Traumatic but Geriatric: Simple but Complex: Amputee Case Study

Title

Traumatic but Geriatric: Simple but Complex

Abstract

The case presents the fitting phase rehabilitation from an elderly French women She was amputated of one led during a car crash and also broke seriously the other one. The case describes the multidisciplinary work to obtain as fast as possible the up standing of this patient. Because of the bone consolidation problems, an intermediate phase of rehabilitation with support one the only amputee leg has been realized, using a weight bearing harness. Without final consolidation, classic rehabilitation with a Sarmiento was continued. Functional walk was obtain despite absence of consolidation.

Key Words

transtibial, geriatric, consolidation problem, traumatic, amputee, weight bearing

Client Characteristics

Miss XXX is seventy seven years old. She lives in, a village in France. She was a farmer but now she is retired. She lives with her husband in a House. She must climb stairs to come in. She has two children, a 65 years old boy, and a 61 years daughter. They leave close to her. She has also 5 grandchildren and nine great grandchildren.
She had a car accident in January 2015. She falls asleep when she was driving an evening. During the crash, she has been amputated under left knee. The right leg was broken and required a surgery with an external fixator and a skin graft. During the accident, she fell in coma and was transferred in reanimation for 2 weeks before wake up.
She was still active before accident. She lives making her garden and walking in the contry
She has some hypertension but is treated for. She has also a polyarthritis.
This case begin at the beginning of fitting phase

Examination Findings

After reanimation exit, and 6 weeks after scratch.
During the pre-fitting phase, none charge on feet where possible because of the unconsolidated right leg. Early walking aid was not decided because of the broken contralateral leg.
Actually, she weights 38 kg and measure 1,55 meters. Before accident and amputation, she was 10 kg heavier. Body mass index is also 15.83
During pre-fitting phase, the principal objective was autonomy. Wheelchair handling, transfers to the bed, to the toilets without support has been learned.
The patient chief complaint is to stand up. This is also team objective because of the patient’s age.
Examination according to ICF :
body structure and function impairments:
Knee and hip joint of the amputee leg are normal.
Knee flexion of the broken leg is limited to 90°
Muscle Strength is also preserved for upper and loxer limbs.
Stump is cicatrized and skin is clean but supervision is important because of the malnutrition.
Fingers range of motion are limited because of polyarthritis.
She was pain free excepted for a phantom pain , only treated by graded motor imagery[1].
Activity limitations:
Support on any leg and up standing are impossible.So, berg scale, AMP no pro have not been evaluated.
walk and support are impossible because of the absence of consolidation.
Participation restrictions:
home return is impossible because of the stairs access. Her principal goal is make her garden and walking in nature.

Clinical Hypothesis

Miss XXX is elderly person. She has spent 15 days in the coma, and 4 weeks more on a wheelchair. Adding to the trauma, prolonged immobility is a high risk not to recover walking ability . Moreover, successful of prosthetic fitting in geriatric is low[2] especially when time without up standing is long. We also decided to shape a prosthetic and to stand up even consolidation is not obtain.

Intervention

Multidisciplinary team decided to put a socket easy for donning and duffing because of hand polyarthritis and also comfortable because of malnutrition problem. We choose a silicon sleeve locking with a SSS Socket. Foot is a SACH.
To ease standing up and walking in one leg and learning how to transfer and walk, support rehabilitation began with weight baring harness and a ceiling rail above the bars: Balance was easier and constraints on the stump were lower. In this conditions, miss XXX learned to support on her prosthetic how to maintain balance, to turn, to transfer, all on one leg.
Out of the bars, she also learned how to transfer to the massage table, to the bed and to the toilets on her prosthetic.
She was educate to watch on her stump after duffing and how donning effectively.
But 6 weeks later, even fixator was out, consolidation on broken leg was not obtained. No more 15 days later.
A multidisciplinary staff with doctor, prosthetic and surgeon decided that progressive support was possible with a Sarmiento orthotic proposed by the prosthetist, so as to allow walking.
At this moment, with adding 10 kg support per week, Miss XXX learned to walk outside the bars.
One month after, despite absence of consolidation, total support on Sarmiento was reached and classic program of balance, support transfer, walk inspired by Bob Gailey[3] has permitted to walk without any walking aid.
In the same time, a specific program of nutrition has been established.

