The rehabilitation of the Bilateral Below Knee Amputee in the acute hospital setting: Amputee Case study

Original Editor ­ Jessica Gatt

Title

The rehabilitation of the Bilateral Below Knee Amputee in the acute hospital setting: Amputee Case study

Abstract

A 66-year-old male, known case COAD and a previous Left BKA who underwent the contralateral BKA due to gangrene of the amputated 1st and 2nd metatarsal. This case study looks at the patient's rehabilitation during his stay in hospital where emphasis was on the management of his COAD and treatment focused on rehabilitating the patient to make him a suitable candidate for prosthetic fitting so that we would be able to return to his previous level of mobility. Treatment and multidisciplinary team involvement is highlighted as well as patient management to prevent post-operative complications.

Key Words

Transtibial, bilateral below knee amputee, diabetic, COAD, rehabilitation, elderly amputee.

Client Characteristics

The patient is a 66 year old male who was being followed in view of a non- healing ulcer over the right 1st and 2nd metatarsal amputation site which developed an infected ulcer down to the bone with infected sinuses involving the ankle resulting in a gangrenous foot. He was admitted in hospital at the end of May 2015 in view of fever, chills and rigors due to his gangrenous foot. Due to the severity of the infection, the patient underwent a Right Below Knee Amputation (BKA) the following day. The patient is a Type 1 insulin dependent diabetic with peripheral vascular disease, ischemic heart disease and high blood pressure, and also suffers from Chronic Obstructive Airway Disease (COAD) (on domiciliary Oxygen).

The patient underwent a Left Below Knee Amputation (done four years prior) for which he has a silicone sleeve prosthesis. The Right 1st and 2nd toe metatarsal amputation and Right CFA endarterectomy and femoro-to-popliteal bypass was done 4 months prior. He was being followed regularly at the Diabetic Foot Clinic, Tissue Viability unit, regular outpatient follow-ups with his consultant and was attending physiotherapy as an outpatient for continued rehab and also in view of the recent metatarsal amputation

Examination Findings

Immediately post- operative the main priority was chest physiotherapy since the patient suffers from COAD. That, in addition to the effects of anesthesia, put him with the increased risk of chest infections and shortness of breath. He had low oxygen saturation on room air (81%) with shortness of breath resulting in the need of oxygen therapy via a venturi mask. On auscultation, the patient had decreased air entry in the bases of the lungs and poor chest expansion. This affected initial physiotherapy treatment, where the intensity of treatment was light if at all.


The residual limb: Range of movement (especially terminal extension) was measured by a goniometer in the acute post-operative period. Muscle power was graded as a 3 on the Oxford Scale. Range and strength was limited due to post- operative pain and fear. Initially the patient kept his residual limb in lateral rotation which was dealt by adequate positioning.


A further limitation was that the patient has to wait for adequate suture healing/ for his prosthesis before mobilising, so until then, the patient spends an extended period of time in sitting or in bed.

Patient/ family goals: The patient is well supported by his wife and children, and due to his previous amputation all the necessary home modifications were made.
 The patient is very motivated to reach the level of mobility prior to surgery where he was mobilising short distances with a frame and was assisted by his wife in bathing, dressing and transfers.

Clinical Hypothesis

I believe that the patient's main problem is a combination of multiple factors that might affect the rate and quality of his rehabilitation.
The patient is a bilateral below knee amputee and is over 65 years of age, rendering him in the elderly bracket, with multiple co-morbidities. He is an insulin dependent diabetic with PVD which will affect the rate of healing in the amputated limb, making him also more vulnerable to infection or poor healing. With increased age, the risk for a higher amputation and the mortality rate (directly correlated with the number of co-morbidities) are higher.

He also has heart disease and has COAD whereby he is mostly oxygen dependent. Prior to the second amputation the patient already had a poor exercise tolerance. That in ad-junction with his COAD him being a bilateral amputee, the energy consumption required by the patient to perform tasks and to (possibly) eventually mobilise will be even greater.

However, the patient has a good social support at home and this will motivate him to train and work hard so as to reach his previous level of mobility. Motivation will be the key to success in his rehabilitation.

