72 year old male TF amputee gait retraining: Amputee Case Study

Original Editor ­ Bonnie Caldwell

Title

72 year old male TF amputee gait retraining: Amputee Case Study

Abstract

A 72-year-old male with right TF amputation was admitted to the provincial rehabilitation unit at the Queen Elizabeth Hospital in Charlottetown, PE, on May 29th, 2015, for prosthetic fitting and gait retraining. Following 6 weeks of inpatient therapy, he was able to attain most of his goals. These included independently donning and doffing his prosthesis, independent ambulation with a 2 wheeled walker/crutches X 200m, independent stairs with railing and a cane/crutch and begin ambulation with a cane and min assist x 1.

Key Words

Transfemoral, diabetic, PVD, locked knee prosthesis, Male, 72 years old

Client Characteristics

The patient is a 72-year-old retired Postal Carrier. He lives of in a wheelchair accessible bungalow with his wife and 11-year-old granddaughter. His past medical history includes, PVD, CHF, ischemic heart disease, permanent atrial fibrillation, aortic valve replacement, CABAG X 2 with an ejection fraction of 35%. Following a failed fem pop graft, the patient had a right TF amputation on January 5, 2015. He is a non-smoker X 40 years and recovering ETOH abuse.

He was an inpatient in acute care at the hospital and received postoperative physiotherapy care including bandaging of residual limb, bed mobility and transfers training, ROM and strength training exercises, ambulation with 2 wheeled walker/crutches. On discharge he was given a home exercise program and was followed by the amputee clinic multi disciplinary team. Once the limb had healed he returned to hospital for prosthetic fitting and gait retraining.

Examination Findings

The patient at the time of the initial assessment was very excited to receive his prosthesis and did not seem to be suffering from any psychological adjustment issues with being an amputee. HADS (hospital anxiety and depression scale) assessment was performed by the nursing staff the day of his admission and his score fell within the normal range. The residual limb was well healed and he was not experiencing phantom limb pain.

He was able to transfer independently from all surfaces, go up and down stairs with crutches and ambulate with either crutches or a 2-wheeled walker a distance of 100m. He used a wheelchair for longer distances in the community. He had returned to most of his pre-amputation ADL's and IADL's except for driving. He was hoping to resume golfing in the futures. In terms of ROM and strength, he did have a flex ion contracture of 15 degrees and grade 4/5 strength for hip muscles. His left leg was within functional limits for ROM and grade 5/5 strength. His upper extremity strength and ROM was within functional limits.

He had been walking with crutches in his home and community prior to admission for prosthetic fitting. The Amp No Pro score was K3. Of concern was the circulation of his sound foot which was showing signs of compromised blood flow. He was fitted with an orthotic and a wider shoe to help to preserve his left leg.

Clinical Hypothesis

The patient presented with a well-healed incision, good ROM and strength of the residual limb, independent mobility, independent ambulation, and good endurance. He was not experiencing phantom pain and showed no signs of depression or psychosocial problems.

Intervention

The patient attended physiotherapy sessions twice per day for 30 to 60 minutes per session. He was given a neoprene liner, which he used with a KISS suspension system and a hybrid style socket. The knee joint was poly centric with a locking feature and a carbon energy foot. He was able to quickly learn how to don and doff the prosthesis independently.

The beginning exercises occurred in the parallel bars and focused on weight shifting and standing on the prosthetic limb.The emphasis was on increasing the amount of weight bearing on the new limb. Exercises such as stepping, trunk rotation and sidestepping began. As this improved he learned to ambulate in the parallel bars and trying to have an equal step length. He then moved out of the bars and ambulated with a 2-wheeled walker. He also did strengthening exercises on the mat and prone lying to reduce hip flexion contractures.

The patient unfortunately was unable to stop lateral trunk bending and correct a lengthened stride on the prosthetic limb. He was getting frustrated and after discussions with the team and the patient along the knee was locked. His confidence and ambulation improved greatly and he was able to progress to independent ambulation with a 2 wheeled walker and crutches x 100m.

During the last 2 weeks of therapy he was able to walk with a single point cane with min assist X11, however, his right sound leg would get sore and he would have to rest. he learned to get up and down from the floor in OT.

Outcome

The scores in mobility, TUG, 6MWT and the FIM all improved. He was discharged home as an independent household ambulator with an aid, level 5 (FIM). His TUG improved from 32 seconds to 25 seconds. The 6MWT improved from 70m to 234m. Amp pro score was K2. He performed 2 walking tests in the gait lab which showed an increase in speed but still an unequal step length. The patient did not require any counseling for limb loss or change in psychosocial status. He did not experience phantom limb pain.

Discussion

A 72-year-old male with a TF amputation was able to resume most of his functional activities except for golfing/driving following 6 weeks on the provincial rehabilitation unit at the QEH. During the course of his stay he attended physiotherapy twice per day for 1 to 2 hours and was able to attain independent donning and doffing his prosthesis, independent transfers, independent ambulation with an aid x 70m and wearing his prosthesis 6 hours per day. This matches best practice guidelines that are discussed in the ICRC book prosthetic gait analysis for physiotherapists and therapy for amputees by Barbara Engstrom[1].

The exercises that were administered to the patient were from Dr. Bob Gailey's[2] prosthetic gait training for lower extremity amputees. New aspects of care that were learned from the course included mirror therapy and hitting the prosthetic foot to improve proprioception in the residual limb as seen in the video of Dr. Bob Gailey in week 5. We have started to include this therapy for all our amputee patients. The impact on my clinical practice following the course confirms that our interdisciplinary team has have been following best practice for amputee care at all stages of the patients recovery. Newer concepts such as tapping on the prosthetic foot to improve proprioception will be added to my treatment regime. This was an excellent and valuable course.

References

[3]

  1. Therapy for Amputees, Barbara Engstrom and Catherine Van de Ven
  2. Prosthetic Gait Retraining for Lower Extremity Amputees, Dr. Bob Gailey
  3. Prosthetic Gait Analysis for Physiotherapists, ICRC Physiotherapy Reference Manual, January 2014