To fit or not to fit? Amputee Case Study

Original Editor - Michelle Lee

Top Contributors - Michelle Lee and Mariam Hashem



Title

To Fit or Not to Fit?

Abstract

Following major lower limb amputation there are many factors to consider when assessing suitability to limbfit. Due to higher abandonment rates amongst TFA compared with TTA, the decision with this patient group is increasingly important. This case study of an 84 year old transfemoral amputee explores some factors which have influenced the decision in this instance and identifies cognitive and functional measures which can help guide the clinician.

Key Words

Transfemoral, elderly, TFP, ACE III, QOL

Client Characteristing

My client is male, 84 years old. He has had a right trans-femoral amputation as a result of PAD. His PMH includes PAD, OA, Osteoporosis, DVT (right 2001), and Atypical TB (2013). It should be noted he is not diabetic. Prior to the TF amputation he was known to the vascular MDT, having had a previous admission for right lower limb bypass surgery (Fem-pop bypass graft 2014) and toe amputation (Right Hallux 2014), in an attempt to salvage the limb and prevent major limb amputation. This surgery was unfortunately only successful in the short term (6-8/12) after which further ischaemia presented in the right foot and a decision was made to proceed to TF amputation. He is retired and lives with his wife in a single story house with 4 external steps to access front/back doors. He has two daughters, one of which lives near by. He is of Hungarian descent but has lived in the UK for around 40 years, English is his second language.

Examination Findings

My client was always willing to participate in his Physio sessions and from an early stage expressed a desire to progress to limbfitting/prosthetic rehabilitation. His goal was to not be restricted to living his life in a wheelchair, but understood that returning to his previous level of mobility was not realistic. During his inpatient rehabilitation it became evident to the MDT that he had a degree of cognitive impairment and this was evidenced by a score of 44/100 in the ACE-III[1]. It was however thought that this score was significantly low due in a large part to the language barrier, as English is not his first language. We completed the self reported LCI[2] in which he scored 48/56, mainly due to the fact that 6 months prior to the amputation he used a stick to walk.

Objectively his wound was well healed and oedema was reducing, he had some mild PLP but no residual limb pain. He had good functional range in all joints, although his posture was mildly Kyphotic in standing. No evidence of any joint contractures including -ive Thomas' test bilaterally. He did present with some weakness around Glut med/max bilaterally. He was independent with bed and chair/toilet transfers (pivot)and self propelling a wheelchair. His balance in standing (single leg) was poor and was highlighted with a score of 33/36 in the TFP[3]. He demonstrated a reduced exercise tolerance, max walking distances with EWA of around 30m using WZF and AO1. No evidence of IC in remaining limb during gait.

Clinical Hypothesis

The main problem that the MDT faced was whether my client was a suitable candidate for limb-fitting i.e. provision of a prosthesis. This debate was due to a number of factors including:

  • Poor score in ACE-III[4] a cognitive screening tool, highlighting poor short term memory/recall and attention as well as language difficulties.
  • Underscore in TFP, a predictor tool developed to assist in the assessment of a clients suitability to limbfit[5]. Ideally patients should be achieving a maximum score to support a referral to the limbfitting centre.
  • Patients age (84 years)
  • Patients reduced exercise tolerance when it is considered that the energy expenditure of an amputee walking with a unilateral prosthesis is at least 120% greater for an TFA compared to normal gait[6]

These factors were combated with the fact that:

  • The patient was in good physical condition despite his age and had been mobile short distances with just a stick up until his amputation.
  • He demonstrated excellent motivation to comply and commit to all aspects of his physiotherapy/rehab interventions and had an unwavering desire to get a prosthesis.
  • He had a very dedicated and able wife (and family) who wanted to support him at home and with all aspects of his rehabilitation in order to help him achieve his goal of 'getting a leg to walk again'


The decision to refer a patient to the limbfitting centre is not taken lightly especially with TFA who demonstrate higher levels of abandonment.

Intervention

Initial inpatient rehab lasted 6/52 and included:

  • General muscle strengthening programme focusing on hip extensors bilaterally, abdominal core and left quadriceps.
  • Maintenance of joint ROM esp. hip extension.
  • Use of compression therapy, specifically Juzo shrinker socks and PPAM AID.
  • Transfer practice to allow independence with bed, chair and toilet.
  • Gait re-ed using PPAM AID within the parallel bars and with a WZF over short distances.
  • Falls recovery practice.
  • Standing balance with and without EWA insitu.

My client was discharged home prior to being fitted with a prosthesis and it was decided to give him a further period of rehab for 4-6/52 as an outpatient (attending class for 1.5hrs twice a week) in order to assess his commitment to rehab and progression to allow consideration for limbfitting. During this time he consistently attended the class and showed improvements in his strength, balance and exercise tolerance. The decision was therefore made to refer to the limbfitting centre where he was successfully fitted with a prosthesis (quad socket, fixed knee)
Once his Prosthesis was delivered we ensured he could independently don/doff and have now begun early stages of gait training encorporating:

  • STS re-education, with use of knee lock mechanism
  • Lateral and A/P weight transference, standing balance
  • Stepping within parallel bars
  • Sound leg step up onto block

We encouraged his wife to attend class, ensuring carryover to home.

