functional Independence Following Left BKA: Amputee Case Study

Title

Regaining Functional Independence Following Left BKA

Abstract

Diabetic patients who have undergone lower limb amputation have usually spent a significant period of time prior, immobilized, deconditioned with declining independence nursing an infected limb.[1][2] They become dependent upon the medical system to manage their health. Rehabilitation following amputation must not only involve helping the patient to be physically independent[3] but also to be independent managers of their condition and function. The following outlines a case presentation of the pre-prosthetic assessment and treatment of a recent lower limb amputee towards functional independence

Key Words

diabetes, pre prosthetic rehabilitation, BKA, functional independence,

Client Characteristics

Mr. S is a 63 yr old retired male from a mining company. He has a longstanding history of diabetes, PVD, hyperlipidemia and arthritis and has not been compliant with managing his health or following up with physicians. Within the past year he has been nursing an amputation of his right 4th toe after undergoing debridement and drainage of a diabetic foot abscess. This subsequently led to a right BKA 1 month ago. He lives alone in a multi level home in a suburb of the city. He is divorced with 3 children, 2 that live in a nearby city. He recently was the caregiver to his ailing parents who have both died within the past year thus he was not focused on his health but on taking care of his parents and dealing with their deaths.

Just prior to his BKA, he was still ambulatory within his home using crutches to mobilize. He is a driver and enjoys travelling across the country attending festivals and cultural events. He would like to return to his home environment and proceed with prosthetic rehabilitation. Post amputation while on the surgical unit Mr. S was experiencing phantom pain and having difficulty with standing and hopping activity secondary to pain when the residual limb was dependent. He was then transferred to the Intensive Rehabilitation Unit for functional pre prosthetic rehabilitation.

Examination Findings

Presents as a thin man with a well healing R BKA incision, staples in situ covered with a dry dressing, bulbous stump with mild dog ears medially and laterally. Complaining of intermittent phantom pain 5/10 and incisional pain 4/10. The remaining limb had no pain, the skin was intact. ROM and strength testing revealed mild weakness throughout both lower limbs gr 4/5, the remaining limb weaker with primary weakness to hip extensors and knee flexors. There were no joint limitations and mild tightness to right knee flexors with right knee extension -5degrees.

Gross sensation testing was impaired to light touch and absent to temperature to his fingertips, lower legs and feet. He had functional U/E ROM and strength with decreased lumbar movement and tendency to posture in posterior pelvic tilt with weak trunk extensors and abdominals. He was independent with bed mobility and was able to perform a standing transfer to/from his W/C but required supervision due to safety issues. He was weak with sit-stand and very dependent for arm support. He was able to hop short distances with a 2 wheeled walker tending to overshoot too far forward within the walker.

Mr. S was noted to be anxious, having difficulty with initiation, processing and displaying memory impairment with day-day activity. With limited functional independence he is not able to currently return to his home environment to live independently. Having an amputation will affect his ability to drive, participate and access his leisure activity.

Clinical Hypothesis

Mr. S is a recent right BKA with a healing incision who is presenting with weakness to his lower extremities and core stability limiting his functional independence. He is also exhibiting some emotional adjustment[4] and cognitive impairment impacting his independence and safety to return to his previous home environment and leisure activity. In preparation for prosthetic rehabilitation, he requires strengthening and functional training as well as cognitive and emotional support.

Intervention

Mr. S was provided education on; goals of pre prosthetic rehab, expected wound recovery and requirements for prosthetic fitting, phantom pain management-desensitization techniques, protection of skin integrity, positioning for stump edema and prevention of contractures. He was instructed on a L/E exercise program for both limbs with focus on hip extension, abduction, knee flexion and extension.

Additional exercises were also added for trunk and core strengthening using a medicine ball. He was also initiated on arm/leg ermometry for upper body conditioning and endurance training. Mr. S was taught proper and safe technique for transfers, sit to stand and hopping with a 2 wheeled walker and this was practiced daily. The PTA also performed additional sit-stand and hopping activity with him on the unit.

Mr. S was given a W/C and he was instructed and encouraged to propel independently on the unit and to attend his therapy sessions. Since Mr. S has stairs within his home with access to only 1 railing, stair climbing practice was also initiated using 1 railing and 1 crutch.

Discussions with Mr. S have begun re planning towards a weekend pass[5] from the rehab unit involving his daughter for assistance and supervision. This will allow practice of skills within the home environment and allow for trouble shooting prior to D/C. Alternatively the rehab team will need to discuss if it is of more benefit to proceed directly with prosthetic fitting in light of safety and home barriers

Outcome

Currently Mr. S has only occasional phantom pain lasting only a few minutes and virtually no incisional stump pain. His edema is resolving along with the dog ears medially and laterally. His wound continues to heal nicely with staples still intact. He is now independent in performance of his exercise program and has progressed to the use of weights with his exercises, he is now able to sit in long sitting with his knees fully extended, can lie prone for 30+ min and has increased his repetitions of his core strengthening exercises. He is tolerating 10 min of arm/leg ergometry.

He is able to perform sit-stand with minimal use of his arms and can maintain standing for a brief period prior to supporting on the walker. He is transferring independently on the unit and within therapy sessions. He is tolerating hopping with a 2 wheeled walker 20m with no stump pain. He is able to manage stair climbing using 1 railing and 1 crutch but is still requiring some assistance as he is having difficulty adjusting his C of M with the crutch and remembering crutch/foot placement.

Mr. S is propelling his W/C independently on the rehab unit and is now attending therapy sessions independently. He is more social and is initiating conversations with staff and patients and appears to be more at ease and happy. Currently, he has yet to go out on a weekend pass and is requiring prompting and assist with the execution of planning this.

Discussion

Mr. S has benefited from a pre prosthetic rehabilitation program.[3] Daily intervention has allowed him repeated practice with carryover and increasing independence with functional activity. The rehab environment and his exposure to other amputee patients have assisted in his acceptance of his condition and motivation to participate in the rehab setting.[4]

He is socializing with other patients, is less anxious and his mood is upbeat. While he is improving physically, his independence remains limited by his cognitive status. This may impact his ability to return home to independent living currently. It is also a concern regarding his potential for prosthetic training. Mr. S will require a very structured prosthetic training program to learn the management of his stump and prosthesis.

Conversely, due to the environmental barriers within his home, proceeding with a prosthesis will allow him a better opportunity to manage stair climbing and accessing the levels of his home environment thereby maximizing his independence, safety and his ability to return home and resume his everyday life and activity.

[6]

References


  1. The Diabetic Amputee: Physiopedia.com
  2. Engstrom B, Van de Ven C: Causes of Amputation:Therapy for Amputees pgs 21-24, 39-45
  3. 3.0 3.1 Acute post-surgical management: Physiopedia.com
  4. 4.0 4.1 Engstrom B, Van de Ven C: Psychology and Amputation:Therapy for Amputees pgs 68-92
  5. Discharge Management of the Amputee: Physiopedia.com
  6. Post-operative Physiotherapy: AustPar