Taking the Next Step: Amputee Case Study

Original Editor ­ Charles Cole

Title

Taking the Next Step

Abstract

Mr. R.G. is a 61-year-old, right hand dominant, US Army Veteran male who underwent a left transfemoral amputation in October 2012 secondary to infection following failed total knee arthroplasty and multiple revisions. Mr. R.G. was an active individual prior to the amputation, however, had difficulty regaining that same level of productivity and function following the amputation for various reasons- mental, physical, and logistical.

Mr. R.G. transferred his amputation rehabilitation care to his assigned VA in January 2015. He was evaluated by the interdisciplinary amputation team and began intensive prosthetic gait training with the physical therapist. Functional outcome measures that were tracked to assess efficacy of treatment and track progress included the 6-minute walk test, L-test, the Locomotor Capability Index, and body weight.

He was able to demonstrate a high level of functional independence and successfully transitioned from wheelchair dependence to a polycentric safety knee and use of crutches/ single point cane to eventual use of a microprocessor knee without the need for an assistive device during ambulation. He continues to work with the interdisciplinary amputation team at the VA with goals to return to golf and hiking activities.

Key Words

transtibial, amputation, physical therapy,

Client Characteristics

Mr. R.G. is a 61-year-old, R hand dominant, US Army Veteran of 8 years who is also a retired commercial pilot. He was married and divorced twice and has one child. He underwent a left total knee arthroplasty in 2009 with multiple attempts at revision. He subsequently underwent a left transfemoral amputation secondary to infection in 2012 in a community-based hospital.

Pertinent medical history includes chronic ischemic heart disease, anxiety, and depression. In addition, Mr. R.G. smokes approximately 1 pack per day cigarettes.

He was essentially non-ambulatory from late 2010 to early 2015. Mr. R.G. originally worked with a community-based prosthetist and received his first prosthesis while incarcerated. He received very little training and, thus, did not use the prosthesis. The prosthesis eventually was lost and Mr. R.G. returned home from prison without a prosthetic leg. Once home his primary mode of locomotion was via manual wheelchair and bilateral axillary crutches for short ambulation distances.

He chose to transfer his amputee his assigned VA in January 2015 with personal goals of using prosthesis and improving his ability to ambulate without an assistive device.

Examination Findings

Mr. R.G. was examined by the interdisciplinary amputation team January 2015.

  • His primary complaints were of difficulty ambulating, falling ten times in the past six months, and residual limb pain rated 7-8/10 per numeric pain rating scale.
  • Pertinent medical history includes chronic ischemic heart disease, anxiety, and depression. In addition, Mr. R.G. smokes approximately 1 pack per day cigarettes.
  • He was essentially non-ambulatory from late 2010 to early 2015. Mr. R.G. originally worked with a community-based prosthetist and received his first prosthesis while incarcerated. He received very little training and, thus, did not use the prosthesis. The prosthesis eventually was lost and Mr. R.G. returned home from prison without a prosthetic leg. Once home his primary mode of locomotion was via manual wheelchair and bilateral axillary crutches for short ambulation distances.
  • He works part-time as a secret shopper in which he has not been able to participate due to his difficulty in ambulating.
  • He chose to transfer his amputee care to his assigned VA in January 2015 with personal goals of using a prosthesis and improving his ability to ambulate without an assistive device.
  • The patient was administered self-report and physical performance measures including Locomotor Capability Index (LCI), Global Rating of Change (GROC), Numeric Pain Rating Scale (NPRS), 6 minute walk test and L test[1].
  • Additionally, the patient's body weight was also tracked.
  • Gait analysis reveals long prosthesis resulting in insufficient toe clearance, and excessive lateral right foot progression.
  • Additional findings include positive Thomas Test on the left and left posterior-lateral hip stability deficits.
  • Considering the examination findings and utilizing the framework provided by the Guide to Physical Therapy Practice[2], a diagnosis of impaired gait, locomotion, balance, and impaired motor function secondary to lower extremity amputation was determined.

Clinical Hypothesis

Mr. R.G. presents with difficulty in ambulating using his current prosthesis and reports a significant history of falling. There is obvious leg-length discrepancy noted with the prosthetic side appearing to be a bit long.

The patient demonstrates great potential to be an unlimited prosthetic user. Mr. R.G. would likely benefit from skilled physical therapy to safely and effectively improve his function, mobility, and self-reliance with the use of a prosthesis.

Intervention

Mr R.G. was seen in physical therapy a total of 46 sessions between the dates of January 15, 2015 and July 8, 2015. He continues to work with physical therapy for more advanced and intensive prosthetic gait training using a microprocessor knee.

