Uncle Joe's First Steps: Amputee Case Study

Title

Uncle Joe's First Steps

Abstract

Our patient J. K. was admitted 6 weeks after his left transfemoral amputation in our setting. 62 years old, with severe co-morbidities, he was ambulating succesfully with a walker by then. His endurance was low but he did not show any trace of depression at all.He got his temporary leg in our inpatient care, and his long-term one as an outpatient visiting our therapy centre every day. Adapted many times, he learned to use it with confidence with one elbow crutch outside and without crutches in his appartement. His function and endurance developed very much, and his phantom pain decreased.

Key Words

Transfemoral, diabetes, PVD, elderly, reamputation, endurance

Client Characteristics

A 62-year-old male patient, a retired waiter by profession with some drinking problem and no inclination for depression. His co-morbidities are severe: diabetes type II, hypertonia, cardiac arythmia, atrial fibrillation, arteriosclerosis universalis (PVD), hyperuricaemia. He used to work hard all his life, do nothing for his health and pay no attention to symptoms of any disease, as our culture suggests to men. But in 2006 it became clear that he had atrial fibrillation and decreased left ventricular function. His lower extremity pains started in 2008, in summer the first slowly healing wound appeared. In 2013 his left first toe was amputated, but the wound developed black gangrene and sepsis followed.So they had to amputate his left leg transfemoral which he had a high risk for [1]. In hospital, he was taught how to use a walker. After leaving hospital,he spent approx. a month at home, ambulating with walker quite confidently, having no tresholds in his appartement and doors are wide enough. He had a fall, though, a week before his admission to our setting.

Examination Findings

His hypertonia and diabetes are improperly medicated, his blood pressure and blood glycose levels are uneven. His endurance is low. His right dorsal pedis artery is hard to find, his foot is cool. He has no excess weight. His alignment shows excessive thoracal kyphosis, his neck and lumbar spine ROM is decreased. His shoulders crepitate and are painful to movement (VAS: 6. ROM: flexion R130, L120 grades, abduction R70, L70 grades, ext. rotation R40, L45 grades, m. deltoideus R-L 5/4). His wrist and finger joints show the signs of beginning osteoarthritis (worsened by excess fatigue from walker use). His hips had no contacture but his muscle power was poor, especially in the stump: m. quadriceps R5/4, L5/3, m. iliopsoas R5/ 4+ L5/3, m. gluteus medius R 5/4, L 5/3, m. gluteus maximus R 5/4 L5/3-, mm. adductores R 5/5, L5/4.Standing Stork Test: 3[2]. His stump has edema (perimeters: R 34, L47 cm, 15 cm from SIAS down) and his scar is uneven and hard at ends. He feels phantom pain and cold (VAS 5) often, but his stump is not painful or hypersensitive. Walks with walker for shorter distances, otherwise he uses a wheelchair. His FIM/FAM Scale findings are 165 at admission.He lives with his wife in their own second floor appartement, has good contacts with family and friends.He is talkative, open and kind, shows no signs of anxiety or depression.His objective is to walk independently at home and in his country town environment as an active pensioner.

Clinical Hypothesis

Main problem is mobility: walking with a frame is slow, difficult and gets painful for shoulders and hands. It is impossible to climb stairs and he lives on the second floor.His country town environment is full of barriers, stairs, kerbs difficult to compromise in a wheelchair in his physical state. So he can not go out and cannot work in the kitchen (cooking is his beloved leisure activity and his share of housework). His participation is severely restricted.His endurance is low and his ADL functions are compromised. His LE muscles are weak, with bad circulation.He has phantom pain.

Intervention 

First,I bandaged his stump. I mobilized his neck and shoulders and strengthened his stump and LE muscles. I mobilized his scars and taught desensitizating skills to massage and rub his stump. He started lying prone but could not bear it long (4-5 min at once). Doing active strengthening exercise,pulling weights and developing his balance, his endurance improved but I was very careful to make pauses at times and to protect his sound foot from shearing forces. Getting his temporary prosthesis with immobile knee, we started basic weight bearing and pelvic motion exercises, then gait elements. Slowly he became confident for prosthesis weight bearing but circumducted his prosthetic limb. Checking length[3] it has been found correct, but his quadratus lumborum muscle was too weak for proper pelvis elevation so I addressed it with focused strengthening.His gait improved, but with double crutches he put too much weight onto them. With one, later, he shifted less weight on the prosthetic foot, so we practiced weight bearing[4] on a HUR balance platform succesfully.I developed his walking skills in an obstacle course.Getting his long-term prostesis with an uniaxial knee and mobile ankle joint, he lost his confidence again. His prosthesis was adjusted many times for proper length. I started basic gait training again, putting emphasis on heel strike of the prosthetic leg.Parallel, I went on with strengthening hip muscles [5]. Finally he uses one elbow crutch and can stand without.

Outcome

Between the two phases of rehabilitaion (inpatient 3,5 months, and outpatient care 5 weeks)his contralateral 2nd toe was amputated. This was no surprise knowing that risks of contralateral amputation within 1 year in case of toes are 3,5 per cent [6], although his diabetic medication has been properly set.He refused wearing orthopedic shoes even though his foot is misshapen.
At discharge he scored 192 at FIM/FAM. He walks confidently with one elbow crutch, can negotiate stairs and obstacles with suitable endurance. His balance is good enough to do his kitchen work without crutch.His muscle strength has improved: m. deltoideus R-L5/5, m. quadriceps R5/5, L5/4, m. iliopsoas R5/5, L5/4, m. gluteus maximus R 5/4+, L5/4, m. gluteus medius R 5/4+, L 5/4.His endurance has developed over expectations, he slowly climbs steps to his apartement without getting short of breath. His participaton has developed, but he feels some discomfort after sitting long. He got a severe allergy against his silicone liner (rash, stump edema and redness) so his socket has been replaced to the one of his temporary prosthesis which he wears comfortably with a sock.Donning and doffing it he has no problem, his stump is painless. He feels phantom pain only when the weather changes (VAS3).He is satisfied with his mobility and participation."

Discussion

An elderly diabetic patient suffering a series of amputation [7] is usually not a success story from the rehabilitation point of view.But in my country (Hungary) this is reality: people work long hours and do nothing for their fitness and health. So their condition deteriorates at a relatively young age. Our patient had many complications and problems during his rehabilitation.As the Diabetic Amputee chapter refers, the contralateral foot needs extra attention and protection against shearing forces. In my country all amputee patients are offered orthopedic shoes for a subsidized price, but our patient has ferused to wear them. Anyway, he coped well and reached a good level of function, endurance and balance beyond expectation.As for our clinical practices, we could have more courage with elderly diabetic patients to reach higher levels of rehabilitation.
[8]

References

  1. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation,
  2. Butler AA, Lord SR, Rogers MW, Fitzpatrick RC. Muscle weakness impairs the proprioceptive control of human standing. Brain Res. 2008 Apr 16. [Epub ahead of print]
  3. Kishner's Gait Analysis after Amputation updated July 2013
  4. Horlings CG, van Engelen BG, Allum JH, Bloem BR. A weak balance: the contribution of muscle weakness to postural instability and falls. Nat Clin Pract Neurol. 2008;4:504-15.
  5. Kishner's Gait Analysis after Amputation updated July 2013
  6. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation,
  7. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation,
  8. Lafond D, Corriveau H, Prince F. Postural control mechanisms during quiet standing in patients with diabetic sensory neuropathy. Diabetes Care. 2004; 27:173-8