Intervention

Physiotherapy treatment was initially limited due to the patient's pulmonary condition, which rendered him medically unstable. Chest physiotherapy was a priority focusing on chest expansion and encouraging deep breaths to increase air entry in the bases of the lungs and strengthen the chest wall. As oxygen saturation started to improve, physiotherapy treatment started with range of movement exercises in both limbs focusing on right knee extension and hip extension.
 Bed mobility was also a priority so as to prevent the development of bed pressure sores and ulcers.

Balance was also trained at the edge of the bed in unsupported sitting. 
Bed transfers were practiced to the wheelchair, initially with the left prosthetic leg donned and the manual help of three physiotherapists with a transfer board.
 The patient had his own wheelchair, so he was given a right stump board so that the knee would be kept in extension and not left hanging over the wheelchair.
 Compression, using an elset bandage was started 9 days post-operative, so as to control the oedema and to give the stump adequate shape for eventual prosthetic fitting as well as serving to reduce flexion deformities and maintain/improve muscle tone.

Therapy is now done in the gym where training is focused on upper limb strengthening, trunk, core and balance training, stretches, Range of movement and strengthening exercises as well as donning and doffing of the prosthesis of the contralateral leg.

Outcome

Chest: Blood oxygen saturation improved on room air and the patient no longer requires the need of oxygen therapy. Chest expansion and air entry is good and the patient is able to comply with physiotherapy treatment without getting short of breath.

Range of movement and Strength: The patient manages full knee extension and has full range of movement in all movements in both limbs with a muscle power of 4 on the Oxford Scale. Strength in upper limbs is a grade 5. He had a good balance in unsupported sitting at the edge of the bed and is able to don and doff his prosthesis independently.
 Due to extensive practicing of transfers and upper limb strengthening, he can transfer to the wheelchair independently with the transfer board and minimal supervision. He is independent in wheelchair management and is able to propel himself round the ward.


Stump condition & shape: The elset bandage has given the stump a good shape for prosthetic fitting. A small ulcer developed on the left side of the stump with some oozing which is being treated by antibiotics. Healing is almost complete making him a good candidate to start the PPAM-aid.

Skin integrity: No pressure sores and ulcers developed as the patient is independent in bed mobility.
 The patient underwent prosthetic casting on the 17/07 (optimal stump healing and length). He's currently waiting to be accepted in a rehabilitation center to continue treatment.

Discussion

The patient is a geriatric amputee who falls in both categories being already a major amputee of having a fresh amputation over the age of 65. Age- associated physiological changes, in combination with his co-morbidities give an increased likelihood for post- operative complications. Post- operative there was an exacerbation of the patients' COAD resulted in the patient having poor oxygen saturations.

The amputee spends more energy during ambulation than a non- amputee. A study that showed that at a self-directed pace the transtibial amputee's VO2 max and heart rate was 16% greater and they walked at a pace 11% slower than a non- amputee[1]. Being a bilateral amputee and suffering from COAD, the demands and energy expenditure to carry out simple tasks are greater, so cardiopulmonary conditioning is an important aspect in rehabilitation.

Ambulation is a priority so as not to be at risk of the geriatric giants where immobility will result in multiple co-morbidities. Mobility by ambulation with prosthesis profoundly improves the quality of life as compared with a wheelchair existence[2]. The PPAM-aid will be considered once the ulcer is fully healed to start gait re- training, balance training and improve his exercise tolerance so that once he receives his prosthesis he will be able to be rehabilitated to his previous level of mobility. Several studies have shown that there is a success of 60%-90% for below knee prosthetic fittings in the elderly[3].

References

  1. Mohanty, R.K., Lenka, P., Equebal, A., & Kumar, R. (2012). Comparison of energy cost in transtibial amputees using "prosthesis" and "crutches without prosthesis" for walking activities. Annals of Physical and Rehabilitation Medicine 55(4). 252-262. doi:10.1016/j.rehab.2012.02.006
  2. Smith, D.G., Burgess, E.M., & Zettl, J.H. (2002). Special Considerations: Fitting and Training the Bilateral Lower-Limb Amputee. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles Chp 24A. Retrieved from http://www.oandplibrary.org/alp/chap24-01.asp
  3. Fletcher, D.D., Andrews, K.L., Butters, M.A., Jacobsen, S.J., Rowland, C.M., & Hallett, J.W. (2001). Rehabilitation of the geriatric vascular amputee patient: A population-based study. Arch Phys Med Rehabilitation 82(6). 776-779. DOI: http://dx.doi.org/10.1053/apmr.2001.21856