Transfemoral rehabilitation of a diabetic elderly patient: Amputee Case Study

Title

Transfemoral rehabilitation of a diabetic elderly patient: Amputee Case Study

Abstract

Mdm Z is an 80-year-old Chinese female who presented with fever and severe right lower leg pain in the Emergency Department. She was diagnosed with right necrotizing fasciitis and underwent an emergency right above knee amputation in March 2013. Her past medical history includes atrial fibrillation, Type 2 diabetes mellitus, hyperlipidemia and hypertension. She was on oral medications for her medical conditions. She was seen in the outpatient clinic in late 2013 and started pre and post prosthetic rehabilitation subsequently for 2 years to enable her to reach her goals of functional ambulation

Key Words

  • transfemoral
  • prosthetist
  • balance
  • ambulation
  • rehabilitation
  • necrotizing fascitis

Client Characteristics

Mdm Z is an 80-year-old elderly Chinese female housewife. She lives with her oldest daughter and helper in a lift-landing unit. She enjoys marketing and visiting the Buddhist temple on a weekly basis. She was pre-morbidly community ambulant without a walking aid. She was also able to manage all her activities of daily living independently. Her past medical history includes diabetes mellitus, hypertension, hyperlipidemia and atrial fibrillation. She is on oral medications. She has good family support and her helper is able to assist her in daily tasks as needed.

She was diagnosed with an acute right lower limb necrotizing fasciitis on admission. She is cognitically intact and does not smoke or drink. Post operatively; she underwent rehabilitation to assist her in gaining independence in transfers and bed mobility. Her physical therapy interventions included ranging, flexibility, strengthening, balance exercises and transfer practices. She was able to stand with a walking frame with assistance on her first visit but could not hold for longer than 10s due to poor balance and decreased strength in her extremities. She has nil claudication on the left lower limb. She has good sensation over her left lower limb and right residual limb with nil resting pain reported.

Examination Findings

Mdm Z underwent a right transfemoral amputation due to necritizing facitis and was seen 12 weeks later. Her residual limb length was medium. It was cylindrical with mild swelling at the base. She had residual limb and phantom limb pain on sporadic occasions since operation. She had full range of motion in all her limbs except right hip abduction. She had good strength in her upper limb and muscle power 4 for her left lower limb and right hip. She had good static and dynamic sitting balance. Her static standing balance and dynamic standing balance was poor.

She was able to stand for 10s with a walking frame before her muscles fatigued so she could rest. She was wheelchair bound with assistance. Her pulses and sensation were normal. She expressed mild grief and resigned into thinking she will not ambulate again. She was able to hop with a walking frame with left side trunk flexion assisted by her helper for 2metres. She could walk for 2 metres with her prosthetic which buckled. She tiptoed on her left foot and her trunk deviated to her right. She also kept her right arm close to her body. Her AmpPro score was K2.

Her Activities specific Balance confidence scale scored 60%. She was assisted in toileting, dressing, showering, washing by the helper. Her children will transport her. She was able to transfer with 1 person assisting. She was largely homebound with little social contacts. Mdm Z wished to ambulate with a walking stick independently.

Clinical Hypothesis

Based on her physical assessment, she has weakness over her gluteal muscles, hip abductors and flexors as well as knee extensors. She also had poor dynamic standing balance and displayed some element of fear. She had reduced muscle endurance and cardiovascular endurance. Weak hip abductors caused her to deviate to her prosthetic side and weak hip flexors produced a circumduction during walking.
 With respect to her prosthesis, after collaboration with the prosthesis it was found to be too short, had a poor suspension causing prosthesis to slip, too small socket, lack of prosthetic wall support and the heel cushion was too firm.

Intervention

Mdm Z underwent physiotherapy for 1 year. She continued with pre prosthetic exercises such as stretches and general strengthening exercises with emphasis on hip flexors, abductors and extensors of both lower limbs. She started mirror therapy to help her manage her phantom limb pain better and was taught residual limb massage and desensitization exercises.

To build up her cardiovascular endurance, Nu-step and cross trainer was used with gradual progression to the duration. Moving on there was progression to balance training with appropriate support initially - orientation over her base of support and weight shifting exercises side to side and back and forth. She was progressed to stand on foam with eyes closed. Trunk rotation and ball throwing was added to challenge her dynamic balance.

Meanwhile the prosthetist corrected the length and changed the socket, added suspension and increased the support over the lateral wall. She was taught swing control and to control knee extension with hip extension through stance phase. She was educated and practiced functional tasks routinely to ensure she was safe. Her step length was improved gradually. As she progressed, her walking aids were gradually weaned and she started on complex activities such as walking sideways and back, walking outdoors and on sloped and getting on and off the floor. She also received exercise handouts with clear explanation specific to her.

Outcome

Mdm Z's long-term goal was to be able to ambulate with a walking stick in the community. Mdm Z had a muscle grade above 4 for both her lower limbs. She had good static and dynamic standing balance. She had nil phantom limb pain and no swelling over her residual limb. She was more participative and optimistic and had started going to the temple. She was ambulating independently without aids at home.

Her AmpPro was K: 3. Her Activities Specific Balance scale was about 75%. Her 10m-walk test with a walking stick was 1 minute 10s compared to 2 minutes with a walker at the start. She had an upright trunk posture, nil circumduction of limbs and no swinging of her arms. Her step length was bigger. She was able to use a walking stick for 15minutes before she felt tired. Her vitals were monitored at all times to ensure that the activities and progression did not cause her tachycardia.

Discussion

Mdm Z was able to achieve her functional long-term goals. The intervention rendered to her were varied and staged towards helping her achieve her goals. There was good collaboration with the prosthetist to ensure a good fitting at all times and gait was observed by both members on a timely basis so improvements could be made.

Although she is able to ambulate in the community, she can only tolerate 15minutes of ambulation. Thus perhaps it would have been more holistic to add ambulation or treadmill as a means of improving her cardiovascular endurance. Pilates is a good way to improve core and trunk control. This can translate to better muscular endurance.

Also it would have been better if fall prevention was included. Caregivers should be roped in to help in motivating patient and improve her emotional state during the first half of the year. The prosthetist was not from the same institution hence time was wasted in communicating and arranging for the dates for the prosthetist to be around. Also the adjustment usually took a longer time wasting precious rehabilitation time.

In my opinion, there should be a multidisciplinary round meeting on a monthly basis for amputee patients to help all members work together to enable patients to achieve their best potential as soon as possible.

References

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