The Diabetic Amputee: Amputee Case Study

Title

The Diabetic Amputee: Amputee Case Study

Abstract

Patient was a diabetic amputee seen in an acute hospital. Her rehabilitation progress spanned over the acute post-operative phase to the pre-prosthetic phase before she was being discharged home with outpatient physiotherapy. Her inpatient rehabilitation plan during her stay in the acute hospital focused on post-operative wound healing and pain control, enhancing mobility without prosthesis, addressing emotional coping, as well as strengthening and conditioning exercises for her limbs and cardiovascular system in order to prepare her for her eventual prosthesis fitting. 

Key Words

transtibial, diabetic, acute post-operative phase, Functional Independence Measure

Client Characteristics

Patient is a 68 years old female retiree. She sustained a left below knee amputation as a result of non-healing left big toe ray wound with dry gangrene. She had previously undergone ray amputation on the same foot followed by debridement as a result of infection one month ago. In addition, she suffered from end stage renal failure secondary to diabetes mellitus and is on peritoneal dialysis 9 hours daily.

Other medical histories include hyperlipidaemia and hypertension. Premorbidly, she was able to ambulate with a quadstick and manage her basic activities of daily livings (BADLs) independently. She was also able to perform simple household chores such as meal preparations, laundry, and home maintenance tasks like sweeping floor. She is a non-smoker and a non-drinker.

Examination Findings

Subjective:


  • Patient complained of lethargy in general, as well as hypersensitivity of stump and pulling pain with full knee extension of the stump.

  • Patient wants to be able to take care of herself and mobilise within the house independently

  • She currently stays with her husband and a helper in a lift landing unit with seated toilet and grab-bars installed. Her husband is an old stroke survivor and his BADLs are assisted by the helper.

Objective:


  • Patient is cognitively intact and is motivated.

  • She required supervision with bed mobility and has good static sitting balance but had difficulty returning back to midline after reaching beyond arm-span.

  • She was able to perform sit to stand with minimal assistance with frame. She had fairly good standing balance with bilateral upper support but was unable to maintain balance in unsupported single-leg stand.

  • Her limbs range of motion were full, with manual muscle testing strength of 3+/5 at all joints. There was some end range tightness with knee extension on her left stump.
  • Her AMPnoPRO score was 16/39

Her Functional Independence Measures(FIMs) scores were as follows:

  • Feeding: supervision
  • Grooming: supervision

  • Toileting: minimal assistance

  • Upper body dressing: supervision

  • Lower body dressing: minimal assistance

  • Showering: minimal assistance

  • Transfer: minimal assistance

  • Wheelchair mobilisation: minimal assistance, propelled 10m

Clinical Hypothesis

Patient's main problems are:


  • Reduced core stability

  • Reduced cardiovascular endurance

  • Reduced strength and endurance of her limbs

  • Tightness with knee extension tightness, which increases risk of developing flexion contracture
  • Presence of oedema and hypersensitivity of stump which could affect future plans for prosthesis

  • Fair dynamic sitting and standing balance

Intervention

To manage knee extension tightness and prevent flexion contracture, a knee extension splint was fabricated to keep the knee in full extension on post-operative day one. Active knee extension exercises with passive stretch was performed daily. Crepe bandage, and subsequently stump shrinker, was applied to the stump post-operatively.

Gentle massage and tapping over bandage were taught to manage hypersensitivity. Strengthening and conditioning exercises with progressive weights were performed using the HITT technique to increase strength and endurance of limbs and cardiovascular endurance. Core stability was trained with gym ball, sit ups and bridging.

For standing balance, activities started with static standing with bilateral upper limb support, and progresses to one-handed reaching task. When patient could confidently perform these, maintaining single leg stance balance while performing bilateral upper limb activity was initiated. Pivot transfer was first taught. As patient improves in her strength and balance, transfer with a frame was taught to increase opportunity for patient to practice lift technique with frame.

As patient is diabetic, it was imperative to remind her not to place abnormal stress on the sound limb by pivoting too much on her foot. Constant repositioning of foot during transfer was taught to minimise shearing and rotational forces. It was also crucial that she stepped with a soft landing by relying on her upper

Outcome

After 3 weeks of rehabilitation in the post-operative phase, patient's FIMs score was as follows:


Functional Independence Measures:


  • Feeding: modified independence
  • Grooming: modified independence

  • Toileting: supervision

  • Upper body dressing: modified independence

  • Lower body dressing: supervision

  • Showering: supervision

  • Transfer: supervision

  • Wheelchair mobilisation: modified independence, propels 100m without rest breaks

In addition, she achieved an AMPnoPRO score of 20/39. Her limbs strength improved to manual muscle test grade of 4+/5, and there was full range of motion in all her limbs. She was able to achieve full extension of her knee with no tightness, and the hypersensitivity and oedema of her stump had resolved.

Her sitting and standing balance had improved and she was confident in performing her ADLs without requiring any external help, even when these activities required her to perform beyond her base of support, and required a certain level of endurance. She was happy with her progress thus far.

Discussion

The acute post-operative phase focused on wound healing and pain control, mobility without prosthesis, emotional coping and strengthening exercises[1]. Patient has made great progress and was discharged home with a supervision level in FIMs. During her rehabilitation progress, it was important to explain the care of the limb, especially for diabetic patients with increased risks of re-amputation[2].

There were often unnecessary stress placed on the sound limb during transfer and standing activities as patient was unaware of her limb position and posture. In addition, education of proper footwear to protect the limb from injury has to be educated as well. The knee extension splint fabricated helped in positioning the knee into full extension. It also provides a passive stretch at the knee joint, preventing knee flexion contracture from developing. One week with the splint, patient was able to achieve full knee extension.

Other components to intervene would be core stability, limbs endurance and strength, and wheelchair skills. These enhance patient's independence in BADLs and mobility, and lay good foundation for eventual prosthesis fitting[3].

It was also crucial to address hypersensitivity of her stump which resolved with tapping over the suture site. Lastly, it was fortunate that patient was motivated throughout the rehabilitation process. Her perseverance and compliance contributed to her success[4].

References

  1. Esquenazi, A., & Meier, R. H. (1996). Rehabilitation in limb deficiency.4. Limb amputation. Archives of physical medicine and rehabilitation, 77(3), S18-S28.
  2. Izumi, Y., Satterfield, K., Lee, S., & Harkless, L. B. (2006). Risk of reamputation in diabetic patients stratified by limb and level of amputation a 10-year observation. Diabetes Care, 29(3), 566-570.
  3. Gailey, R. S., & Clark, C. R. (1992). Physical therapy management of adult lower limb amputees. Atlas of limb prosthetics: surgical, prosthetic and rehabilitation principles. 2th edition, Bowker JH, Michael JW. St. Louis, editors. Baltimore: Mosby Yearbook, 569-97.
  4. Esquenazi, A., & DiGiacomo, R. (2001). Rehabilitation after amputation. Journal of the American Podiatric Medical Association, 91(1), 13-22.