The Diabetic Amputee 1: Amputee Case Study

Title

The Diabetic Amputee 1

Abstract

An estimated 350,000 diabetics live in Jamaica, of which, approximately 350 amputations of diabetic feet done each year 5. Mr X, a 63 year old male diabetic to the hospital’s physiotherapy department after undergoing a transtibial amputation.
He 8 weeks rehabilitation programme: education, strengthening, balance training and gait training with crutches. Poor and prolonged wound healing delayed prosthetic fitting.
Mr. X gained independence in ADLs with the use of crutches. Mr. X unfortunately defaulted for management, but plan of prothesis is discussed.

Key Words

Transtibial
Diabetic
Balance
Endurance
Ambulation
Wound

Client Characteristics

Mr. X is a sixty-three year old male patient who is known to have diabetes mellitus for greater than twenty year. Mr X is also known to have hypertension for a similar duration of time. He is currently managed oral medication. Mr X works as messenger for a large corporate organization. He carries out his function as a messenger by driving a car. He sometimes operates as taxi as well. Mr. X lives with his consort and 15 year old son in a 2 story home with modern conveniences. The lower level of the house consisted of a bedroom, bathroom and kitchen which meant Mr X did not need to go upstairs in the early stages post amputation

Examination Findings

Due to poor wound healing and vascular compromise, and after developing gangrene of the right foot, he had transtibial amputation in 2014.
Complaints:

Inability to use crutches, pain and sensitivity at end of stump, poor wound healing and inability to work and function independently.


Objective:

He ambulated with walker but tired easily and lost balance. Nil contractures noted. Stump oedematous. Sitting posture normal.
Dressing was soiled. Residual stump length from inferior pole of patella to end of the stump was 25.5 cm, with a circumference of 41cm,

ROM: actively within normal movement

MMT: 4/5 throughout both lower limbs.

Sensation – Sole (L) foot – impaired to light touch, pin prink

Proprioception - intact

Balance: Sitting dynamic balance – Fair,
Static standing balance – poor.

Endurance: required seated rested period after ambulating with the walker approximately 8 metres and RPE of 15.

ICF

  • Body Structure & Function: Musculoskeletal system: Decreased Muscle strength, Impaired balance, Pain
  • Activity Limitation: Inability to stand unsupported, inability to walk with crutches, unable to drive
  • Participation Restrictions: Unable to participate in instrumental ADLs such as cooking, cleaning, gardening. Unable to work

Contextual Factors

  • Personal: +ve : Lives with wife and son who are supportive
  • +ve: Motivated to return to a vocation
  • -ve: Frustrated about current status
  • Environmental: +ve home modern, -ve 2 story home, no ramps

Clinical Hypothesis

Patient identified problems

  • Inability to walk/climb stairs
  • Inability to drive
  • Inability to cook, clean, wash at home

Non-patient identified problems

  • Pain
  • Reduced muscle strength
  • Impaired balance
  • Impaired cardiovascular endurance
  • Poor wound healing


Anticipated Problems:
Due his reduced muscle strength, and impaired balance may have difficulty using a crutches effectively. He also has delayed wound healing delaying the time it takes to have Mr. X use a prosthesis. He may required to use crutches for an extended period of time. The possibility of a transfemoral amputation may become apparent due to delayed wound healing.

Intervention

At the first session with Mr. X, he was educated on the intended progression of rehabilitation. He followed a programme of strengthening for both lower limbs and upper limbs starting with light resistance and progressing to heavier resistance. Balance training was done using the parallel bars for static and dynamic work. Purtubations in sitting and standing. Reaching outside his base of support in siting and standing. Resistance bands were used following a progression from light to medium resistance. Gait training using a walker was done, initially with minimal support of a gait belt to just standby assist. Verbal cues were given to correct deviations. Distances walked using the walker was gradually increased with each session to improve his cardiovascular endurance. A Cycle ergometer was used to facilitate endurance training. When safe ambulation was achieved using the walker, he was progressed to ambulation with axillary crutches. This was done on level surfaces with assistance of a gait belt and progressed to just standby assist. This took quite some time before a progression to using crutches up and down stairs with assistance of a gait belt and standby support. Mr. X required prolonged rest periods between exercises.
Throughout the treatment sessions, Mr. X still had problems with wound healing and superimposed infection. He was receiving dressings three times weekly. Though not the purview of the physiotherapist, this was monitored and the wound checked.

Outcome

After eight weeks of physiotherapy management, Mr X showed improvement in many areas. He reported less pain in the residual stump and increased ability to tolerate tactile stimulation at the end of the stump.
There were significant improvements in manual muscle testing of both upper extremities which recorded a 5/5 on reassessment. The unaffected left lower extremity improved to grade 5/5 in knee extension, ankle dorsiflexion and plantarflexion. All left hip movements improved to grade 5/5 except left hip abduction and adduction. There was also improvement in hip flexion on affected right limb. All other muscle groups remained at grade 4.
His cardiovascular endurance showed marked improvement with Mr. X now being able to ambulate greater distances. He would ambulate approximately 15 metres before needing to rest, indicating an RPE of 13.
Sitting balance at reassessment was good and standing static balance improved to good. He was completely independent with the axillary crutches but still standby assistance when using the axillary crutches up and down stairs. Mr X reported improvements in some activities at home such as standing in kitchen to prepare meals, bathing self and minimal house chores. He also reported that he had started to ambulate in the community using the crutches.

Discussion

This 63 year old male who lives with wife and 15 year old son. Mr X work includes driving and is the primary breadwinner of his family.
He presents with deficits in strength and balance and poor cardiovascular endurance. Impaired wound healing and infection requiring antibiotic treatment affected rehabilitation, delaying fitting of appropriate prosthesis, with the possibility of a progression of the amputation to transfemoral[1].
Improvement in most parameters including his independence with crutches, were noted. Mr X started to show signs of depression. He withdrew from the community, became non-compliant with his home exercise programme and missed some days to get the wound dressed[2]. Mr. X eventually defaulted from therapy.
This highlights two challenges. One being the complications of uncontrolled diabetes and two, the lack of financial aid as hospital care is not free nor are the prosthesis. Early walking aid devices [3] are beneficial but are not available here. Had the opportunity presented for prosthetic fitting and subsequent post fitting rehabilitation, Mr. X would have been recommended for a patella tendon bearing socket rather than a total surface bearing socket to prevent direct pressure contact to the end of stump and directly into the wound. The PTB is cheaper to manufacture and also easier to don and duff, ideal for Mr. X [4]. Following fitting, corrections and alignment, he would have been progressed to gait training in various environments.

[5]

References 

  1. Izumi Y, Satterfield K, Lee S, Harkless L. Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation. 2006; 29(3) 566-570 http://care.diabetesjournals.org/content/29/3/566.long, Diabetes Care.
  2. Morris S.The Psychological aspect of Amputation. http://www.amputee-coalition.org/first_step_2003
  3. Redhead RG. The early Rehabilitation of Lower Limb Amputees using a Pneumatic Walking Aid. London. 1993 http://www.oandplibrary.org/poi/1983_02_088.asp
  4. Yiğiter K, Şener G, Bayar K. Comparison of the Effects of Patellar Tendon Bearing and Total Surface Bearing Sockets on Prosthetic Fitting and Rehabilitation Prosthetics and Orthotics International. 2002;26: 206-212.
  5. Ministry of Health. The promotion of healthy lifestyles in Jamaica. [Retrieved Sept 30, 2008]; Available from http://moh.gov.jm