Young Male Below Knee Amputee with High Level Goals: Amputee Case Study

Title

Young Male Below Knee Amputee with High Level Goals

Abstract

Young, male transtibial amputee referred to exercise physiology for lower limb strengthening, and high level mobility for return to recreational activities (basketball). Therapy was completed alongside physiotherapy who was focusing on gait retraining. Patient initially ambulated with two elbow crutches and lack confidence with weight-bearing through prosthesis. Current mobility includes single elbow crutch outdoors and nil aids indoors with supervision. Patient is also now independently attending gym with strengthening program to compliment therapy.

Key Words

Transitibal, high level mobility, multi-disciplinary, exercise physiology

Client Characteristics

Client is a 20 year old Sudanese-Australian male presenting for rehabilitation at our Community Therapy Service. He is a Sudanese refugee who arrived with his family (parents and 4 siblings) in 2003. He was undertaking a carpentry apprenticeship. Pre-morbid he was highly active attending the local gym 5-6 days a week completing his own strength program, he extra-curricular hobbies include basketball.

Medical History:

Client presented with Meningococcus sepsis in September 2014 with progressed to multi-organ failure and resulted with dialysis dependant end stage renal failure, left ischemic forefoot with toe necrosis, left hepatitis, myocarditis (resolved) and multiple chronic skin wounds (resolved).

Amputation:

Client initially had a left mid-foot amputation but was upgraded to a below knee amputation due to poor wound healing and ongoing local infection. Client experienced acute stump pain and transient phantom limb sensations. He has received specialist pain, nursing, prosthesis and podiatry input. He is currently attending as an outpatient and receiving prosthetic, physiotherapy and exercise physiology input.

Chronic Renal Failure: He is currently undergoing outpatient tri-weekly dialysis. Currently taking Selevamer.

Client's mood is euthymic and reactive affect was normal. Clinical psychology has been offered given recent life-changing event.

Examination Findings

Patient was referred to exercise physiology by his physiotherapist and prosthesis for strength and conditioning, community integration and introduction to recreational options. At time of referral patient was in Phase Four of R.S and A, Gailey's of a Functionally Progressive Amputee Program[1]. Where his reason for referral focused on increasing strength, progressing gait and agility and endurance training.

Goals : 

  • Using Appendix 2: WHO Organisation ICF Framework - amputee elements[2] 

Condition:

  • Client is a transtibial amputee with a stump length of approximately 25cm

Body Functions affected:

  • Independent ambulation with two elbow crutches, reduced muscle endurance and strength, Left lower limb muscle wasting, reduced static and dynamic balance, sporadic phantom limb sensations ('funny feeling').

Activities affected and restrictions in participation:

  • Not currently driving, no longer participating in gym program or recreational activities (basketball), carpenter apprenticeship on hold

Objective Outcome measures:

  • 6 minute walk test: 420m with two elbow crutches and minimal weight bear on left lower limb
  • TUG: 10.1secs
  • 6 meter walk test: 11.5 sec, 11 steps
  • Lower Limb 1 Repetition Max Strength Test: Right Lower Limb - 6 plates, Left lower Limb - 3 plates
  • Single Leg Stance: Right - 30sec, Left - Unable

Clinical Hypothesis

Patient is a young male transtibial amputee with high level functional goals including returning to basketball. Currently his main issues include inability to ambulate unaided secondary to limited confidence in weight-bearing through prosthetic limb. He is also limited by regular dialysis and therefore variations in stump shape and volume from day to day often requiring frequent adjustments in socks thickness and regular sock adjustments. This limits his progression due to sporadic fit discomfort preventing him from completing his gait, strength and endurance therapy.

Intervention

Patient has weekly one on one physiotherapy and exercise physiology input for gait and prosthetic training, lower limb strengthening and high level mobility goals.

Exercise physiology provide lower limb strengthening program focusing on equal lower limb strengthening and equal weight-bear. Education regarding incidental exercises and a home exercise program was provided and encouraged.

Centre-based EP program included a mixture of cardiovascular, strengthening and balance exercises with particular focus on prosthetic side. Strengthening exercises included targeted exercises for hip abductors and VMO control. Through-out sessions education regarding exercise-related stump shape changes and adjustment to sock thickness/number was provided similar to those provided by Fitzsimons, T [3][4]. Continual discussion between multidisciplinary team, with at this stage of rehabilitation involved predominantly the consultant, physiotherapist, Prosthetic, Occupational Therapist, Social Worker and Exercise Physiologist was completed. Particularly regarding socket fit and in the early stages of therapy wound care of residual skin wounds. Patient responded well to education and was independent with sock adjustment and wounds have fully healed.

Outcome

Subjective Outcome Measures

  • Ambulation with prosthesis: 2 elbow crutches outdoors, single elbow crutch indoors and nil aid indoors with supervision approximately 100m.
  • Independent with community gym and home exercise program
  • Increased incidental exercise with encouragement
  • Increased confidence in weight-bearing through prosthetic lower limb.
  • Re-assessed Objective Outcome measures:
  • 6 minute walk test: 360m with 1 x elbow crutch, increased weight-bear through crutch last 90 seconds
  • Lower Limb 1 Repetition Max Strength Test: Left lower Limb - 4 plates
  • Single Leg Stance: Left Lower Limb - 4 sec

Discussion

This client was a young male in phase four of his rehabilitation[5], he was previously physically very high level and had goals of returning to previous level of activity and work. From a psychological aspect patient was already at an acceptance and hope stage of grief[6] at the time of referral and was eager to commence therapy to assist in achieving his goals of returning to work and gym and eventually playing basketball.

The client was seen in a multidisciplinary approach with regular interdisciplinary discussions, to ensure a holistic approach. From an exercise physiology perspective, it was good to have clarification and affirmation for the provision of exercises for lower limb amputees[7] and I will definitely be referring to the ICRC resources in the future. Further down the track in this patient's rehabilitation I hope to utilise the Five Steps for introducing Running to lower-limb amputees[8] to assist with his higher level mobility goals.

References

  1. R.S and A, Gailey (1994) Balance, Agility, Coordination and Endurance for lower limb extremity amputees. Advanced Rehabilitation Therapy Incorporated. Miami Florida
  2. Physiopedia course who adapted framework from: The Lancet 2011; 377:1693-702, Langhorne P et al, The International classification of function, disability, and health framework for the effect of stroke on an individual. Rehabilitation Therapy Incorporated. Miami Florida.
  3. Fitzsimons, T (2007) Care of Your Stump and Skin. NSWPAR
  4. Fitzsimons, T (2007) Care of Your Stump Socks, Bandages and Shrinkers. NSWPAR
  5. R.S and A, Gailey (1994) Balance, Agility, Coordination and Endurance for lower limb extremity amputees. Advanced Rehabilitation Therapy Incorporated. Miami Florida
  6. Morris, S (2008)The Psychological Aspects of Amputation. Amputee Coalition of America
  7. International Committee of Red Cross (2008) Exercises for Lower-limb Amputees, Gait Training. Switzerland
  8. Gailey, R. Five Steps for Introducing Running to Lower-Limb Amputees. Amputee Coalition of America, U.S Arm Amputee Patient Care Program. America