War Vetern Case Presentation: Amputee Case Study

Title

War Vetern Case Presentation: Amputee Case Study

Abstract

The pt, KP is s/p L trans-radial BEA and R trans-femoral AKA, injuries sustained from Improvised Explosive Device (IED) while deployed in Iraq with secondary dx of possible TBI from explosion. Pt was recommended to out-patient therapy to increase independence with ADL, IADL, mobility, regulate emotions, reduce pain/edema, sensitivity in residual limbs and improve overall cognitive ability. Pt has potential to improve with skilled healthcare services.

Key Words

veteran, amputee, trans-radial, trans-femoral, ADL, phantom limb pain

Client Characteristics

KP is a 45 y/o women war veteran. KP lives with her husband, Sam, in a two-story house with no elevator. They have no children or pets. They live 3 hours from their closest family members. KP has a close group of friends that she goes out for lunch with and long walks frequently. Though, she fears that, with her amputation and mental health issues her friends are beginning to avoid her more. They have a cleaning woman that cleans the entire house and does the laundry once a week. Frustrated with current ADL performance, anxious for LE prosthesis and not sleeping well. Emotional and unsure of future career status.

  • Primary dx: s/p R trans-radial BEA and L trans-femoral AKA, Amputation conducted at hospital
  • Secondary dx: possible mild acquired brain injury (TBI) and/or PTSD
  • Precautions/contraindications: None
  • Treatment setting client being seen in: out-patient rehabilitation; KP has received training in stump care, prosthetic hygiene, and physical therapy for training in ambulation with a focus returning to a high level of rehabilitation.

Examination Findings

Subjective: Patient complains of phantom limb pain and weakness. The patient hopes to successfully use a prosthetic limb to ambulate at a high fitness level and reduce or eliminate the phantom limb pain. Patient is currently working with PT, doctors, OT, Prosthesist, social worker and nursing staff. Frustrated with current ADL performance, anxious for LE prosthesis and not sleeping well. Emotional and unsure of future career status.

Self Report Outcome Measures

  • Activity Specific Balance confidence scale UK (ABC-UK) - Results: 75%
  • The Amputee Mobility Predicator (AmpPro/AmpNoPro) - Results: 37/43
  • Pain Scale: 6/10

Physical Performance Measures

  • Barthel ADL index - Results: 80/100

Objective:

Physical Examination Tests and Measures

  • Orientated to person, place and time
  • Sensation is intact
  • Surgical incision are healed well
  • Edema present
  • No Presence of ulcers or neuroma
  • Skin integrity: normal skin color, no signs of infection, and no potential areas for breakdown
  • Shape of residual limb: conical
  • Balance:
    • Static sitting balance: Good
    • Dynamic sitting balance: Good
    • Static standing balance: Good
    • Dynamic standing balance Good-
  • Range of Motion (ROM) of residual limb joints and remaining extremities- WFL
  • Vital Signs:
    • HR: 72
    • BP: 125/40
    • SpO2: 95
    • Temp: 97.4 F
  • Assess prosthesis: good
  • Fit of socket: good
  • Able to don/doff and care for prosthesis independently
  • Pt participation in A

Clinical Hypothesis

s/p L trans-radial BEA and R trans-femoral AKA, injuries sustained from Improvised Explosive Device (IED) while deployed in Iraq. Possible TBI from explosion. Possible PTSD. Restore self-care skills, establish transfer skills, and regain social cognition skills. Also, restore strength, sensitivity, reduce edema, reduce pain and establish relaxation techniques. Cognitive compensatory strategies include: AE training, Prosthetic training and ADL and mobility retraining. Long term increase ADL, IADL and mobility, regulate emotions and improve overall cognitive ability.