Outcome

My client has been successfully limbfitted and is now progressing through gait training with his new prosthesis. We have not reached his potential yet, but it is expected that he will use a walking aid such as a WZF to assist with indoor mobility. He and his family are delighted with this outcome and have reported an improvement in his mood at home - just being able to stand from his wheelchair for periods has allowed him to be more independent with simple ADL tasks around the house e.g. reaching up to cupboards in the kitchen and helping with the washing up. In general he and his family feel that his quality of life has improved since he has had his prosthesis and feelings of improved body image and self worth have given him more confidence to socialise again and has lifted his mood. No specific QOL measure was taken pre/post limbfitting, but is something that i feel would be of benefit to use with clients in the future (see discussion section!) He remains forgetful and relies heavily on his wife to remember information such as appointments dates, but involving his wife in aspects of his rehab has ensured his safety with use of his prosthesis at home.

Discussion

Prosthetic rehabilitation and fabrication are expensive and time consuming. Many transfemoral amputees may gain more benefit from therapy aimed at restoring adaptive skills without a prosthesis rather than undergo a lengthy, arduous, and potentially unsuccessful course of prosthetic rehabilitation[7]. This viewpoint was a consideration for my client due to factors weighing heavily against him in the case to not limbfit, namely his age, ACE III and TFP scores. During his rehab, before the decision to limbfit was made, he showed such determination and drive to succeed, backed up by a very supportive family. These factors went a long way in helping the MDT to come to a decision to proceed to limbfitting as well as his good general health and physical ability. Limb amputation not only affects people's ability to walk, but may impact on their participation in valued activities,body image perception and quality of life[8]. Although my client may not achieve a great walking distance with his prosthesis and will always need to use a walking aid, the improvement in his reported QOL is marked in that he can now be more independent within the house and complete simple but valued ADL tasks that give him improved self esteem and sense of worth. Pell et all[9] identified that QOL after lower limb amputation is significantly associated with mobility so it works both ways! I plan to introduce more QOL measures with my clients as I feel it is often overlooked in favour of functional gain.

References 

  1. Sharpley Hsieh, Samantha Schubert, Christopher Hoon, Eneida Mioshi, John R Hodges (2013) Validation of the Addenbrooke's cognitive examination III in frontotemporal dementia and Alzheimer disease. Dementia and geriatric cognitive disorders 36 (3-4), 242-250
  2. Franchignoni F, Orlandini D, Ferriero G, Moscato TA (2004) Reliability, validity, and responsiveness of the Locomotor Capabilities Index in adults with lower-limb amputation undergoing prosthetic training. Arch Phys Med Rehabil;85:743-748
  3. Condie M.E., Treweek,S.P., Whitehead L., McFadyen A.K. (2011) The transfemoral fitting predictor (TPF) - A functional measure to predict prosthetic fitting in transfemoral amputees: validity and reliability. Arch. Phys. Med. Rehabil: 92 (8), 1293 - 1297
  4. Sharpley Hsieh, Samantha Schubert, Christopher Hoon, Eneida Mioshi, John R Hodges (2013) Validation of the Addenbrooke's cognitive examination III in frontotemporal dementia and Alzheimer disease. Dementia and geriatric cognitive disorders 36 (3-4), 242-250
  5. Condie M.E., Treweek,S.P., Whitehead L., McFadyen A.K. (2011) The transfemoral fitting predictor (TPF) - A functional measure to predict prosthetic fitting in transfemoral amputees: validity and reliability. Arch. Phys. Med. Rehabil: 92 (8), 1293 - 1297
  6. Aisling M Fleury, Salih A Salih and Nancye M Peel (2013) Rehabilitation of the older vascular amputee: A review of the literature Geriatr Gerontol Int; 13: 264-273
  7. Condie M.E., Treweek,S.P., Whitehead L., McFadyen A.K. (2011) The transfemoral fitting predictor (TPF) - A functional measure to predict prosthetic fitting in transfemoral amputees: validity and reliability. Arch. Phys. Med. Rehabil: 92 (8), 1293 - 1297
  8. Kate Sansam, MRCP, Vera Neumann, MD, FRCP, Rory O'Connor, MD, MRCP and Bipin Bhakta, MD, FRCP Predicting Walking Ability Following Lower Limb Amputation:A Systematic Review of the Literature. Journal of Rehabilitative Medicine. 2009; 41: 593-603
  9. Pell JP, Donnan PT, Fowkes FG, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. European Journal of Vascular Surgery 1993; 7: 448-451