Rehab of an elderly patient with traumatic AKA amputation: Amputee Case Study

Title

Rehab of an elderly patient with traumatic AKA amputation: Amputee Case Study

Abstract

At the edge of 67, the patient was hit by a car while crossing the street on 12/8/2011. Her right leg could not be salvaged and she underwent an AKA amputation. She woke up in the hospital without a leg. Her goals were to walk without an assistive device and return to work in house cleaning. She was treated in an outpatient setting for two courses of PT. She used her own health insurance (Medicare) to cover her care, as the person that hit her had no car insurance.

Key Words

transfemoral, elderly, gait training, prosthesis, traumatic, amputation

Client Characteristics

At the start of outpatient rehab, the patient was 68 years old, African-American, 10th grade educated, lives alone in a house with steps, moderately obese woman who underwent right traumatic AKA. Her other injuries included bilateral shoulder strains and LB strain. She had mild depression. Her comorbidities include DM, high cholesterol, arthritis of hands, 2006 excision of breast cancer, and 2003 left TKR.

Her previous treatment included six weeks in a rehab facility. She had been fitted with an ischial containment socket, with pin lock system, with safety knee (weight activated stance control), and with a SACH foot. She used a liner and socks of various ply. She took public transportation or cabs to physical therapy. Her finances were limited as she could not work.

Examination Findings

  • The patient's goals were to walk without assistive devices and return to work as a house cleaner. She hoped she could get a better prosthesis that would help her walk better.
  • She complained of bilateral shoulder and LBP and pain around the socket brim. She reported that she was using her third prosthesis as her leg was continuing to shrink. She was able to don/doff her prosthesis but needed guidance on how many ply socks to use for the best fit. She understood how to clean her prosthesis.
  • She ambulated with a rolling walker independently. Her limb was in excellent condition.
  • Her second course exam measures: Speed of gait .7 ft/sec with two small based quad canes; Two minute walk test 160 ft with rolling walker; R hip strength 4/5; 1-5 degrees less hip ROM on right compared to left.

  • ICF d4500

    • body structure and function: R AKA amputation
impairments: decreased mobility, altered gait, decreased balance, low endurance

    • activity limitations: could not work in house keeping, transportation difficulties, decreased ability to walk and do housework
restrictions: decreased ability to socialize and go to church
    • environmental/personal factors: lives alone in a house with stairs, limited income, low education level, depression, insurance coverage limitations

Clinical Hypothesis

The patient's main problem is difficulty walking with prosthesis.

Intervention

She was seen 1-2x/wk for 12 weeks. Her home exercise program included hip stretching and strengthening as well as shoulder and back exercises. She progressed to weight bearing exercises to work on further strengthening the right hip; weight shifting to the right; and balance as well as improving her gait mechanics; progressing from the walker to 2 SBQCs; ambulating on even surfaces, stairs, and ramps; getting up from the floor in case of falls; and education in the correct sock ply.

PT was limited by her insurance benefits running out. She returned for a second course of PT about 2 years later after getting another new prosthesis due to leg shrinkage and persistent difficulty in walking. She had good hip ROM but hip weakness. She was educated on the importance of doing home exercises to strengthen the hip so she could maneuver the prosthesis. She was educated in the correct number of sock ply to use and how it may vary during the day to improve her socket fit.

In PT, she worked on progressing from 2 SBQCs to 1 as well as walking short distances without assistive device while carrying things like a cup of water; improving gait mechanics to decrease her flexed posture, uneven step lengths, and uneven step timing; improving endurance; and improving dynamic balance with walking on different terrains and changing directions. Her prosthetist attended 1 PT session so we could work together to improve her gait mechanics otherwise the prosthetist went to her home.

Outcome

This patient worked very hard in PT. The patient progressed from using a rolling walker to two then one small based quad canes to no assistive device for short distances (30 ft). She was able to walk on level surfaces, ramps, stairs, and curbs. Her speed of gait improved to .8 ft/sec with a small based quad cane and to .5 ft/sec without assistive device. Her two minute walk test improved to 184 ft with rolling walker, 85 ft with small based quad cane.

Discussion

For this elderly woman with limited walking distance and endurance, an appropriate physical performance measure had to be chosen to initially assess the patient as well as show progress. The 2-minute walk test was chosen and she did show improvement[1]. This elderly woman worked very hard in outpatient rehab but she attended PT inconsistently and was not compliant with her home exercise program nor with wearing the appropriate sock ply to improve her socket fit as her limb volume changed throughout the day[2].

Compliance in the lower extremity amputee population I have worked with has been a common challenge. Psychological counseling may have helped improve her compliance. She was referred to an amputee support class but she did not attend. She was also limited by her financial status and her insurance. If she had better insurance or better financial resources she may have gotten a prosthesis with components that could allow her to be more functional and return to work and be a community ambulator[3].

The most improvements in her mobility were noted after sessions were the prosthetist came in to work with the patient during PT reinforcing the importance of the team.
I wish I took this course before I treated this patient. This course has provided me with more tools I can use to evaluate the functional level of the patient with an amputation, many educational resources as well as reinforcing the need to get help for the patients in other area.

References

  1. Brooks D, Parsons J, Hunter JP, Devlin M, Walker J. The 2-minute walk test as a measure of functional improvement in persons with lower limb amputation. Arch Phys Med Rehabil. 2001 Oct;82(10):1478-83.
  2. Sanders JE, Cagle JC, Allyn KJ, Harrison DS, Ciol MA. How do walking, standing, and resting influence transtibial amputee residual limb fluid volume? J Rehabil Res Dev. 2014;51(2):201-12. doi: 10.1682/JRRD.2013.04.0085.
  3. Aisling M Fleury, Salih A Salih and Nancye M Peel Rehabilitation of the older vascular amputee: A review of the literature Geriatr Gerontol Int 2013; 13: 264-273