Rehabilitation of a young transtibial amputee: Amputee Case Study

 Title

Rehabilitation of a Young Transtibial Amputee

Abstract

This case presentation outlines the first seven weeks of rehab for a nineteen year old gentleman who suffered a traumatic right transtibial amputation. He is now ambulating independently with his prosthesis (no gait aids) in physio and looks forward to returning to university studies and a part-time cafe job.

Key Words

young, transtibial, traumatic

Client Characteristics

"Mr P" is a 19 year old man who suffered a traumatic right transtibial amputation after being hit by a train 7 weeks ago. He was taken by ambulance to the nearest trauma centre where his right lower leg was declared unsalvageable. It was amputated that evening. He also suffered multiple right rib fractures. He remained in the acute hospital for 7 days. His medical recovery was uncomplicated. He was seen by physiotherapists to monitor his breathing and teach transfers and crutch ambulation. He was then transferred to our inpatient rehabilitation centre. As he was mobile and from a safe home environment, he was discharged home Day 12 post amputation.
Mr P had no significant medical past history. He is a ""social"" smoker and drinker, although admits to binge drinking when out with friends. Prior to the accident, he lived with his parents and younger siblings in a 2 storey house (access via 2 front steps, bedroom/bathroom upstairs but kitchen/living room downstairs). He had finished school the year previously and was in his first year of university, studying Arts. He had previously walked unaided, an unlimited distance and had no history of falls. He drives an automatic car and often catches public transport (trains, buses). He was not particularly sporty, reporting playing the odd game of golf or tennis with his mates. He did no formal exercise but enjoyed riding his bike and skateboarding. He worked part-time at a cafe and enjoyed socialising with friends and playing his guitar."


Examination Findings 

7 weeks post amputation:

  • Full ROM and strength (5/5) both ULs and left LL
  • Good core strength and full spinal ROM
  • No skin/circulation issues. Wound fully healed. Scar sensitive to touch.
  • Right LL: full ROM at hip/knee, quads/hams strength difficult to measure on Oxford scale due to sensitivity to pressure
  • 19cm residual limb, moderate swelling, bulbous shape, no dog ears
  • No stump pain, regular phantom sensations. No pain meds
  • Taking an anti-depressant. Has progressed through early stage of depression, now very motivated
  • with rehab


Without prosthesis:

  • Independant transfers, including standing-floor
  • Balance on foam eyes closed on left LL >30sec, reaches out of base of support forwards and sideways, can pick up object from floor
  • Independant ambulation with crutches 250m, including stairs
  • AMPnoPRO score 39 (indicates potential K Level 4 ambulator)
  • Using shrinker for oedema control


With Prosthesis:

  • PTB SC socket, pelite liner, SACH foot
  • Wear time 40 mins limited by ""pressure soreness""
  • Walks unaided, slightly decreased stance time on right leg, equal step length, endurance 200m
  • Ascends/descends stairs non-reciprocally
  • Able to weave between cones, change directions, walk backwards, outdoors on grass


Main activity limitations:
1. Limited walking distance
2. Can't drive yet
3. Can't skateboard

Main participation restrictions:
1. Not back at university
2. Not back at part-time cafe work
3. Not going out with friends (e.g. to pub)

Clinical Hypothesis

At present, Mr P's main problems are:

1. Able to wear prosthesis for only 40mins before needing to take it off to ""rest"" the residual limb (due to pressure discomfort)
2. Gait endurance only 200m
3. Discomfort in right single leg stance: holds for 2-3 sec only
4. Is only using prosthesis in physiotherapy gym.

This problem list was developed by physio and patient together.


Intervention

As Inpatient and Pre-fitting:

  • Full physio assessment
  • Standing balance
  • Leg strengthening: free weights both legs, weight machine left leg only
  • Arm strengthening: free weights, weighted pulley, arm ergo
  • Right hip flexor and hamstrings stretching
  • Advice on positioning: prone lying, sitting with knee in full ext
  • Advice on self-massage and desensitisation (has not been compliant with this)
  • Ambulation with crutches, increasing distance, teaching stairs and floor transfers


Post-fitting:

  • Independant on/off
  • Standing weight shift: side to side, forwards/backwards
  • Part-practice of walking in parallel bars: stance phase, swing phase
  • Walking in parallel bars
  • Weight bearing activities e.g. tapping left foot onto step
  • Walking with stick and then unaided
  • Increasing walking distance and prosthetic wear time
  • Uneven surfaces
  • Wobbleboard for balance, rolling a ball under left foot
  • Education in stump monitoring
  • Hydrotherapy x 3 sessions: relearning to swim


Prosthetist:

  • Oedema management: RRD, then shrinker
  • Casting, fitting, adjustment
  • Education re care of prosthesis

OT:

  • Light meal preparation with prosthesis on
  • Showering/dressing advice


Psychologist:

  • Ongoing review to monitor for coping/signs of relapse of depression/adjustment issues


Outcome

The outcome of our intervention so far is that Mr P will most likely take his prosthesis home for the first time next week. He will start with a graduated wear programme of 40mins three times per day, progressing gradually up to 2 hours three times per day. At this point, he will go to 3 hours, twice per day and gradually build this up until he is wearing his prosthesis for most of the day. His mother is very supportive and has attended several physio sessions recently so she will assist Mr P with his graduated wear programme. He will continue attending physio for another week or so after he takes his prosthesis home but will then be given a six week therapy break to allow him to concentrate on returning to university, hobbies, etc. His OT is liaising regarding returning to driving and also a graduated return to work programme once he is tolerating longer wear times.

After the six week break, Mr P will be invited to resume therapy to concentrate on any higher level activities he may wish to pursue, for example climbing ladders, running, golf, bike riding. He will also be guided to formulate an ongoing exercise plan for life-long health to counteract the negative effects of a sedentary lifestyle (weight gain can be particularly problematic for amputees).

Discussion

In summary, Mr P's case demonstrates the speed at which a younger client can be progressed, as opposed to the older clients with multiple co-morbidities that make up the bulk of the current patient population in our rehab centre. It is unusual for us to have a client that does not require a wheelchair for non-prosthetic mobility. It is unusual for us to have a client that does not have some combination of cognitive difficulties, visual/hearing loss, peripheral neuropathy/circulation deficits or joint/cardiac/lung disease that limits mobility.

However, psychologically Mr P has had greater adjustment issues than most of our clients. Often our clients have had pain and lack of limb function for so long that is almost a ""relief"" to have the amputation. Many describe looking forward to a new beginning whereas Mr P has to re-imagine his future.


References

  1. Morris, S. ""The Psychological aspects of Amputation"" Amputee Coalition of America (2008)
  2. International Classification of Functioning, Independence and Health. World Health Organization (2001) ISBN/WHO Reference number 92 4 154544 5
  3. Engstrom, B and Van de Ven, C ""Therapy for Amputees, 3rd Ed."" Elsevier (1999)
  4. Clinical Practice Guidelines for Rehabilitation of Lower Limb Amputation Dept. of Veteran's Affairs, Dept. of Defence (2007)
  5. Broomhead, P et al ""Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. Chartered Society of Physiotherapy, London (2006)
  6. Gailey, R.S. and A.M. ""Prosthetic Gait Training for Lower Extremity Amputees""
  7. Pescatello, L.S et al ""ACSM Guidelines for exercise testing and prescription"" American College of Sports Medicine (2014)