  • Treatment principles were aligned with the VA/DoD Clinical Practice Guidelines[2]. Initially, physical therapy was aimed at improving left hip extension mobility and gross left hip stability in open kinetic chain.
  • We then progressed to more functional and closed chain activities with principles of improving stance control of the prosthetic knee, achieving and maintaining vertical alignment of the pylon, improving L hip stability in standing, improving core stability in various stance positions (i.e. split stance, tall kneeling, half kneeling).
  • In addition, a cardiovascular fitness routine was developed to improve overall conditioning/endurance and to manage weight as the patient had significant weight fluctuations for approximately 2 months that ultimately led to increased pain and need for a replacement socket.
  • The patient's pain and increased residual limb girth led to increased instability of the prosthesis during ambulation. During prosthetic gait training, etiology of falls appeared to be consistent with an early flexion moment at the prosthetic knee during stance phase (possible due to poor socket fit and placement of the knee in relation to the socket) and poor heel strike during turning.
  • Co-treatment with the prosthetist during prosthetic gait training proved to be valuable, especially during this time, to adjust the prosthetic knee to improve stability in addition to gait training to improve mechanics of turning. Mr. R.G. had additional complications that slowed his recovery down including depression and anxiety. PT intervention to address these issues included visualization and supportive discussion.
  • Furthermore, the patient was offered a peer visitor in which Mr. R.G was matched with another veteran with limb loss and similar etiology for support, comradery, and help with coping. The patient also began participating in monthly limb loss support groups with other veterans. These approaches together aided Mr. R.G. to continue with prosthetic gait training while managing associated mental health issues.
  • As Mr. R.G. demonstrated a need for higher functioning prosthetic knee and a desire for return to sporting activities including golf and hiking he reported motivation to transition from polycentric mechanical knee to microprocessor. As such, prosthetic gait training essentially restarted as the patient needed to become comfortable with the ability to control a new knee and the functions that come with it. Prosthetic gait training principles during this phase were similar in nature to initial gait training: progressing from open kinetic chain to closed kinetic chain and more advanced functional activities (weight shifting, stepping, changing stance positions, resisted gait, etc.).

Outcome

During Mr. R.G.'s recovery and rehabilitation, he demonstrated good compliance with the plan of care and direction of treatment. He was able to transition from use of a manual wheel chair and ambulating only a few feet at time with bilateral axillary crutches to using a microprocessor knee without the need of an assisted device.

During his course of physical therapy, he demonstrated a preferred walking speed from 0.09 m/sec to 0.80m/sec. He was able to eventually maintain a healthy and consistent weight. In addition, Mr. R.G. self-perceived disability with his prosthesis decreased evident by the LCI and his self-reported global improvement in pain and function improve significantly to a +5, evident by the Global Rating of Change Scale (GROC).

Lastly, the patient's ability to navigate turns and transfers improved from 40.4 seconds to 25.7 seconds during the L-test. Mr. R.G. continues to work with physical therapy to maximize his potential and use of a microprocessor knee.

He has returned to work as a secret shopper, requiring extensive distance of walking and negotiating multiple flights of stairs. He uses a SPC approximately half of his walking time and he wears his prosthetic leg throughout the day. He has not returned to the level of golf or hiking he desires, but is committed and hopeful that he will again be able to participate in these roles.

Discussion

The role of a physical therapist in the recovery of an amputation is imperative and multi-faceted. Even more, the cooperative work of an interdisciplinary team is necessary to fully address the needs of the patient. To truly understand the patient, their goals, and potential, an in depth evaluation much occur including past medical history, range of motion, strength, balance, coordination, agility, endurance, skin inspection, roles at home and in the community, activities of daily living, social and leisure integration, work commitments, and self-perceived disabilities.

Functional outcome measures are essential in determining efficacy of treatment approach and progress (or lack thereof). Functional testing should be validated, reliable, and replicable. Such testing may include: 2 or 6 minute walk test, L-test, and LCI. Patient education is also an important aspect throughout the process from preoperative to community reintegration. Overall, management of the amputee must be evidence based with the patient at the center of all decision and goal making.

[3]

References


  1. Kaplan SL, Outcome measurements and management: First steps for the practicing clinician. Philadelphia, FA Davis Company, 2007.
  2. 2.0 2.1 VA/DoD Clinical Practice Guideline for Rehabilitation of Lower Limb Amputation, Department of Veterans Affair, Department of Defense, January 2008.
  3. Guide to Physical Therapist Practice. Second Edition. American Physical Therapy Association. Phys Ther. 2001 Jan; 81(1):9-746.