The Diabetic trans-femoral amputee: Amputee Case Study

Title

The Diabetic trans-femoral amputee: Amputee Case Study

Abstract

This case study describes learning that I gained through reflection on a client I had treated previously. This case study is an example of mistakes that can be made and a description of the valuable lessons learned regarding the management of the diabetic trans-femoral amputee.
 Key learnings: to be realistic with mobility expectations in this type of patient, regarding cardiovascular disadvantage and high energy requirements; to thoroughly investigate and manage pain if it is a barrier to rehabilitation; to ensure good patient education in order to prevent regression in functional abilities.

Key Words

transfemoral, diabetes, pain management, learning, ambulation, amputation

Client Characteristics

Mr. P is a 69 year old male who is a director of a Plastic Injection Molding Company. He is responsible for managing and supervising the employees. He is married and lives with his wife in a single story house. He was not very active (in terms of sport and recreation) pre-morbidly and is an ex-smoker. He was driving independently pre-morbidly. Mr. P had an above knee amputation in July 2014 following progressive complications after a below knee amputation the month before. The amputation was preceded by multiple vascular procedures to both his limbs. He has extensive peripheral vascular disease, which lead to the initial amputation. He also several co-morbidities namely: Type 2 Diabetes, cardiomyopathy and cardiac failure. Mr. P was admitted to a rehabilitation facility following his amputation in the beginning of August 2014. He received extensive in-patient rehabilitation while waiting for his wound to heal. During his rehabilitation he had difficulty with hypotension as well as severe phantom limb pain, which settled prior to his discharge. He was discharged after 8 weeks, at which stage his wound had healed and he had started coning the stump. He had also had his first prosthetic fitting with a test socket prior to discharge. He commenced therapy as an out-patient 3 weeks following his discharge.

Examination Findings

Initial examination was conducted on 27 October 2014 (3 months after amputation and 3 weeks after being discharged from in-patient rehabilitation)
See medical history under "Patient Characteristics" above. Mr. P's goals and expectations were:

  • To be able to walk independently with the prosthesis, without the use of crutches

  • To be able to return to driving by making adaptations to his vehicle
  • To be able to return to playing golf


Examination within ICF framework:

  • 
Pathology: Type 2 Diabetes, cardiomyopathy, cardiac failure, peripheral vascular disease; Right above knee amputation *Impairments: Poor endurance; Poor static and dynamic standing balance; Phantom limb pain which does improve with Larica. Residual limb pain when weight bearing through the stump; AMPnoPRO: scored 13/39, and was at a level K1; Grade 3+ (Oxford Scale) muscle power in major muscle groups in both lower limbs
  • Activity Limitations: Unable to walk independently with assistive devices - unsafe; Dependent on a wheelchair for complex mobility and long distances; Unable to negotiate stairs independently; Unable to drive; Independent in ADL's, but with extra time
  • Participation Restrictions:Cannot get to work by himself; Unable to participate in golf; Restricted social interaction and independence due to reduced mobility and safety

  • Environmental Factors; Low level of motivation and commitment to home exercise program; Good support from his wife; Good support form his work.

Clinical Hypothesis

Initially I had considered Mr. P's goal of being able to walk independently, achievable. I launched in to a high level exercise program. It soon became apparent that he was severely limited by pain, poor endurance and his co-morbid conditions. After a discussion with Mr. P we agreed that trying to achieve walking without crutches (or even with crutches) was unrealistic. He had already fallen twice at home and we were not willing to risk further falls. The risk of walking without an assistive device out-weighed the importance of fall prevention and preservation of his remaining limb. Considering this, Mr. P's main problem is poor mobility with a walker, and the inability to drive. The decision was made that the priority of treatment was to optimise gait with a walking frame, improve endurance, manage pain and facilitate return to driving.

Intervention

  • Driving - Referred Mr. P to an organisation that makes adaptations to vehicles.
  • Mr. P was meant to receive bi-weekly physiotherapy intervention (45 minute sessions) for 6 weeks. He was still using a test socket and the prosthesis had not yet been finalised:
  • Endurance & strength - Did a lot of bed exercises to improve balance in sitting as well as strengthening exercises of his lower limbs. We emphasised strengthening of the hip extensors and abductors of his residual limb, using a Thera band in side-lying, prone and 4-point kneeling.
  • Gait training with walking frame - We spent a lot of time working on standing with the prosthesis, including lateral weight shifts (which he found very difficult) as well as practicing good lift off and soft landing with the contralateral leg during walking. Once we managed to get an improved gait pattern we worked on walking for longer distances to improve endurance (+- 10m at a time)
  • Pain management -Tried some myofascial release and massage of the stump to desensitise it. Mr. P was also referred back to his vascular surgeon, who sent him for surgery to remove a neuroma that had developed at the end of this stump.
  • Emphasised the importance of safety and of preservation of the remaining limb and gave Mr. P a home programme to follow at home, including instructions to lie in prone twice a day to stretch his hip flexors.
  • Therapy sessions ended when he had to go for surgery to remove the neuroma. He did return for therapy until 3 months later.

Outcome

Due to the gap in therapy, Mr. P's outcomes worsened when he was re-assessed 3 months after his neuroma surgery.

  • Right hip extension was weak due to disuse and the muscle strength was reduced to Gr 2/5
  • Mr. P had right developed a hip flexion contracture and was unable to actively extend his hip beyond neutral
  • The removal of the neuroma had improved his pain, but he was still experiencing pain in the residual limb when he was using the prosthesis.
  • Static sitting balance was good - able to displace his centre of gravity and maintain his posture
  • Dynamic Standing balance was poor - unable to reach outside of his base of support.
  • His endurance remained poor and he could not even maintain standing for 1 minute without tiring.
  • He could walk up to 10 meters with his prosthesis and a walking frame before requiring a rest
  • He had achieved a rehabilitation outcome of productive activity and was back at work, despite requiring a lift to get there.
  • He had not used his prosthetic leg during the 3 month absence from therapy due to pain and fear of falling.

Discussion

My expectations initially were that we would be able to achieve independent walking without crutches. There were many obstacles during his post-prosthetic rehab that prevented us from achieving this goal. Firstly, his pain was not appropriately addressed. The causes of pain are complex and should have been investigated more thoroughly [1] . It was often overlooked and became a big barrier to progress.

Mr. P had a number of co-morbid conditions. In hindsight I can now see that he battled with the exercises prescribed because of his poor endurance. The energy expenditure for a trans-femoral amputee is 150-170% more than normal [2], and his cardiovascular system was already compromised. My sessions should have been broken up with more rest periods and lower level exercises, which may have made him more compliant with a home program. I feel I had pushed him to ambulate too soon, placing his contralateral limb under undue risk.

I have now learned that it is exceptionally important to protect the contralateral limb in diabetic amputees. [3]

The time that Mr. P spent at home without any exercise caused him to regress. This may have been due to a number of reasons, but the lesson learned here is the importance of discharge management even if it is for temporary discharge. I should have ensured he understood the importance of his home exercise program and stretching of his hip flexors. Good patient education may have made a difference to his outcomes when he returned after 3 months. [4]

References

  1. Maurice D. Schnell, M.D. Wilton H. Bunch, M.D., Ph.D. Management of Pain in the Amputee, Digital Resource Foundation for the Orthotics and Prosthetics Community,
  2. ICRC Reference Manual - Prosthetic Gait Analysis for PhysiotherapistsfckLR
  3. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation, http://care.diabetesjournals.org/content/29/3/566.long, Diabetes Care, March vol. 29 no. 3 566-570fckLR
  4. 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