Using Prosthesis: The chance of a new life: Amputee Case Study
Using Prosthesis: The Chance of a New Life
Lower limb amputations for people brought a considerable decrease in the performance of their activities and without proper management by health personnel can worsen the limitations and slow the rehabilitation process to which they are entitled.
Will see in this clinical rehabilitation case, process development of a woman with bilateral (transtibial and Chopart) amputation that represented a great challenge; careful assessment involving the whole rehabilitation team, together with the amputee and his/her carer(s)to gain independence in ADL(activities of daily living) was key to success.
Amputation, Atherosclerotic, Bilateral, Chopart, Lupus, Prosthesis , Transtibial, Rehabilitation
Demographic Information:At the present time, Liris is a 55-year-old woman; she lives in an urban area; the city of Cucuta, Norte de Santander,in Colombia, She is a housewife and have always liked the personal business.
- Medical diagnosis: Cryoglobulinemic vasculitis: due to Systemic Lupus Erythematosus Affection.
- Co-morbidities: Arterial hypertension.
- Previous care or treatment: When we asses Liris first time, she was 51 years old. Liris arrives our institution after bilateral amputation two years and a half ago,She received in another institution (belonging to the national health system) Pre-operative Assess evaluation: body condition,surgical level discussion, postoperative prosthetic plans,she didn't receive patient education.
Then she received the next phase: Amputation Surgery :Transtibial Amputation in right lower limb and Chopart level amputation in Left lower limb.
Liris received very little assessment in Acute post-surgical: It means little and poor Wound healing , pain control, proximal body motion, and emotional support. And that institution gave her Prosthesis to both legs.
ICF Personal factors:She had been amputated in March 2009 because of complication´s infection as she presented vasculitis with palpable purpura in the legs due to Systemic Lupus Erythematosus. She is a married woman and has three young daughters (Fortunately two of them working in physical rehabilitation, one is PT and the other OT).She is very well supported by her husband Antonio who accompany and assists in her activities. Liris had poor post operative and pre prosthetic fitting assessment and eight months after surgery She started using her first prosthetic devices . She tried to use them but there were many difficulties, thus in 2011,they decide to attend the Rehabilitation Center in Cucuta supported by ICRC.
ICF Environmental factors:The environment is typical of the small urban city, where houses and street are in cement.People move by car, or motorcycle, and is very common,people walk on foot.In the team´s intervention moment she came in wheel chair.
ICF Structure/Function levels: Liris had sensitivity and stump´s pain, She presented:overweight and difficulty transfers, increased energy costs, and muscle weakness retractions.Prosthesis were not functional, just to stand not for gait. Liris developed fear,mistrust and depression.
ICF Activities/Part.levels: As a mother home she used to help in houseworks ,and she had her independent business. Liris loves dance with her husband and going to the mall,but feel frustrated in wheel chair unable to enjoy that.
After evaluation by the team, we concluded that we were facing a challenging but very interesting to implement and develop the best strategies for rehabilitation case. Liris is a person who despite his sadness shows eager to get ahead and hope for a better lifestyle. Our patient did not receive appropriate treatment after surgery.
Prosthetic implementation was inadequate, it served to compensate aesthetically but not allowed to develop the gait activities, so stopped her rehabilitation. Depressed decreased physical activity and weight gain.
Liris spent almost a year and a half in a wheel chair without making physical activity and inactivity related problems of amputee became evident: Patient presents weakness,unbalanced difficulty transfers, muscle contractures, oedema and increased sensitivity. The volume of the waste shall increase to the point that it was not possible to accommodate the volume of the stumps to put on the prosthesis and not served at least to stand.
In this case, we are convinced that although it is not an easy task and may take a long and exhausting period for our patient; Liris can overcome all difficulties supported by our team and achieve their expectations. This requires an extensive evaluation, an integral plan of rehabilitation adequate to improve their conditions before the prosthetic phase. As prosthetist I'm sure new prosthesis can fits the level amputation and comply the biomechanical requirements for successfully rehabilitation.
An interdisciplinary board it was made,We decided to restart the process of rehabilitation from post quirurgical management:Breathing exercises, AROM, Resistance exercises, PROM, Desensitising techniques. Stump management: Dressings, Prevention of oedema, Pain.
An important topic was managed and monitored throughout the process : Psychological support and education of the patient and family.
