A Diabetic wife, mother and amputee: Amputee Case Study

Original Editor ­ Lee-Anne Barker-Cobb

Contents

Title

A Diabetic wife, mother and amputee

Abstract

A person is not defined entirely by their disease. Patients who are wives and mothers are used to being in a caring role and are therefore often reluctant to be a burden. Mrs. MB was an excellent example of a person who understands what needs to be done and will work hard to accomplish her goals. This showed in her rapid improvement with the exercises given and the verbal correction that was taken on board. She will be an excellent candidate for a prosthesis and should return to near functional independence.

Key Words

Transtibial, diabetes, balance, gait, strengthening, family

Client Characteristics

Mrs. MB is a 53-year-old African female who lives in a rural area with her husband. She is currently unemployed but has received approval for a disability grant. Her primary language is Zulu but is able to communicate effectively in English. She completed Grade 11 of high school dropping out because she was pregnant with her first child. She presents with a left transtibial guillotine amputation. She is a type 1 diabetic (b5401.4) and is hypertensive (b4200.2) on chronic medication. She has cataracts in both eyes (s2204.37) limiting her vision.

She lives with her husband and 2 children in a 4-bedroom house. She has 3 other children who do not reside with them. Her husband and 1 daughter work and the son who stays at home cannot care for her (e310.20). There are no stairs at all on the property but her garden is steep. She has an indoor toilet, running water and electricity. She and her husband own the property. Her house is accessible with wide doors and the bathroom is close to the bedroom. She does not smoke or drink.

Examination Findings

Her foot ulcer was initially treated with topical antiseptic and oral antibiotics. Her GM's were 14. After 2 weeks, the foot darkened, became painful and foul smelling. Admitted to hospital 29/05/2015. Left Transtibial guillotine amputation (s7501.42) performed on 31/05/2015. She is currently unhealed. There is bone protrusion noted. Clean wound with minimal slough. Stump length: 19cm.Stump shape is cylindrical. She is alert and responsive. Numbness (b2702.2) and a "poking" pain of right foot reported. Foot is warm on palpation with good skin condition and perfusion. She has had unstable sugars since surgery.

Self reported Outcome: Return home and care for herself, her family and the garden.

Decreased light touch sensation in right foot, hot/cold and pinprick sensation is intact. Proprioception limited in toes. Phantom limb pain (b1801.3) noted NS* = 7/10.

Bilaterally upper limbs - FROM & Gr V muscle strength. Bilaterally, lower limbs have FROM. Bilaterally Grade III muscle strength in Gluteus Maximus, hamstrings, hip abductors & adductors. Right quadriceps & tibialis anterior - Grade IV

Good sitting balance. Poor standing balance (d4154.34) (<3s) Gait: walks 8m (d4500.22) with walking frame (e1201.00) tires quickly. Short shuffling steps with minimal heel strike and toe off. Her left stump held in hip & knee flexion with no reciprocal movement. (AmpnoPro 20/39)

She is independent in ADL's only limited with walking and stairs (d4551.44). Barthel index 80/100

Clinical Hypothesis

  1. The Phantom limb pain felt in her big toe & ankle.

  2. Poor standing balance, this impacts on her independence with ADLs in standing and she needs to be independent as she is unsure of her family support at home during the day.
She needs to be able to care for herself at home therefore this is an important measure

  3. Poor gait pattern - there is a lack of toe off and heel strike and no reciprocal movement.

  4. Poor endurance, she is only able to walk 8m before tiring.

  5. Patient has unstable blood sugar levels especially after lunch.

  6. Stump length is incorrect with protrusion of bone which will delay healing and make her unsuitable for prosthesis.

Intervention

  1. Mirror therapy completed 15 minutes over 3 days.

  2. Manual active resisted right hip abduction strengthening in side lying (20 reps x 3 sets. Active bridging in supine, holding for 10s X 10 reps x 3 sets. Core strengthening exercises done - bridging with foot on a ball (holding for 10s x 10 reps.
Standing balance in parallel bars. Verbal correction on posture and abdominal bracing and using mirror for feedback.

  3. Patient placed heavy theraband under forefoot in long sitting and held both ends tightly. Pushing her foot into plantar flexion (20 reps X 3 sets) Also carried over as a ward program. Alternating Heel raises & toe lifts in standing in the parallel bars.
Verbal gait correction in the parallel bars.

  4. Distance walked increased over 5 days of treatment allowing for rest periods when needed.

  5. Referred to the dietician to speak about food intake.
Liaised with nurses about diet.

  6. Discussed with surgical doctor in charge of patient with regards to healing and delay. This discussion was documented in medical notes.

Outcome

  1. Patient's pain was monitored over 5 days. Her initial NS* rating of 7/10, decreased to 5/10 and on day 5 dropped to 3/10. The pain moved during treatment from being felt in her big toe, to her ankle.
  2. Patient's standing balance improved from standing without holding for <4s to >20s in 2 days of practice. She was then able to start with rhythmic stabilizations and by the end of the week was starting dynamic balance exercises. Her AmpnoPro score increased from 20/39 to 32/39.

  3. Patients' gait pattern improved, both heel strike and toe off are increased. She holds her amputated side in neutral hip flexion and knee extension now but is still having some difficulty with reciprocal movements.

  4. The initial distance reached by the patient was 8m walking with a walking frame before becoming fatigued. She is now able to walk 32m without rest.
  5. Blood sugars are still unstable but peaks have reduced from 18 - 21 to 12 - 16.

  6. Patient has been booked to go to theatre for a surgical revision next week if wound remains clean and patient's condition is stable.

Discussion

MB is first and foremost a wife & mother. It's in her nature to be the carer, not the cared for so all interventions and tests aimed at ensuring her functional independence. The Barthel index showed that the patient was proficient is self-care but unable to walk functionally. Her poor static balance was deemed would limit her independence with household tasks.

She responded well to treatment due to her cooperation and determination to do the ward program as instructed improving her AmpnoPro score by 12 points. Her phantom limb pain was rated according to a numeric scale[1] (7/10).

Mulvey MR et al showed that there have been no RCT to show conclusively that TENS was effective in treating phantom limb pain[2] whereas Chan BL et al showed mirror therapy[3] to be a very effective thus this was the treatment used although clinically TENS has proven an effective treatment for many amputee patients. Mirror therapy however showed excellent results even with impaired vision the pain reduced to 3/10.

Her poor gait pattern and endurance would limit her independence at home and increase her risk of falling. She responded well to verbal cues and strengthening exercises. Her gait and endurance improved over a short period. This patient also benefited from an interdisciplinary approach with the surgeon, nurses and dietician working together to regulate her sugar levels and she will need referral to an occupational therapist to ensure she is fully functional before she returns home.

References

  1. Pain management for patients. National Limb loss information center.1
  2. Transcutaneous electrical nerve stimulation (TENS) for phantom pain and stump pain following amputation in adults (Review). Mulvey MR, Bagnall AM, Johnson MI, Marchant PR, Cochrane Library, 2010, Issue 5.
  3. Mirror Therapy for Phantom Limb Pain, New England Journal of Medicine, Nov 2007, 357(21):2206-2207