Diabetic Amputee - Mr. C: Amputee Case Study

Title

Diabetic Amputee - Mr. C

Abstract

Mr. C was admitted to my service following a R BKA due to vascular insufficiency secondary to his type 2 diabetes. Upon admission, Mr. C was mobilizing via self-propelling in a standard wheelchair and was transferring with supervision using a sliding board towards his left. Mr. C was very interested in getting a prosthetic fitted for his right leg in order to be able to walk and transfer independently. During his stay, he focused on increasing his strength, reducing all risks of contractures, and promoting independence in preparation for a prosthetic fitting at the specialist.

Key Words

Amputee, diabetic, postoperative, pre-prosthetic, rehabilitation

Client Characteristics

•Age: 55 year old
 •Occupation: Unemployed, formerly construction worker •Gender: Male
 •Medical Dx: type 2 diabetes, L/E vascular insufficiency R>L, R BKA, L plantar ulcer (stage II)
 •Co-morbidities: mild obesity

Examination Findings

Examination
 •Subjective: Upon admission, patient was 4-week post R L/E BKA due to vascular insufficiency secondary to his type 2 diabetes. Patient was diagnosed with diabetes for over 30 years and has been struggling to control his levels via diet and medication. Patient was undergoing dialysis 3x/week from home. Driven by wife, mobilizes with wheelchair. Likes to spend time outside and at trailer during the summer. Wife is having difficult time dealing with recent changes, feels heavy burden to take care of husband - is often afraid he will fall and hurt himself. Patient is very bold, attempts transfers with little insight and forethought, can be dangerous and impulsive due to independence. •Objective: Patient capable to full knee extension on L, limited -5 in extension on the R. Patient transfers from wheelchair to bed (at different heights) with supervision using sliding board going to his left. Mobilizes with wheelchair and self-propulsion with his left foot. Uses a knee board for R L/E while in wheelchair ~50% of the time. Stump is fully healed, no residual pain. 
•Body Functions and Structures
: R knee extension limited to -5 degrees, 
R and L hip ABD strength 4-/5 •Activity Limitations: requires wheelchair for mobility, transfers with supervision using sliding board to/from wheelchair-bed •Participation Restrictions: Unable to navigate through trailer with wheelchair •Environmental Factors: Trailer has stairs to enter, very narrow hallways and small bath

Clinical Hypothesis

Following the evaluation of Mr. C, it is determined that he has the potential to be a very good candidate for prosthesis. His main problems are that he needs to decrease his R knee extension contracture/limitation to 0 degrees (from -5 degrees) and increase his L and R hip abductor strength (currently 4-/5 on both sides). We also need to work on improving the patient's safety and precautions during transfers and mobilization to improve from "supervision" to "independent".

Intervention

First, we began with patient education, focusing on safety, foresight, precautions, as well as contracture prevention. We ensured the patient used the knee board 100% of the time when in his wheelchair and spoke about proper sleeping positions that avoid knee flexion and the possible repercussions of spending too much time in these types of positions.
 Next, we worked on transfers and muscular strengthening. Our primary focus for muscles strengthening were his hip abductors, but a general L/E strengthening program, to be completed while lying down, was given to the patient. This program was done in the gym and we also instructed the patient to do the program a total of 2-3x/day outside of the gym or when he was unable to attend. The transfer training focused on increasing the patient's safety when using the sliding board. 
Lastly, we worked on unipodal balance and sit-to-stand, starting in parallel bars and moving to a standard 4-point walker. This was done to increase the patient's strength and balance and to become accustomed to increasing weight bearing on his left leg.

Outcome

Upon discharge, the patient's L/E was 4+ to 5 / 5 bilat. His knee extension has reached -2 degrees in extension on the R (full on left) and his transfers were independent using a sliding board. The patient was also able to sit-to-stand independently at a standard 4-point walker 5x and stand for 10-15 seconds each time on his L leg.

Discussion

In summary, Mr. C was a relatively straightforward case for prosthesis. He has many of the required qualifications for prosthesis including the psychosocial, emotional, and environmental aspects, as described by Broomhead et al. His stump, upon observation and reflection, also reflected positively according to the Roehampton stump score. Our postoperative and pre-prosthetic care followed many outlines described by Lusardi et al, including contracture limitation, L/E strengthening, balance and coordination, and core strengthening.
Upon discharge, Mr. C was seen by the local prosthetics department and was cleared for the fitting of prosthesis in the coming weeks.

References

Broomhead P, Dawes D, Hancock A, Unia P, Blundell A, Davies V. 2006 Roehampton stump score - A method of estimating the quality of stump for prosthetic rehabilitation.' Presented by Dr Sooriakumaran at ISPO world congress in Hyderabad 2013 Lusardi, MM, Jorge, M Nielsen, CC editors. Orthotics and Prosthetics in Rehabilitation, Third Edition. Missouri: Elsevier, 2013.p. 532-594.

References will automatically be added here, see adding references tutorial.