A case study of a diabetic elderly amputee patient in the United Kingdom: Amputee Case Study

Title

A case study of a diabetic elderly amputee patient in the United Kingdom: Amputee Case Study

Abstract

This a case study of a 73-year old gentleman who has had a right trans-tibial amputation due to dysvascularity in his right lower limb. This patient has only been seen by outpatient amputee clinic for twice; however, his demographics and examination findings are discussed along with his rehabilitation plan. Further discussion about patient rehabilitation potential and planning is also presented.

Key Words

elderly, diabetic, trans-tibial amputation, physiotherapy, rehabilitation

Client Characteristics

Patient is a 73-year-old retired fisherman. Patient presented with right trans-tibial amputation 3-week postoperatively due to worsening dysvascularity caused by peripheral vascular disease. Claudication was noted pre-operatively and his 1-week pre-operative mobility was 15 meters without claudication and then had to stop due to ischemic pain. Looking at his past medical history, patient has type 2 diabetes mellitus (DM2) (diet-controlled), left total knee replacement (TKR), chronic cardiac failure (stage 1), atrial fibrillation, bilateral lower limb cellulitis and ulcer, where he is frequent visitor for diabetic foot clinic.

Patient lives in a bungalow with his wife who is fit and healthy and able to take care of him. Additionally, his granddaughter lives nearby and visits them every evening. He has no particular hobbits but he was an active volunteer working at a charity shop. He was previously independently mobile with a walking stick for short distance (150m) about 3 months ago and he was independent with activity of daily living (ADL). Now he is an independent wheelchair user.

Examination Findings

Patient reported he has experienced minimal phantom sensation but only occasionally experienced extreme sharp pain at mid-night (VAS: 8/10); still have some background surgical wound pain (VAS: 2/10). He is taking gabapentin and paracetamol as painkillers. This was first amputee outpatient appointment. Patient reported that he had been doing exercises and stretches given by a physiotherapist when he stayed at the hospital; he had no problems with the use of wheelchair. However, most of the activity of daily living was required his wife to take care of.

Patient was used to be a volunteer actively working within the community; however, now he was unable to do it due to poor mobility. Patient and his family aims to regain mobility by owning a prosthesis. Observing in sitting on wheelchair, patient had good posture, nothing abnormal detected (NAD).

Observing in lying supine, about 5 degrees of right knee flexion noted, otherwise NAD. Sensation was all NAD. Range of movement for right hip extension was -5; aduction was 25; adduction was 15;external rotation was 20; all with stiff end feel. Range of movement of right knee extension was 5 with elastic end feel. Otherwise, all range of movement for lower limb was normal. For muscle power, right lower limb was 4/5 throughout all plane of movement in Oxford Scale; otherwise NAD. Modified Thomas test was positive on right. Amputee mobility predictor (Gailey et al., 2002) score was 13/47. Wound was healed but tender.

Clinical Hypothesis

Based on the examination findings, the patient developed several key problems after amputation, and they were pain, right knee contracture, right osteoarthritic hip, right hip extensor muscle weakness and global knee muscle weakness. These problems were caused by reduced activity level post-amputation (becoming a wheelchair user), his comorbidity. Although he had reported he has been doing physiotherapy exercise, he might not do them correctly and hence developing contracture. Other relatively minor problems are: tenderness around wound, slight leakage from wound due to compression from shirker sock, slight swelling on residual limb.

Intervention

Residual Limb care was reminded to patient, including how to clean and monitor wound, phantom pain management and as well as scar tissue massage to reduce adhesion around wound area to reduce tenderness. Physiotherapy exercises were reviewed with the patient.

Previously during acute stay at hospital post-operatively, a vascular physiotherapist had already introduced some simple exercise on ward. Physiotherapy exercises following trans-tibial exercises (PIRPAG, 2004) were then instructed and taught to patient and these included: static quadriceps, straight leg raise, inner range quadriceps, hip adduction with resistance, outer range quadriceps, hip flexor stretch, bridging, hip flexion and extension in side lying, hip adduction in side lying, and knee flexion in prone lying. The exercise programme emphasised the need of re-strengthening hip extensor and global knee muscles, and regaining full range of movement.

