Rehabiliation Following a Transtibial Amputation in a Young Male with Peripheral Vascular Disease: Amputee Case Study

Title

Rehabiliation Following a Transtibial Amputation in a Young Male with Peripheral Vascular Disease

Abstract

This case study presents a 36 year old male with a left trans-tibial amputation following a history of peripheral vascular disease. On assessment he has a -5o hip flexion contracture bilaterally, he is transferring independently and is mobilising with the use of the parallel bars. His goals are to return to cycling, snowboarding and motorcycling. Following a 4 week period of rehabilitation focused on gait re-education, functional activities, balance work and psychological discussions undertaken in an interdisciplinary team approach this patient was discharged mobilising independently.

Key Words

Transtibial, peripheral vascular disease, gait re-education, balance training.

Client Characteristics

The patient presented is a 36 year old male who has a 3 month history of a left transtibial amputation. He previously worked as a software designer and is married with a one year old daughter. He has a past medical history of peripheral vascular disease in the left leg since the age of 22. He previously underwent two failed femoral popliteal bypass operations and an angioplasty. He then developed sores and cellulitis on his left shin and foot and reported intermittent claudication following mobilising 40-50 yards. He opted for a transtibial amputation rather than a further bypass as failure would have led to a transfemoral amputation. Other than triple therapy for H.bacter and a family history of heart disease he has no further medical history. He is currently independent in a self-propelling wheelchair on loan from the Red Cross and is wearing a Juzo shrinker. He lives in a bungalow and is independent with transfers and with ADL's. His wife provides help if required. He is unable to drive at present. His hobbies include watching and taking part in sports and he would be keen to return to golf, mountain biking and motorbikes. Prior to amputation he spoke with a psychologist were he expressed feels of low mood and depressive episodes for many years due to pain.

Examination Findings

Subjective: see above for history of present condition

Pain - VAS 2/10, controlled by pregabalin

Previous mobility limited by claudication after 40 -50 yards

PMH: see above (No MI, CVA, DM, OA, RA, dialysis, allergies)

Medication:

  • Pregabalin - neuropathic medication to reduce phantom pain
  • Tramadol - pain relief
  • Clopidrogel - blood thinner
  • Omeprazole - reduce stomach acid

Physical Assessment

  • Observation - red scar line with a few scabs along it. Prominent head of tibia
  • Hip flexion contracture of -5o bilaterally. No knee flexion contracture
  • Full ROM and MMS in upper limbs
  • MMS of lower limbs is Grade 5 throughout except bilateral hip extension and left knee flexion which scores 4/5
  • Normal hand dexterity
  • Independent sitting balance
  • Transfers from wheelchair to plinth independently
  • Standing balance with WZF independent for 3 min
  • No issues with contralateral limb
  • Self Reported outcome measures - LCI5 4/56
  • Physical Performance Measures - unable to complete TUG, 2MWT


The ICF checklist shows:

  • Impairments with energy, sleep, attention, pain, joint mobility, muscle power, emotional functions
  • Complete impairment with partial absence of lower extremity
  • Impairments in lifting/carrying objects, using transportation, interactions and relationships, domestic life, walking and driving
  • Facilitated by support and attitudes of friends and family
  • Barriers include attitudes of society and social norms and social security, housing and transport 

Clinical Hypothesis

This patient is presenting at the initial stage of fitting when he has just been fitted with a prosthesis. His prosthesis is made from a polypropylene socket with supracondyler suspension and a dynamic elastic response foot.

His main problems are:

  • Unable to don/doff prosthesis
  • He is mobilising with prosthesis, however, he requires maximum support of the parallel bars
  • Poor gait pattern. He is displaying gait deviations such as poor step symmetry and knee flexion in stance phase
  • Decreased balance and weight transference onto prosthetic side - tends to favour contralateral limb on standing and mobilising
  • Potential skin issues - requires close monitoring
  • Psychological issues as a result of losing the limb and due to previously history

Intervention

There were numerous interventions undertaken to aid full rehabilitation over a period of 4 weeks. These include:

  • Donning and doffing practice using the errorless technique
  • Education on skin care and monitoring
  • Sensory feedback through the prosthetic limb
  • Gait re-education progressing from the parallel bars, unto elbow crutches, unto two sticks, unto one stick and then to independent without aids

Interdisciplinary working with the prothesist to correct gait deviations. This was solved by both corrections which the patient could make and alignment issues solved by the prothesist such as:

  • Early knee flexion in stance phase - strengthening exercises, verbal feedback, socket extended and translated posteriorly
  • Asymmetry in step length - verbal and visual feedback
  • Circumducting limb - limb shortened by prothesist
  • Weight bearing on lateral border of foot - socket adducted by prothesist
  • Functional progression to complete steps, stairs and outdoor mobility
  • Functional assessments by Occupational Therapist regarding transfers and personal care. Information given regarding return to driving and shower stool issued.

