Kyphotic Below Knee Amputee: Amputee Case Study

Title

Kyphotic Below Knee Amputee

Abstract

Patient underwent a right below knee amputee, due to critical limb ischemia and wet gangrene. Patient also has a significant kyphosis due to previous spinal fractures. Due to this both trunk, upper and lower limbs and the respiratory system where impaired. These impairments as well as numerous environmental factors considerably limited the patient in returning to both previous activities and social participation. A programme of education, stretching, strengthening and mobilisation was undertaken as well as referrals to other members of the MDT. Patient is now independently mobile.

Client Characteristics

David is a 70 year old retired computer specialist who lives in a 3 bedroom house with his wife. He underwent a right below knee amputation on 12th April 2015 for critical limb ischemia and wet gangrene of his right toes. He has a 20 year history of Peripheral Vascular Disease and sustained an ulcer to his right foot in June 2014 after dropping a pair of garden shears on his foot. He also had a fall backwards down the stairs in November 2014 resulting in multiple spinal fractures and a significant kyphosis. He reports he is no longer receiving treatment for this but feels his breathing has deteriorated with his change in posture. He has a history of previous angioplasty for PVD in 2000, High cholesterol, Hypertension and a Pulmonary Embolism in 2011 for which he takes Warfarin. He is an ex-smoker but stopped this 24 years ago. Prior to amputation David was limited by rest pain and was mobile for the 6 months prior to amputation with a walking frame indoors and a mobility scooter outdoors. Prior to this, he was mobile with one stick but limited how far he could walk by claudication, mainly in his right leg after approximately 150m.
After his initial inpatient stay he had been transferred to a Community hospital and then discharged home with community therapy input. This had since ceased but David was still performing his given exercise programme on assessment.

Examination Findings

David was self caring except with washing his back, shopping and preparing food. His wife assisted with these. He was unable to access the kitchen or get out of his property due to steps. He has a stairlift but was strip washing due to an inability to get in and out the bath. He had no history of falls post operatively. David was a keen gardener and reported his goals were:

• To access the garden and return to gardening.
• To get in a car and access friends and families houses.
• To go on holiday and out for meals
• To be able to walk up the steps into local shops from his mobility scooter

On examination he presented with a considerable kyphosis which limited ROM at shoulders and caused him to sit in posterior pelvic tilt with protracted shoulders and chin. David reported he was unable to lie supine or prone due to his posture and difficulties in breathing. He demonstrated weak core stability in his trunk. He had grade 5 Upper limb strength and grade 4 muscle strength in bilateral hips and knee. Left ankle grade 5. Lower limb range of movement was full except -10 left and -15 right hip extension. Residual limb was tender and swollen. Scarline was a posterior flap and although healed was very tethered laterally. Tenderness placed on NRS 4/10. No complaint of phantom limb pain. Perceived exertion on mobilising in the Ppam aid was 13 (Borg scale) and 2 minute timed walk test with a frame was 12m.

Clinical Hypothesis

Socially isolated with dependency on wife. Reduced independence has affected confidence, self esteem, mood and relationships.

• Unable to re-engage with social activities and interactions.
• Posture, reduced exercise tolerance and poor core control is impacting on breathing, function, movement patterns and reduced range of movement in upper and lower limbs.
• Swollen and tender residual limb with scar tethering, likely to cause discomfort and prosthetic issues.
• Reduced lower limb strength. As a current wheelchair user at risk of further reduction in strength and range of movement.
• Remaining limb at risk and previous claudication likely to limit prosthetic mobility

Intervention

David was referred to the Occupational therapist for review of environmental and personal care issues. Car transfers were practised to allow community access and re-engagement in social activities with his wife. Information regarding counselling and returning to driving was supplied. David was prescribed a core stability and stretching programme(15,3&4). Hip flexor stretches were taught in standing and side lying and his wife educated in how to assist (8). Positional advise was given and breathing exercises taught. An upper and lower limb strengthening programme was prescribed both though a home exercise programme and within therapy time (4&3). Patient was taught scar and residual limb massage techniques (5&12) and a silicon liner was prescribed. Patient was educated in swelling management and a stump shrinker sock provided (13&15). Patient was also mobilised twice weekly in the Ppam aid prior to casting for a prosthesis (11&15) A graduated fitness programme using a static arm and leg bike and a seated exercise programme was also prescribed, to increase his exercise tolerance and cardio-vascular fitness.
Patient was educated in remaining limb care (10,16&1) and a referral made to both podiatry and also orthotics for provision of specialist footwear(10&16). Patient underwent a graduated prosthetic rehabilitation programme working on correct weight transfer and prosthetic use (6&16).
Functional tasks (2&7) were also practised relevant to the patient."