Individuals With Amputation In Low Resource Setting: Amputee Case Study

Title

Individuals With Amputation In Low Resource Setting

Abstract

Lower limb amputation is one of the oldest known surgically performed procedures. Many previous studies from Nigeria have recognised trauma and complications of management of musculoskeletal conditions by traditional bone setters as the leading cause of amputation in Nigeria. An example of which is my case presentation of a 44 year old farmer who had a motorcycle accident on his way to the farm and because of the lack of health facility in the primary health center he was taken to, he decided to visit a traditional bone setters resulting in a more serious complications

Key Words

Trauma, below knee amputation, phantom limb pain, fracture, low resourced setting, fracture

Client Characteristics

My client is a 44-year-old male farmer who lives and farm in a rural area of North Central part of Nigeria. He was involved in a motorcycle accident on his way to the farm and had a comminuted tibia fracture of the right leg. He was taken to a primary health center within the village but due to lack of medical personnel and facility in the health center, he was referred to a tertiary facility about 20km to the village.

My client felt the referred facility was too far for him and also did not have the financial resources to be managed in such facility. He thus reported to a traditional bone setter where he was managed for six weeks with no significant improvement before finally reporting to the tertiary health facility which is where I practice.

He reported to the tertiary health facility with a leg ulcer and foul smelling discharge from the leg. Stiffness of the knee and ankle joint.
 Absent of sensation to deep and light touch from the knee joint down to the foot

Examination Findings

My client was referred to the physiotherapy unit of the health facility after surgery. The tertiary health facility where I practice is yet to incorporate interdisciplinary team approach into practice. Patient had a below knee amputation done.
Patient chief complaint: Right phantom limb pain


Patient history: patient had below knee amputation done secondary to trauma with history of trauma as documented in the abstract. He was met lying prone on bed with stump bandaging in place. Afebrile, acyanosed, conscious and alert and not in obvious respiratory distress. Segmental

Examination:

• 
Head and Neck:Nil area of abnormality

• Upper limb: Gross muscle power-4, muscle bulk is preserved, sensation to light and deep touch is intact
• Chest and abdomen: chest is clinically clear and moves with respiration, no area of abdominal tenderness, weak trunk muscles
• Lower limbs:left lower limb: gross muscle power is 3, sensation to light and deep touch is intact, right lower limb: gross muscle power is 2, diffuse sensation, reduce muscle bulk, phantom limb pain, hip flexion contracture

• Client goal:reintegration back to society with a prosthesis, reduction in phantom limb pain.
• 
Phantom limb pain using VRS was reported to be 6/10 by the patient. Katz index score for ADL was 3/6. Berg's balance score was 42.

Outlining client ICF findings:

• 
Impairments:phantom limb pain, muscle power
• 
Activity limitations:mobility, transferring, toileting

• Participation restrictions:restrictions in ADL's

Clinical Hypothesis

• Evaluation of client's main problem
• Phantom limb pain
• 
Atrophy of right hip muscles
• 
Reduced muscle power of both lower limbs Inability to transfer without support
• Weak trunk muscles

• Problem with static and dynamic balance
• Right Hip flexion contracture

Intervention

• Core strengthening and stabilization exercises to strengthening trunk muscles
• 
Pain managed with systemic opioids prescribed by the physician
• Range of motion exercises
• Strengthening exercises to both lower limbs
transfer training

• Balance education in sitting and standing

• Gait retraining within parallel bar with progression to outside parallel bar with a pair of axillary crutches when patient can fully transfer and balance both in sitting and standing
• Client was assessed to be fit for prosthesis but did not have the financial capability to procure one.
• Consult was sent to the social services department to assist patient in getting a prosthesis.

Outcome

After about 20 treatment sessions both in the ward and the department gym, client can now ambulate with a pair of axillary crutches, nil contracture and now has an increase performance and independence with functional mobility at an ambulatory level. Good gait pattern and good strength of his residual limb. Can now climb stairs with proper gait mechanism. Pain level reduced significantly to 0/10 on the VRS

Discussion

After about 20 sessions of physiotherapy, patient now has good gait pattern with good strength of the residual limb.
 Data from Nigeria on lower limb amputation is sparse but most studies reported a tune of about 80% from lower limb amputation with a high prevalence of male more than females.

Rehabilitation of amputees aims at restoring them to the best possible functional status. In the USA, immediate postoperative lower limb amputation prosthetic application was found to reduce average rehabilitation time from 128 to 31 days.

In contrast, in West Africa, Nigeria amongst, many amputees never have prosthetic replacement they mobilize permanently on crutches, which is just in line with my client who could not afford the cost of fabricating a prosthesis and was referred to social workers. Social workers also have little to do to assist in this regard as they get little or no funds.