Patient was treated with pneumatic post-amputation mobility aid (PPAMaid) to practice weight bearing with right side and to reduce oedema. Donning and doffing was taught; weight-transfer and stepping exercises between parallel bars were completed. Patient appeared to be reluctant to weight-bear with right but improved with verbal prompt. Initiating of hip hinging was quick and lack of control. Stepping foot placement was poor and required physical help to guide the step. Tissue viability nurse was called for re-dressing at the end of the session.

Outcome

On the next appointment (3days later), physical assessment was also completed for monitor purpose. Although all of the objective markers remained the same, now patient feels confident to all the physiotherapy recommendation and the end feel of joint movement was slightly more loosen.

Patient was now able to weight transfer horizontally between parallel bars and able to hinge his right hip smoother. Stepping still required manual guidance but patient had more controls on movement with better foot placement. However, pain around the residual limb was increased to 4/10 (VAS) at rest and occasionally had sharp pain 8/10 (VAS). Phantom sensation could be more intensive, resulting shooting sharp pain and feeling the "limb" was still there; otherwise, sensation is intact.

Patient was engaged with physiotherapy and stayed positive throughout so far. He still wanted to walk again for short distance as a community user. He also decided to quit smoking, where liaison to smoking cessation worker was done for him.

Discussion

This gentleman is a typical case as a diabetic elderly amputee patient. Often an elderly amputee patient has comorbidities that limits patient rehabilitation potential, such as heart and lung condition, long history of smoking and poor pre-amputation mobility. This gentleman presented with right knee and hip contractures and right hip extensor hip muscle weakness and these symptoms were due to inactivity caused by pain and reduced mobility.

Exercise plays an important role to maintain function range of movement and strengthen for the use of prosthesis in later stage by re-training the muscle and improving muscle length[1]. Couture et al[2] showed significant reduction in leisure participation but significant increase in satisfaction of physical state for amputee population.

Amputee population has a much lower activity level compared to the national average and the recommended activity level to maintain wellbeing[3], where psychosocial factors such as body image and environmental adaptation limit their activity level.

Dean et al.[4] states motivation is the main barrier to prosthesis users participation in physical activity, exercises and sport; having a strong will and ability of positive thinking during early rehabilitation does make a difference. Some patients may underestimate the efforts and might not be able to realise their physical limitation due to amputation; positivity is still one of the key of successful rehabilitation.

[5][6]

Referencesr

  1. British Association Charted Physiotherapists Amputee Rehabilitation (BACPAR), (2012).
  2. Couture M, Caron CD and Desrosiers J. (2010) Leisure activities following a lower limb amputation. Disabil Rehabil, vol.32 (1), pp.57-64.
  3. Kars C, Hofman M, Geertzen J, Pepping G and Dekker R. (2009) Participation in sports by lower limb amputees in the Province of Drenthe, Netherlands. Prosthet Orthot Int, vol;33(4), pp.356-367.
  4. Dean S., Burns D., McGarry A. and Mutrie N. (2012) Motivations and barriers to prosthesis uesers participation in physical activity, exercise and sport: a review of the literature. Prosthet Ortho Int, vol.36(3), pp.260-269
  5. Evidence Based Clinical Guidelines for the Physiotherapy Management of Adults with Lower Limb Prostheses.
  6. Gailey, R.S., Roach, K.E., Appllegate, E.B., Cho, B., Cunniffe, B., Licht, S., Maguire, M. and Nash, M.S. (2002) The Amputee Mobility Predictor: An Instrument to Assess Determinants of Lower-Limb Amputee's Ability to Ambulate. Arch Phys Med Rehabil, 83, pp.613-627