Balance and proprioceptive work -

  • Using orthobalance board to find centre of gravity and complete weight transference activities
  • Using foam cushion, aearostep, wobble boards, wii fit
  • Theraband to encourage pelvic rotation


Psychological - referred to clinical psychologist and arranged conversation with an amputee of a similar age.

Outcome

On discharge from physiotherapy this patient was able to don and doff his prosthesis independently. He was mobilising independently without aids with a normal gait pattern and he was independent in skin care and monitoring his residual limb. He felt that he was psychologically better off and found the conversation with the fellow amputee very encouraging and motivating. The outcome measures completed at discharge showed:

  • Timed Up and Go (TUG) - 15.73 seconds
  • Socket Comfort Score (SCS) - 8/10
  • 2 Minute Walk Test (2MWT) - 102 m
  • SIGAM - E - requires stick when mobilising in inclement weather or over rough terrain
  • Locomotor Capabilities Index (LCI5) - 52/56 - as above. Requires an aid on rough terrain and inclement weather and on stirs with no handrail
  • Activities-specific Balance and Confidence Scale (ABC) - 72.3% - decreased confidence on the more complex activities such as in a busy environment, stepping onto a chair and on/off an escalator
  • At his 6 week review appointment, this patient had a TUG of 13 seconds, 2MWT of 112m and an ABC of 85%. His SCS, SIGAM and LCI5 remained as on discharge. This shows that he continued to progress post-discharge and his confidence had also increased. On a further review appointment this patient was independently mobile, he had returned to work and had commenced cycling. He had also involved with a local amputee support group.

Discussion

Transtibial amputations are the most common amputations, however, loss of the foot and ankle results in a loss of shock absorption and sense of positioning. Peripheral vascular disease as seen with this patient is the cause of 90% of amputations in the UK[1].This patient's rehab was undertaken in an interdisciplinary team approach which is shown to promote higher levels of teamwork and team effectiveness and makes rehabilitation more likely to succeed[2].A key component was gait re-education. Maintaining equal step length is the most difficult part of gait training, often due to pain or insecurity, causing the amputee to transfer his weight quickly from the prosthesis to the intact limb, producing a short, rapid step with the intact foot [3].There is also a lack of proprioception on foot placement often resulting in a large prosthetic step.There also is the increased length of time spent on the sound limb during stance phase corresponding to a study by Bateni and Olney[4] showing that transtibial amputees have a longer stance phase.Single limb support is 37% of the gait cycle for the affected limb but 43% in the unaffected limb.This can be rectified by balance training as following, stance on the prosthetic limb is increased[5]Balance training is important for a patient to re-orientate to their centre of gravity and decrease risk of falls[6].    

[7]  [8]         

References

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  2. KORNER, M., 2010. Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team approach. Clinical Rehabilitation, 24(8), pp. 745-755
  3. YIGITER, K., SENER, G., ERBAHCED, F., BAYER, K., ULGER, O.G. and AKDOGAN, S., 2002. A comparison of traditional prosthetic training versus proprioceptive neuromuscular facilitation resistive gait training with trans-femoral amputees. Prosthetic and Orthotics International, 26(3), pp. 213-217
  4. BATENI, H. and OLNEY, S. 2002. Kinematic and Kinetic Variations of Below-Knee Amputee Gait. Journal of Prosthetics and Orthotics, 14(1), pp. 2-10
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  7. ENGSTROM, B. and VAN DE VEN, C., eds. 1999. Therapy for Amputees.3rd edn. London: Churchill Livingstone
  8. BERGER, N. 1990. Analysis of Amputee Gait. In: J.H. BOWKER, J.W. MICHAWL, eds. Atlas of Limb Prosthetics: Surgical, Prosthetic and Rehabilitation Principles. 2nd edn. St Louis: Mosby Year-book. Pp. 371-380