Intervention

Goal Method

  • Educate on hygiene for residual limbs [1] -Demonstrate how to clean skin and had her practice
  • Educate on dressing for residual limbs [1] -Demonstrate how to properly dress and have him practice (stump shrinker)
  • Decrease edema in LUE and RLE -Retrograde massage, positioning in wheelchair, bed [1]
  • Decrease pain in LUE and RLE -Desensitization, tapping, mirror therapy[2]
  • Increase strength in LUE and RLE -Strengthening exercises (theraband, free weights, etc.)[1]
  • Increase balance during ADLs/IADLs -Activities that take him off center of gravity (wiping a table, etc.) [1] (I) with BADLs will increase -ADL re-training
    • AE training[1]
  • Increase independence with IADLs - IADL re-training
    • AE training[1]
  • Functional transfers independence will increase -Transfer training[1]
  • Increase sleep participation -Sleep schedule, sleep log [1]
  • Increase emotional awareness for successful social interaction -Role play different scenarios, emotion reflection journal
  • Increase cognitive ability -Cognitive compensatory strategies -Sequencing tasks [1]
  • Educate patient on prosthesis usage and management -Practice donning/doffing
    • Prosthetic training [1]

Outcome

Goal Outcome

  • Educate on hygiene for residual limbs - Pt able to perform cleaning stumps independently
  • Educate on dressing for residual limbs - Pt able to dress residual limbs independently
  • Decrease edema in LUE and RLE - Reduced pain
  • Decrease pain in LUE and RLE - Desensitized to a tolerable level
  • Increase strength in LUE and RLE I - mproved UB strength to 4 from initial 3- and LB 4+ from initial 3, based on MMT.
  • Increase balance during ADLs/IADLs Able to perform functional mobility during ADL performance with sup, requiring verbal and visual cues for correct hand/foot placement (I) with BADLs will increase - Able to perform BADL performance with sup, requiring verbal and visual cues for correct hand/foot placement
  • Increase independence with IADLs Able to perform IADL with sup, requiring verbal and visual cues for correct hand/foot placement
  • Functional transfers independence will increase Able to transfer with CG, requiring stand by assistance if balance is lost.
  • Increase sleep participation - Sleeping 3/7 nights
  • Increase emotional awareness for successful social interaction - Able to recognize emotional awareness in social situations.
  • Increase cognitive ability - Cognitive compensatory strategies such as list making were successful
  • Educate patient on prosthesis usage and management Pt is able to don and dof socks/prosthesis (I)'ly.

Discussion

KP had a R trans-radial BEA and L trans-femoral AKA with a secondary dx possible mild acquired brain injury (TBI) and/or PTSD, complicating KP's ability to retain new information. KP's case reinforces previous evidence that endorses the use of retrograde massage, positioning in wheelchair, bed for edema treatment. KP's case reinforces previous evidence that endorses desensitization, tapping, mirror therapy to decrease pain [2].

"Although all 27 (100%) of the amputees were able to maintain satisfactory family functioning, only 13 (48.1%) of the study participants were able to remain productively employed after undergoing amputation, and 20 (74%) reported long-term psychological problems in addition to their physical pain" [3].

More research is needed on compensation strategies and coping mechanisms specifically for war veterans with amputations due to the psychological impacts of war. KP was referred to VA, veteran support group, OT for a driving evaluation and strength coach[4].

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Radomski M.V. & Latham C.A.T. (2008). Occupational therapy for physical dysfunction (6th ed.). Philadelphia: Wolters Kluwer Lippincott & Williams; Wilkins
  2. 2.0 2.1 Timms, J., & Carus, C. (2015). Mirror therapy for the alleviation of phantom limb pain following amputation: A literature review. International Journal of Therapy & Rehabilitation, 22(3), 135-145.
  3. Ebrahimzadeh, M. H., & Rajabi, M. T. (2007). Long-term outcomes of patients undergoing war-related amputations of the foot and ankle. The Journal of foot and ankle surgery, 46(6), 429-433.
  4. Khadir, S.A. (2015). High-level rehabilitation of amputees. Retrieved from http://www.physiopedia.com/High_level_rehabilitation_of_amputees