Young Diabetic Transfemoral Amputee: Amputee Case Study

Title

Young Diabetic Transfemoral Amputee


Abstract

27 year old female, who had a L Transfemoral amputation in April 2014. Following rapid onset of secondary complications due to Type 1 Diabetes. She was seen by myself for Physiotherapy at the Limb Fitting Centre from June 2014 until present.


Key Words

transfemoral, young, diabetes


Client Characteristics

Diagnosed with Type 1 Diabetes as a child. Very rapid progression of Diabetes. Information limited as patient is Russian and was treated in Russia. Moved to UK in 2012.
Pt on dialysis 3x a week prior to Kidney and Pancreas Transplant in January 2014. Pt now effectively cured of diabetes. However shortly afterwards pt underwent a L Transtibial Amputation, which did not heal, wound broke down & became necrotic. Due to this it was revised to a L Transfemoral Amputation in April 2014.

She also had a grade 1 heel ulcer on her right foot. This was reviewed weekly by podiatry and resolved. She also has regular vascular studies to monitor the circulation in her remaining leg.


Examination Findings

Her objectives were to regain a high level of mobility to allow her to go to unversity, get a job, start a family and learn to drive. She expressed thinking that once she had her transplant life would start as she would be free from dialysis and constant hospital appointments. However amputation changed her vision for life, and she had some difficulty adjusting to this initially.

Due to longterm health problems and diabetes, she had a low weight of 46kg. She had reduced exercise tolerance, reduced muscle power particularly around gluts and core strength following having multiple surgeries in a 4 month period.

Pre-prosthetic exercises were commenced with particular focus on hip strength, gluts strength, core strength and sitting & standing balance. This was also combined with cardiovascular exercise and upper limb strengthening exercises. Walking training using the femurett was commenced within the parallel bars and progressed onto crutches and then sticks. Due to her low exercise tolerance, sessions were required to be shortened and more frequent, varying the exercises to allow her rest periods. At this point she still had a heel ulcer on her contralateral limb, so regular monitoring of this pre & post walking training was completed. She was very anxious particularly early on in her rehab.

Cosmetic appearance of the prosthesis was also particularly important to this lady, she expressed difficulties with adjusting to her changes in body image.


Clinical Hypothesis

Despite her age, this lady was more complex than some young transfemoral amputees as her general health prior to her amputation meant that her exercise tolerance and strength were much lower than expected. Due to all of her previous health problems she was very anxious about losing her other leg so lots of time was spent educating her on how to care for her residual limb & remaining leg. [1] She lacked confidence and needed lots of reassurance and lots of practice with each task before progressing to something new.

Many joint sessions were completed with both the Psychologist, Prosthetist and her husband. Over the course of her rehab her anxiety levels reduced and she began to develop her own coping strategies.

She was able to identify her own goals, however required encouragement/would almost ask permission from therapists prior to trying something new. She was well supported by her Husband & Mother in Law, however at times they appeared to be overprotective of her which reduced the need for her to use her own independence.

Stump pain & phantom limb pain were both problematic early on in her rehab and also affected her prosthetic fit and socket comfort. Pain appeared to be increased by anxiety so lots of work was completed with the psychologist re. pain management & coping strategies as well as the use of mirror therapy, graded motor imagery & neuropathic pain relief. [2]


Intervention

Pre-prosthetic training was mentioned above.
On delivery of the prosthesis, joint sessions were completed with the prosthetist and then later as required throughout her rehab.
Gait re-education in parallel bars was completed, then progressed to sticks. This was combined with muscle strengthening exercises, particularly gluts, hip abductors and core strength as well as stretches to prevent the development of hip flexion contractures. Standing balance exercises were completed, initially static then progressed to dynamic, throwing, catching, football, badminton, stepping over objects, picking objects up off the floor, use of wobble boards & cushions. A gym ball was used to supplement core stability exercises. She expressed a desire to be able to do yoga & go to the gym so floor based exercises were practiced both with & without the prosthesis, getting on & off the floor as well as the use of gym equipment e.g. cycling on a static bike.[3]
She initially received an Ischial Weight bearing socket with TES belt, with a free knee. She was very anxious about the free knee initially so lots of time was spent working on weight transfer, gait and mobility both indoors & outdoors on uneven surfaces, slopes & steps. She was later progressed to a suction suspension method.


Outcome

At present she is able to mobilise indoors unaided and uses 1 stick outdoors when out for longer distances or on less even ground. She wears her prosthesis all day & does not require the use of her wheelchair. Outcome measures have been used throughout her rehab including the LCI-5, Timed up & go, 2 minute walk test & Berg balance scale (score 45/56). She still lacks confidence with higher level balance activities, single leg stand on the prosthesis, ascending & descending steps and slopes unaided & walking on less even ground unaided. Her ongoing rehab will focus on this.

Her confidence has improved significantly. She is less anxious and more able to initiate doing things. She regularly goes out walking in country parks, to the zoo, out shopping, for meals and to the cinema. She is keen to return to driving soon however she has had additional complications with her eyes requiring surgery that have delayed her rehab. Following her eye surgery she intends to explore joining a gym and starting studying part time maybe through the Open University. She also has a shower prosthesis, allowing her to stand and use the shower independently, this has meant that she has not required any adaptations to be made at home.

She has an adjustable foot on her prosthesis, allowing her to adjust this her self to allow her to where heels. Her ongoing rehab will also include mobility practice in different height heels


Discussion

This lady is a combination of a diabetic amputee and a young higher activity amputee. This made this case more interesting as the diabetic amputees I have treated previously have been much older, however the complications due to her diabetes meant she progressed at a slower rate to a younger trauma amputee. As she progresses with her rehab she may benefit from a Microprocessor knee, however due to current funding in the UK this is not able to be prescribed on the NHS. In her case the increased security and confidence she may get from a microprocessor knee and the reduction in energy expenditure may be particularly beneficial as her exercise tolerance remains reduced. There is some hope that a policy for the prescription of microprocessor knees may be approved in the future, allowing these to be prescribed for NHS patients. [4]


References

  1. Engstrom, B. Van de Ven, C. (1999) Therapy for Amputees. 3rd Edition. Edinburgh: Churchill Livingstone.
  2. Lorimer Moseley, G. (2008) Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain. 138, 7-10
  3. Engstrom, B. Van de Ven, C. (1999) Therapy for Amputees. 3rd Edition. Edinburgh: Churchill Livingstone.
  4. Sedki I. Fisher K. (2015) Developing prescribing guidelines for microprocessor-controlled prosthetic knees in the South East England. Prosthetics & Orthotics International. 39(3):250-4