Transfemoral amputation and psychosocial aspects: Amputee Case Study

Title

Transfemoral amputation and psychosocial aspects

Abstract

75-year-old male admitted to inpatient rehabilitation following a transfemoral amputation due to a non-healing ulcer. Rehabilitation had a multidisciplinary focus with physiotherapy looking at transfers, standing practice and exercises to increase strength, range of motion and balance. Education was also an important part of the rehabilitation process particularly with regards to safety. This patient achieved his main goal of returning home, however I believe further input is required with regards to psychosocial aspects and family involvement throughout rehabilitation.

Key Words

Client Characteristics

75-year-old male admitted to inpatient rehabilitation after a high left transfemoral amputation due to a non-healing ulcer. This gentleman had an extensive past medical history including a previous stroke and diabetes. This patient was previously able to mobilise independently and lived at home with his wife.

After his amputation the patient spent 10 days on the acute vascular wards where he began the initial stages of rehabilitation. However, during this time he developed delirium and suffered a fall, which created a lot of fear around transfers. Patients receive little to no input from allied health prior to their amputation, the medical team tends to only provide limited basic information on the amputation and the potential follow-up required afterwards.

Examination Findings

The following information was gleaned from an initial subjective and objective assessment completed with the patient and his wife on arrival to rehabilitation by the MDT


  • Health condition: transfemoral amputation
  • Body function and structure: decreased strength upper limb and lower limb bilaterally, oedematous stump, slow wound healing, decreased left hip extension and decreased balance.

  • Activity: assistance required with all transfers to the commode, bed and wheelchair. Assistance required with most activities of daily living, including showering, dressing and toileting. Assistance required with domestic tasks such as cleaning and cooking. The patient was also unable to stand.
  • Participation: unable to visit family and friends, including looking after his grandchildren. Unable to participate in several social groups he had been a part of, including the Probus group. Unable to play bowls.
  • Environmental factors: 1 step into the patient's house, the toilet had no rails or raised seat, the shower was a cubicle with no rails or seat. The other furniture in the house was standard with no adaptations. The patient had a very supportive wife and family, but lived in an isolated location.
  • Personal factors: anxiety around transfers initially due to a previous fall, pride and difficulty asking for help. Reduced insight into his safety due to his previous stroke.
Patient goals: transfer independently, return home and eventually be fitted for a prosthetic limb and learn to walk again

Clinical Hypothesis

The patient's main problem for inpatient rehabilitation focused around not being independent with transfers, due to decreased lower limb and upper limb strength, decreased balance, limited safety insight and decreased activity tolerance.

Intervention

The patient received a variety of different interventions from the multidisciplinary team, including the following:


Physiotherapy: transfer practice from the bed, commode and wheelchair using a banana board, starting with assistance and moving onto independent transfers. Standing practice also started with assistance and the aid of a plinth and then parallel bars, and progressed to an independent stand before the prosthesis application. Strengthening and range of motion exercises for the upper limb and lower limb bilaterally. Exercises for both arms and the right leg focused on general strengthening to help with transfers and standing. The left lower limb received exercises to increase range of motion and strength in a supine, prone or side-lying position as needed. The patient also worked on his sitting and standing balance, plus increased his activity and exercise tolerance.

The patient was regularly educated on safety particularly during transfers and activities, and caring for his amputation and right leg. Oedema management started. Occupational therapy: assessed the home environment, supplied the necessary equipment and reviewed functional tasks.

Artificial limb centre: education on the next rehabilitation stage prior to getting a prosthesis and learning to walk. S

ocial worker: organising additional carer support for activities of daily living and personal cares.


Medical team: oversaw wound healing, management of the patient's co-morbidities and pain management.

Outcome

The patient achieved his main inpatient rehabilitation goal of returning home. He was able to transfer independently between a bed, wheelchair and commode using a banana board and could self-propel himself in a wheelchair. The patient was also able to stand up independently to a rail and stand there for several minutes, one of the necessary requirements to receive a prosthesis. His balance in sitting and standing improved to being independent. His left hip extension range of motion increased so he was able to achieve neutral. Overall all limbs increased in strength. Oedema management helped to decrease the size of the stump assisting towards a suitable shape for prosthesis application.

The patient and his family also increased their awareness of the patient's safety during transfers and daily activities and the ways they could assist. This increase in independence with transfers and activities of daily living helped in the patient returning home and reintegrating to the community. The patient was able to attend start attending previous groups and visit some family and friends in areas that were wheelchair accessible. The patient also continued to have rehabilitation at home with regular allied health and carer input prior to further rehabilitation once the prosthesis was applied. I meet the patient several months later at a prothetist appointment where he was learning to walk with a new prosthesis despite developing a left hip flexion contracture of 15 degrees.

Discussion

This patient achieved his main inpatient rehabilitation goal of returning home, however after completing this course I feel there is one particular area of inpatient rehabilitation and my clinical practice that could be further improved for patients' benefit.
 I believe further input and support is needed around psychosocial aspects and the key role they have in rehabilitation. These aspects can include bereavement of the lost limb, depression management, changes in social life, and societal perceptions of amputees as identified by Pantera et al.[1] They can be managed in a variety of ways including building up resilience in amputees through social support from national groups, caregiver resilience, psychopharmacologic intervention, individual psychotherapy, and reinforcement of positive coping strategies[2].

Family members also play a vital role in rehabilitation and can assist with managing adaptations and the new situation. Therefore they should have an active role in exercises and home programmes. However it is also important to remember that these supporting family members can also have difficulty adjusting and may need support through the process too[3]. Overall I believe psychosocial aspects have a key role along with family involvement in ensuring the success of rehabilitation and are aspects that can be easily over looked but need to be kept in the forefront of therapists' minds.

References


  1. 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.
  2. Bhuvaneswar, C., Epstein, L., & Stern, T. (2007). Reactions to Amputation: Recognition and Treatment. Prim Care Companion J Clin Psychiatry. 2007; 9(4): 303-308
  3. Cheriet, I., & Al-Mosa, A. (n.d.). Discharge management of the amputee. Retrieved 18/7/15 from http://www.physio-pedia.com/Discharge_management_of_the_amputee