Rehabilitation of patient with a left TTA: Amputee Case Study

Title

Rehabilitation of patient with a left TTA

Abstract

This case presentation is of a 69 year old German man who had a (L) TTA in April 2015 due to PVD. He had a relatively "textbook" recovery and rehabilitation, complicated only by (R) knee arthritis, which occasionally caused his (R) knee to give way, and some (L) phantom limb pain. He is now a proficient prosthetic user, who lives in a low-level care nursing home, and mobilises independently with a 4ww. He can also manage a set of 3 stairs with (r) hand ascending rail with a SPS and s/v when he goes to visit his daughter in the community. This outcome is inline with his rehabilitation goals.

Key Words

Transtibial, PVD, Phantom limb pain,

Client Characteristics

Demographic information:
 69 y.o. Male, German, recently widowed.
Previously lived with his wife in a high set home in the community until she passed away, and concurrently the condition of his (L) foot worsened and he found it too painful/difficult to manage his stairs. Was receiving MOW 3/7 and cleaning assistance 1/14.
 Was independently mobile with SPS. He had 2 recent falls due to his (R) knee "giving way" due to arthritis.
He decided to go to a low level nursing home on discharge from hospital.
 He has one supportive daughter living nearby.

Medical diagnosis: (L) TTA due to PVD Comorbidities: PVD, diabetes, poor exercise tolerance, arthritis (R) knee, ex smoker Previous (L) 2nd toe amputation in 2013. No previous physiotherapy

Examination Findings

S/E: English as a second language. Able to understand all commands, and communicate well in return
PMHx a/a


Patients goal: to mobilise safely around nursing home independently, and to manage the steps at his daughters home.

Doesn't drive due to (R) knee arthritis and personal preference. Some phantom limb pain on initial assessment, which deceased in intensity and frequency over time.

O/E (on initial Ax):
(L) TTA dressings in situ. Appear clean and dry.
 All joint ROMs full except slight decreased flexion ROM (R) knee MMT - all upper limb 5/5. (R) knee 4/5 F/E. (L) hip E and Abd 4/5. Able to transfer independently from bed to w/c with (L) stump support. 
Independent w/c mobility

Clinical Hypothesis

Recent (L) TTA, good prosthetic candidate. Limiting factors will be (R) knee arthritis, decreased (L) LL strength, pt reported decreased exercise tolerance.
 Phantom limb pain also present but decreasing in intensity and frequency.

Intervention

Acute post op: preprosthetic bed exercises, t/f practice, w/c mobility. Progressed to exercises in // bars (STS, (R) mini-squats, (L) resisted hip extension and abduction. Education re desensitisation of stump, expected post-op course, physiotherapy and other amputee team member roles.

2 weeks post - op: applied tubigrip to stump as TTA scar healed nicely. 4 weeks post - op: juzo applied as stump tolerating compression well, scar looking good.

6 weeks post-op: cast for prosthesis 7 weeks post-op: initial fitting with prosthesis, working alongside prosthetist. Practiced donning and doffing prosthesis. Education re skin care and prosthesis care.

In the following weeks: wt shifting, standing exercises focusing on glut med, step ups, sideways walking, gait rehabilitation alongside prosthetist. Then progressed to walking with 4ww short distances, and stairs with s/v, (R) hand rail and (L) SPS Emotional support and opportunities to discuss patients wellbeing were provided throughout. 


Referred to Physician for consult re phantom limb pain.
 Referred to the hospital's amputee exercise class for further physiotherapy input, and monitoring down the track. Given information re the local amputee support group.

Outcome

Increased (L) LL strength to 5/5 all muscle groups.
Increased exercise tolerance
. Achieved patients goal of independent mobility with 4ww and steps with SPS, rail, and s/v for access to daughters home. Patient and therapist concluded together that walking with a 4ww would be the best form of mobility as he was nervous about his (r) knee giving way without warning and so felt much more confident with mobility with a 4ww.

Discussion

This case presentation is very typical of the kind of patient that comes through the doors of an amputee rehabilitation clinic. His examination findings deemed him to be a good prosthetic candidate, and indeed this was confirmed throughout his rehabilitation.

The following are some "future directions" that i would take after completing this course: Will attempt mirror therapy[1], and 60 minute sessions of TENS for residual phantom limb pain as per the literature[2]. 
Even though this patient did not experience persistent acute oedema, I would be interested to discuss with the surgeons the possibility of introducing immediate post-surgical rigid/semi rigid dressings in our hospital, as there is evidence in the literature that it prevents acute oedema[3]. Similarly I would be interested to discuss with the amputee team the introduction of PPAM aids to our early rehabilitation program.

References


  1. Moseley GL, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain 2008;138:1387-10.
  2. Bryant G. Stump Care. The American Journal of Nursing 2001; 101(2); 67-71
  3. Nawijn SE, Van der Linde H, Emmelot CH, Hofstad CJ. Stump management after transtibial amputation: a systematic review. Prosthetics and Orthotics International 2005; 29(1); 13-26.