Working with Aunty Lim: the diabetic transtibial amputee: Amputee Case Study

 Title

Working with Aunty Lim: the diabetic transtibial amputee

Abstract

This case study deals with a female patient (given name Madame Lim for example purposes) who I worked with in an Acute hospital in Singapore. She underwent a below knee amputation primarily due to a diagnosis of DM and PVD. I saw her from the pre-operative phase to the pre-prosthetic phase

Key Word

Transtibial amputation, diabetes, occupational therapy, peripheral vascular disease, acute hospital

Client Characteristics

"Madame Lim is a 63 year old lady who is married with two children. She stays with her elderly husband in an apartment with lift landing access with a seated toilet facility. Her children are both married, with one of them living nearby and the other living overseas. She was previously independent in her activities of daily living (ADL) such as showering, dressing and grooming. She works in a local food centre cooking noodles from 7am-9pm daily. Her husband is not working and requires a walking stick for ambulation.He assists Madame Lim with the housework and marketing. Madame Lim takes the bus to work every day.
Her pre-morbid medical history includes type 2 diabetes, hypertension, peripheral vascular disease and hyperlipidaemia. She has a history of non-compliance to taking insulin or controlling her diet, and smokes 20 cigarettes per day for the past 25 years. She was hospitalized following a visit to her local GP due to a non-healing right food wound. She was found to have right great toe, 2nd toe and 3rd toe celluitis with gangrene likely secondary to PVD. Acute medical intervention included a left crossover right femoral angioplasty, and right big toe ray amputation. It was found post-op that the wound was healing poorly with further advancement of the gangrene into the right lower. The medical team met with the patient and family to discuss further medical options. It was deemed necessary for a right lower limb transtibial amputation to be performed."

Exam Findings

Madame Lim was assessed by the OT pre-operatively. Cognition was assessed, she was able to follow commands, was oriented to her surroundings and understood why she required an amputation. Emotionally, she was noted to be tearful and was worried about whether she can return to work. She was also concerned as her husband would be unable take care of her.
Regarding home environment, the patient has 2 steps at the entrance to her home and a kerb into her toilet. She stays in the master bedroom with ensuite toilet. There were no grab bars in place and the toilet was a low height. The patient's work environment is a ground floor food centre. Her duties include standing for extended periods and serving customers.
Physically, the patient was found to have full upper limb range of motion, MMT of 4/5 bilaterally and intact fine motor skills. During sensory testing using blind light touch localisation, the patient was noted to have mild sensory loss over her fingertips. She was noted to have full range of motion over her unaffected left lower limb, similarly she was noted to have mild sensory loss over the left foot with skin dryness. The patient was able to perform bed mobility with supervision and sit on the bed edge with minimal assistance. She required moderate assistance to transfer to the chair keeping the right lower limb non-weight bearing. She was noted to have decreased activity tolerance and required rest breaks during assessment. "

Clinical Hypothesis

Body Functions and Structures/Impairments: Poor skin integrity and neuropathy over distal extremities, decreased activity tolerance, poor compliance to DM control.
Activity Limitations: decreased sensation over upper and lower limbs affecting safety during ADL and IADL and increasing the risk of further trauma to the skin; non-compliance increases risk of poor wound healing long-term and increasing risk of further amputations
Participation Restrictions: Loss of role of as worker and wife, with consequent loss of locus of control
Environmental Factors: Environmental physical barriers in the home and work environment; lack of carer at home to assist patient

Intervention

The OT emphasized self-management of the stump and educated the patient on the wound healing process and risk factors for poor wound healing. Madame Lim was educated on correct positioning of the stump to reduce the risk of contractures and oedema. The OT initiated teaching bed mobility and lower limb PROM moving onto AROM exercises for the stump and unaffected lower limb. Sitting balance practice was performed using functional activities. Transfer training was initiated using single leg pivot transfer to the wheelchair. This was progressed onto hopping with a walking frame and pivoting into the wheelchair. Transfers were graded to include wheelchair to toilet and wheelchair to toilet transfers.
ADL retraining included dressing practice using the walking frame. A shower assessment was also performed with the use of a commode chair. A kitchen assessment was performed using walking frame and wheelchair where necessary to assess patient's ability to make a simple drink independently.
A home visit was performed with patient and MSW. It was collaboratively decided that the patient would benefit from grab bar installation and purchasing a wheelchair and commode. It was also decided that the patient would benefit from having a ramp installed into the home and into the toilet.
The OT monitored how the patient was managing with the amputation and provided supportive counselling as needed."

Outcome

Madame Lim stayed in the acute ward for 3 weeks post-op and received OT and physiotherapy services. The OT advised the team doctor that the patient would benefit from being fitted for a prosthesis given her premorbid ADL independent and ambulant status. The doctor assisted by referring the patient to the Foot Care and Limb Design Centre for prosthesis fitting and vocational rehabilitation. While awaiting prosthesis fitting the multidisciplinary team advised the patient be transferred to a step-down community hospital to provide further rehabilitation. During this process, the OT liaised with the MSW to assist patient in getting a standard lightweight detachable wheelchair and a commode. The MSW also liaised with the patient's housing association to apply for ramp installation into the patient's home and at her toilet. By the time the patient was transferred to the community hospital she was independent in transfers from bed to wheelchair and was able to perform lower body dressing with supervision. The patient was limited mainly by decreased activity tolerance and decreased standing balance. She was motivated for further therapy and keen for prosthesis fitting with the hope of returning to work.

Discussion

This case dealt with a female patient who fulfills several recurrent themes noted amongst Singaporean patients in the health system. She had a diagnosis of DM and PVD, she was from a lower socio-economic class and she lived in government housing which presents several environmental barriers. She was limited primarily by a decrease in activity tolerance however managed to slowly overcome this due to the graded nature of therapy. She was also seen in conjunction with the Physiotherapist and had significant social worker input. Despite initially finding it difficult to adapt to her change in function and role, she engaged well in therapy and was successfully discharged to step down care with a follow-up to a prosthetic clinic for prosthesis fitting. In future, I would hope that my practice would successfully work as an interdisciplinary team with clearly defined roles. Furthermore, it would be beneficial if home visits were made a crucial aspect of therapy as opposed to only being available for complex cases.

References

  1. Acute Care. AustPar (2015). http://www.austpar.com/portals/acute_care/post-op.php
  2. Prosethetic Gait Analysis For Physiotherapists. ICRC.
  3. Therapy for Amputees, 3e 3rd Edition, Engstrom & de Ven