Rehabilitation of an amputee with Parkinson's Disease: Amputee Case Study

Abstract

This case study involves a 72-year-old gentleman who was a left transtibial amputee who is also a person with idiopathic Parkinson’s Disease. Additionally, there were unique gait difficulties and an underlying complex cognitive and social aspect to this case which were difficult to find holistic solutions for. 

Key Words

Transtibial, Parkinson’s disease, geriatrics, rehabilitation, freezing

Client Characteristics

Mr Z was a 72 year old, overweight gentleman with a left transtibial amputation secondary to peripheral vascular disease of which he had surgery for several years previously. His relevant past medical history included Parkinson's disease which was under treated through levodopa therapy.

He was admitted with falls secondary to a urinary tract infection as well as decreasing mobility over the past three months. At home he had no care provider other than his 75-year-old wife. He lived in a house with one flight of stairs which he was unable to do and had been sleeping downstairs for approximately three weeks. His prosthesis did not fit correctly. Additionally he was using an old prosthesis he was not supposed to be wearing, clarified by his prosthetist through MDT collaboration (CSP 2012).

Examination Findings

Subjectively Mr Z  was very reluctant to accept any alterations to his current prosthesis but demonstrated full capacity and ability to make his own decisions. His Parkinson’s Disease was also a factor; he suffered from lower limb mid-walk freezing as well as a shuffling-type gait which made him prone to falls.

In terms of range of movement he demonstrated a 10° loss of full extension in his amputated limb and this is typical of transtibial amputees[1] and not as a consequence of weak quads but due to a contracture which had developed over time[2]. Overall his strength was 5/5 on the oxford scale on his right leg. However, his left was 3+/5 in his quadriceps, hamstrings and glutes, all of which were integral to his mobility whilst using his prosthesis and were a large focus of our rehabilitation in keeping with national guidelines[3].

Clinical Hypothesis

Summary of problems
:

  • Complex social situation

  • Inappropriately donning prosthesis
  • Decreased mobility

  • Decreased range of movement

  • Decreased strength in his left leg

  • Freezing of gait

  • Shuffling gait

Intervention

  • Consultant-led management of PD medications with pre and post 10m walk test.

  • CBT led and directed by occupational therapists for the management of his psychological distress and coping with losing his favourite prosthesis
  • Targeted specific lower limb strengthening programme in supine, sitting and standing

  • Gait re-education in relation to PD including external cueing (since there were no abnormalities seen that would typically be associated with amputees).

  • MDT discharge planning
  • 
Medical management of the UTI

  • Change to modern and well fitting PTB socket (the previous prosthesis had become poor fitting and several socks were being used by the patient to fill in gaps and subsequently he was at very high risk of developing pressure area complications)

Outcome

Overall the MDT collaboration was deemed a success. A valid and appropriate outcome measured was used to assess Mr Z’s fall risk as well as progression of his rehabilitation; in this case it was the timed-up-and-go[4]. His time improved from 1 minute 46 seconds to 59 seconds, which is considered a statistically significant improvement and demonstrated the effectiveness of the MDT intervention[5].

From a psychological perspective, our management through CBT[6] was moderately successful because Mr Z was willing to accept further rehabilitation which he initially declined as well as accepting that his 'newer' prosthesis was more suitable than his favored 'old' one. It is possible that he was going though the bereavement cycle for a second time after having his mobility taken away from him for a second time[7].

Discussion

An interesting consideration in this case was the psychological impact of asking Mr Z to replace his preferred but old and ill-fitting prosthesis in favour of a new and unfamiliar albeit safer and more appropriate prosthesis. This recommendation could have been interpreted by Mr Z as a second time he had gone through the bereavement process of losing his limb thus a goal of the MDT was to help address this potential complication[8].

References

  1. Bella J. May, AMPUTATIONS AND PROSTHETICS, F.A Davis Company, 2rd Edition, 1996
  2. Kishner's Gait Analysis after Amputation updated July 2013 http://emedicine.medscape.com/article/1237638-overview (accessed 3 February 2015)
  3. British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR). (2006). Clinical Guidelines for the Pre and Post Operative Physiotherapy Management of Adults with Lower Limb Amputation.
  4. Resnik, L. and Borgia, M., (2011). Reliability of outcome measures for people with lower-limb amputations: distinguishing true change from statistical error. Physical Therapy, 91(4), pp. 555-565.
  5. Huang S, Hsieh C, Wu R, Tai C, Lin C, Lu W. Minimal detectable change of the timed "up go" test and the dynamic gait index in people with parkinson disease. Phys Ther. 2011;91(1):114-121.
  6. Beck J. Cognitive Therapy: Basics and Beyond, 2nd ed. New York: Guildford Press, 2011.
  7. Morris P. 2008. Psychological aspects of amputation [Online] available from http://www.amputee-coalition.org/first_step_2003/psychological-a spects-amputation.html accessed 10/07/2015.
  8. Pantera, E., Pourtier-Piotte, C., Bensoussan, L.,Coudeyre, E. (2014). Patient education after amputation: Systematic review and experts' opinions. Annals of physical and rehabilitation medicine, 57(3), 143-158.