Outcome

Final outcomes are on June 2015.
Miss XXX is in totally autonomous considering prosthetic management (cleaning, donning and duffing, volume variation management, etc.) and for any transfers including how to stand up from the ground.
Skin is in good conditions. Joint range of motion of the knees and hips are great, muscle strength has been recovered.
Balance is good but impossible on one leg.
She weights 42 kg.
We change the foot for an ESAR foot (Sureflex), so as to learn how to use energy restitution.
She can walk 500 meters on average outside without any walking aid. Sarmiento is still necessary on the other unconsolidated leg.
10 meters walk test in 11 seconds; she walks 130 meters on the 2 minutes walking test and 320 meters on the 6 minutes walking test. At the and of the test, borg scale 12 and there is no pain in the socket.
On the walkway report, step length is symmetric but time of double support is much higher than normal.
Bone consolidation is still not obtain.

Considering functional outcomes:

  • Time up and go test is 11 seconds
  • Berg assessment scale is 49 : she is so considered as independent
  • Amputee mobility predictor[4] is 37
  • Locomotor capabilities index[5] is 40
  • ABC-UK score[6]  is 55% which means that confidence must progress

Outcomes conclusion: Objective of a functional walk is reached. Personal objective to return walking in country as before needs more time because of walking distance ability and confidence, but is achievable.

Discussion

Miss XXX is considered as an elderly person because of her age. Nevertheless, the complexity of the geriatric amputee rehabilitation stick to the overall health and co-morbidity factors[7] like vascular diseases, diabetes, pulmonary problems. But finally, miss XXX was rather healthy expected to the treated hypertension and the polyarthritis. She has been treated more like a traumatic case than a true geriatric one.
But the case was very interesting according to the intermediate phase of unilateral support on the prosthetic. The use of weight bearing harness was really uncommon for an under knee amputation. but our conclusion is that the opposite broken leg was finally a chance for miss XXX. She has been forced to support on his prosthetic. It was probably a reason of the rehabilitation success especially considering the balance and the confidence.
Moreover, the case illustrates the importance of multidisciplinary team[8]. Collaboration of the surgeon, prosthetist, doctors and physio to take the best decision regarding support and equipment was probably another factor of success.

References 

  1. Moseley GL,Graded motor imagery for pathologic pain A randomized controlled trial, neurology, 2006
  2. Aisling M Fleury, Salih A Salih and Nancye M Peel Rehabilitation of the older vascular amputee: A review of the literature Geriatr Gerontol Int 2013; 13: 264–273
  3. Gailey RS, prosthetic gait training for lower limb amputees, 1989
  4. Gailey R.S.Predictive Outcome Measures Versus Functional Outcome Measures in the Lower Limb Amputee. Journal of Prosthetics and Orthotics. 2006; 18:1S: 51-60
  5. Franchignoni F, Orlandini D, Ferriero G, Moscato TA.Reliability, Validity, and Responsiveness of the Locomotor Capabilities Index in Adults With Lower-Limb Amputation Undergoing Prosthetic Training. Archives of Physical Medicine and Rehabilitation. 2004; 85:743-748
  6. Parry W, N Steen, S R Galloway, R A Kenny, J Bond,outcome measures in an older British cohort., Postgrad Med J 2001;77:103–108
  7. Fried L, et al. Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care; Journal of Gerontology. 2004; 59(3): 255–263
  8. Körner M. Interprofessional teamwork in medical rehabilition: a comparison of multidisciplinary and interdisciplinary team approach, Clinical Rehabilitation, 24 (8):745-755