Then we implemented Pre-prosthetic Phase: Strengthening, Range of Motion, Functional Activities, General Conditioning, Bed Mobility, Transfers,Wheelchair Propulsion, Unsupported Standing Balance, Ambulation With Assistive Devices.
A new Teams meeting assessed an implemented Pre-gait Training: Balance and Coordination, Orientation to the Centre of Gravity and Base of Support, Single-Limb Standing (Chopart).
After two months of work, the team decided to implement: conventional prosthesis for Chopart (left)amputation,distal Silicone inner filling, with frontal high support and flexible filling fingers. Modular prosthesis for transtibial amputation, double socket and supracondylar suspension.
Gait-Training Skills: Donning and doffing,Prosthetic Limb Training, ( first Chopart, then transtibial side),Pelvic Motions, Variations.
We worked some Advanced Gait-Training Activities: Stairs, Step By Step, Uneven Surfaces, Ramps and Hills, Sidestepping, Backward Walking, Multidirectional Turns.
Another topics worked: Falling, Floor to Standing, Recreational Activities.
Initially, the intervention plan was developed slowly, because the physical condition allowed us Liris small advances. Before surgery she weighed 80 kg and when the team assess her weighed about 110 kg and could not move from the wheel chair to a chair or bed on their own. While carrying out the pre-prosthetic training, counselling psychology and the constant support of his family helped us achieve the goals.
After two months of work, Liris was down weight nearly 15 kg and physical and mental condition had markedly improved their residual limbs were free of pain, oedema, with good shape and suitable for prosthetic equipment ROM. In less than two weeks Liris walked off the parallel bars without external devices
She initially supported only one minute stand using prostheses and in less than three weeks Liris walked off the parallel bars without external additions, transfers and activities performed with greater confidence.
In February 2012, Liris finished her training, and the team met again to assess the results of the plan initially. We could implement discharge plan. To one side was the wheelchair and Liris he told us that she had a new opportunity in her life to do what she likes.
In May 2012 she visited to control and told us she now going to the mall with his family enjoy shopping and at home she makes more activities as in the past.
Last I heard about her it was Liris call! to thank us for our work and tell me that she had returned to dance in the New year holidays.
When we assessed Liris, the team concluded it will be a challenge; It means for the team including our patient start from scratch, forget past events, previous prosthesis and outline the management plan. Is necessary to adopt a posture of perseverance and teamwork,so that the results are successful. According to BACPAR guidelines, specialist multidisciplinary team (MDT) achieves the best prosthetic outcomes o provide an effective and efficient service the team work together towards goals agreed with the individual prosthetic user.
In my role as a prosthetist I must comment, bio-mechanical requirements for the implementation of a prosthesis for Chopart amputation became more delicate. As for the conditions of our patient (overweight, and contralateral transtibial amputation) it was necessary to design a special model to accommodate the residual limb, while distributing loads and allow proper training gear. According Stark G, with the Chopart prosthesis the patient can fully load bear at heel strike, but depending on the surgical technique may have pain late in stance. The load must be transferred to the rigid anterior pre-tibial shell and be firmly coupled to prevent A-P migration during anterior foot progression.
Carefulness...In patients with vascular disorders issue the demands of training and energy expenditure the heart rate and blood pressure of every patient should be closely monitored during initial training and thereafter as the intensity increases.
- Ramos-Casals et al,Vasculitis in Systemic Lupus Erythematosus, Prevalence and Clinical Characteristics in 670 Patients. Medicine � Volume 85, Number 2, Lippincott Williams & Wilkins March 2006.
- Morris,S. The Psychological Aspects of Amputation. Taken from: First Step, Amputee Coalition http://www.amputee-coalition.org/first_step_2003/psychological-aspects-amputation.html
- Lusardi MM, Postoperative and preprosthetic care. In Lusardi, MM, Jorge, M Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.
- Barbara Engstrom and Catherine Van de Ven. Therapy for Amputees, 3rd Edition. 1999
- Prosthetic Gait Analysis for Physiotherapists,ICRC Physiotherapy Reference Manual.January 2014
- British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR). (2012). Evidence Based Clinical Guidelines for the Physiotherapy Management of Adults with Lower Limb Prostheses
- Stark G. Clinical Biomechanics of the Partial Foot http://www.acpoc.org/newsletters-and-journals/2012_01_005.asp
- Robert S. Gailey,Curtis R. Clark, Physical Therapy Management of Adult Lower-Limb AmputeesfckLRChapter 23 - Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles