A multidisciplinary approach to a typical transtibial amputation: Amputee Case Study


Original Editor - Maria Meilak

Title

A multidisciplinary approach to a typical transtibial amputation: Amputee Case Study

Abstract

Mrs. Mizzi is a 76 year old lady who underwent a left transtibial amputation and was referred for OT intervention. She is diabetic and obese. She lives alone in a first floor apartment. Pre-op she was fully independent in both PADLs and DADLs. Mrs. Mizzi is very well supported by her daughter. Post-op patient needed assistance in bed mobility and transfers and required assistance in bathing and toileting. Through multi-disciplinary teamwork she managed to be discharged home at her daughter`s house, she regained her independence in ADLs and is also starting to engage in her social occupations

Key Words

occupational therapy, therapeutic rapport, bathroom adaptations, team approach, psychosocial

Client Characteristics

Mrs. Mizzi is a 76 year old lady who has been referred for occupational therapy intervention post Left BKA. She has been diagnosed with coronary artery disease and type 2 diabetes as a result of morbid obesity. She weighs 120kgs. Two years ago she sustained a left toe amputation. She is a widow and lives alone in a first floor apartment. A flight of 24 steps lead to her main door. Bathroom facilities include a wash hand basin, a toilet and a bath. Her main living quarters includes a kitchen/living room, 2 bedrooms, a main yard and a washroom. Prior to admission she was independent in both personal and domestic activities of daily living. She used to enjoy going to the local day centre and take part in the activities being organised for them. She used to be very active in the parish activities. Elective amputation was carried out to meet the goal of pain control and improve her quality of life. She is currently still in the acute stage of amputee rehabilitation.

Examination Findings

An OT interview was carried out 2 days post op. Mrs. Mizzi was found propped up in bed since she has just finished her bed bath. She was fully oriented to time, place and person and had intact cognitive abilities. Mrs. Mizzi stated that she is well supported by her daughter who offered to welcome her and take care of her since currently she is finding it hard to settle back in her own apartment and to live on her own. Mrs. Mizzi stated that her daughter lives in a terraced house. A low step leads to the main door. The ground floor includes a kitchen/living area, a bedroom (which Mrs. Mizzi will be using), a bathroom which includes a wash hand basin, a toilet and a shower, and a yard.

A physical assessment was carried out. Mrs. Mizzi had a good muscle power in her upper limbs grade 4/5. Static sitting balance was fair and dynamic sitting balance was poor. She stated that occasionally she still feeling a ``funny`` sensation in the amputated leg as if it was still there[1]. A Barthel Index was carried out, Mrs. Mizzi stated that currently she is managing to eat by herself. She is also independent in grooming, managing to do her hair and brush her teeth. She is also managing to assist in upper body bathing and dressing. She is currently using a bed pan for toileting however she needs assistance to transfer. She identified managing functional transfers independently and gaining her independence in toileting as her main goals.

Clinical Hypothesis

The following challenges where identified from the initial assessment:

  • impaired static and dynamic sitting balance
  • decreased mobility and dependence in functional transfers
  • phantom limb sensation in her Left foot
  • long standing obesity
  • dependence in PADLs including lower body bathing and dressing and toileting
  • environmental barriers within her/daughter`s house including bathroom adaptations to maximize her safety and independence

  • lack of engagement in social activities, including meeting with her friends at the day centre and participation in parish activities

Intervention

  • Built a therapeutic rapport with Mrs. Mizzi based on trust, communication and respect

  • Liaised with the PT re: postop dressing, pain management techniques and stump care to facilitate good healing, reduce edema and prevent contracture of the left knee
  • Addressed the issue of phantom limb in liaison with the PT and instructed Mrs. Mizzi to carry out desensitizing techniques including tapping the residual limb, gentle massage and also explained to move the intact limb when she has phantom limb sensation in her left foot
  • Improved static and dynamic sitting balance through participation in PADLs including practicing upper body dressing in sitting (unsupported) to increase core muscle endurance
* Raised the issue of weight management with Mrs. Mizzi and suggested a referral to a nutritionist to help her deal with her challenge
  • Practiced functional transfers initially on/off bed pan then progressing to transfers from bed to chair etc

  • Organised a family training session prior to discharge. The aim of the session was to empower her daughter in being able to offer her mother the right assistance to facilitate her functional independence

  • A home visit was carried out (daughter`s hse) and bathroom adaptations where suggested including modifications in the walk in shower: the removal of the shower cubicle and installing a curtain, installing a bariatric shower stool and two 18" grab rails

  • Contacted the parish priest who visited her regularly during her stay in hospital

Outcome

  • We managed to instill a healthy therapeutic rapport whereby Mrs. Mizzi was open in confiding any issues that cropped up during the acute rehabilitation phase. She stated that the issue of obesity set in after loosing her husband who was her companion for 50 years. Thus it was deemed necessary to liaise with the other members of the team and involve the psychologist since there were issues which still needed to be tackled and also to help Mrs. Mizzi go through the grieving process of loosing her Left leg
  • A good team approach resulted in restoring a good stump shape which is a prerequisite for prosthetic assessment and eligibility

  • Sitting balance was improved both static and dynamic and Mrs. Mizzi mastered independence in functional transfers. She also achieved her main goal of gaining independence in toileting
  • Mrs. Mizzi had met the nutritionist for a consultation, and she has started on a healthy lifestyle and weight management programme
  • Mrs. Mizzi was discharged home together with her daughter and her family. She is managing to transfer on/off toilet independently, she is being supervised by her daughter during transfers on/off shower stool however she is managing to bath independently. Due to the weight issue she is still needing assistance in lower body dressing. Mrs. Mizzi is also helping her daughter in light domestic activities including preparing meals and folding clothes etc.
  • Mrs. Mizzi has managed to attend mass at the parish church post d/ch

Discussion

Losing an anatomical part, such as a lower limb, is not an easy experience to go through. Breakey[2] stated that an amputation causes a threefold loss in terms of function, sensation and body image. This was particularly evident in this case study, whereby Mrs. Mizzi has lost her functional mobility, experienced phantom limb pain and was also going through the grieving process of loosing her left limb. Belon et al[3] document a significantly greater frequency of depression among a sample of amputees than would be expected in the general population. It has been overly emphasized that having a good support system of family and friends would help in this process. I have seen Mrs. Mizzi calm and re assured when the issue to discharge planning came up since she was very well supported and accepted by her daughter. Sansam et al[1] support the hypothesis that a relationship exists in lower-limb amputees between their perception of body image and their psychosocial well-being, namely, the degree to which they experience anxiety, depression, self-esteem and life satisfaction. A team approach is paramount in instilling a good level of life satisfaction and a better quality of life through independence and engagement in activities that are meaningful to the individual. Breakey[2] emphasized the importance of identifying strategies to deal with body image and focusing on increasing positive attitudes toward the body following amputation, during the rehabilitation process.

[4][5]

References

  1. 1.0 1.1 Sansam K; O'Connor RJ; Neumann V; Bhakta B, (2014) Clinicians' perspectives on decision making in lower limb amputee rehabilitation. Journal Of Rehabilitation Medicine [J Rehabil Med], ISSN: 1651-2081, 2014 May; Vol. 46 (5), pp. 447-53; Publisher: Swedish Foundation of Rehabilitation Information; PMID: 24590358, Database: MEDLINE Complete
  2. 2.0 2.1 Breakey J. W. (1997) Body Image: the lower limb amputee. Journal of Proceedings, Vol. 9 (2): 58-66. http://www.oandp.org/jpo/library/1997_02_058.asp
  3. Belon, Howard P.; Vigoda, Diane F. (2014) Emotional Adaptation to Limb Loss. In Amputee Rehabilitation, Physical Medicine & Rehabilitation Clinics of North America. February 2014 25(1):53-74 Language: English. DOI: 10.1016/j.pmr.2013.09.010, Database: ScienceDirect
  4. World Health Organisation (WHO). International classification of functioning disability and health (ICF). World Health Organisation 2001. Geneva.
  5. Gill, Stephen D.; Dunning, Trisha; McKinnon, Fiona; Cook, Desma; Bourke, Jo; (2014) Understanding the experience of inpatient rehabilitation: insights into patient-centred care from patients and family members. Scandinavian Journal of Caring Sciences, 2014 Jun; 28 (2): 264-72. (journal article - research, tables/charts) ISSN: 0283-9318 PMID: 23789871, Database: CINAHL Complete