A Case of Below Knee Amputation for Prosthetic Rehabilitation: Amputee Case Study

Title

Prosthetic Rehabilitation in Below Knee Amputation

Abstract

This case presentation describes the prosthetic rehabilitation of a diabetic below knee amputee. It entails client's characteristics, medical diagnosis, examinations and findings using the International Classification of Functioning, Disability and Health (ICF) adopted by the World Health Organization. The ICF provides for a globally accepted framework and system of classification.
At the end of my prosthetic rehabilitation, client was able to achieve her goals of regaining confidence, mobility and independence resulting in reintegration into the society and return to work.

Key Words

Amputation, Transtibial, Diabetic, Phantom Limb Pain, Sensation, Range of Motion, Muscle Strength

Client Characteristics

Client is a 55 year old married woman, residing in a rural area in Mbaise Local Government Area in Imo State, Nigeria with her family (husband & children) in a bungalow. She is a teacher by profession. Client presents with a Below Knee Amputation secondary to Diabetic Foot Ulcer
She is a known Diabetic (Diabetes mellitus) with a familial history of diabetes.
Client is also hypertensive and reports symptoms consistent with diabetic retinopathy.
She visits an endocrinologist for Diabetes control, an ophthalmologist for treatment of diabetic retinopathy and she is on antihypertensives for blood pressure management.

Examination Findings

Amputation is secondary to Diabetic Foot Ulcer (DFU) and amputation surgery was at the transtibial level of the right lower leg (RLL).Surgery was carried out in August, 2014. Client has a stump length (knee centre to distal end of stump) of 15cm. She complains of Phantom Limb Pain—a sharp feeling usually experienced at cold temperatures and which has lasted for the 3 months following amputation surgery.
Client goal is to regain mobility with a prosthetic limb, increase independence and confidence.
ICF Findings
Her amputation is on the right lower limb at the transtibial level. Range of motion at the knee joint is normal (flexion&extension 1100), good skin integrity, good muscle strength (flexors +4, extensors +3); stump is distally heavily padded, sound contra-lateral limb and good upper limb function for donning and doffing of prosthesis. Client has no other impairment except for the amputation on the right lower limb.
Client was a teacher before amputation surgery. Following the surgery client has been unable to perform her teaching duties effectively. She is independent for some activities such as cooking, washing, dressing etc. She cannot walk for a long distance with her crutches due to increase in energy consumption and she is willing and motivated to use the prosthesis. Her environment is a rural environment and the major form of transportation is with the use of cycle. This limits her mobility as she cannot ride with the disability but she has a good support from her family.She scored 18/30 in AMPnoPRO

Clinical Hypothesis

Based on my evaluation, clients ultimate goal is to regain mobility and confidence. From my assessment using Amputee Mobility Predictor Assessment Tool (AmpPro/AmpnoPro), I, therefore, deduce a clinical hypothesis alternate that client can be rehabilitated successfully using a prosthesis.

Intervention

Client was referred to me by an orthopedic surgeon for prosthetic rehabilitation.
As a Prosthetist, she was cancelled and advised on the type of prosthesis that will be suitable for her. She was assessed; measurement of the stump and contra-lateral limb was taken (length of foot inclusive), followed by casting to get an impression of the stump. A positive mould was made from the cast and was modified to suit client measurement with due consideration to the pressure sensitive and tolerant areas.
Using Resin Technology, the socket (PTBSc) was produced and coupled with other prosthetic component (Aluminium pylon and SACH Foot).
Client was invited for initial prosthetic fitting and gait training. During this stage, her complaints were noted such as length discrepancies (between normal and prosthetic limb), gait deviations (valgus movement) were observed, recorded and corrected. Alignment was made as necessary to give client good comfort and confidence.
Gait training was done intensively thrice in a week for 2 weeks due to the high cost of transport. Client was able to ambulate on prosthesis and this was done with a walking frame at the first week of training and then with a quad cane at the second week. She showed good confidence during gait training.
After the stage of successful gait training, the prosthetic limb was given a good cosmetic appearance based on the clients taste and need and finally fitted on patient.
she ambulates on prosthesis with a cane and follow up was done.

Outcome

After the prosthetic rehabilitation, my client was able to achieve her goal of regaining mobility, independence and confidence. She meets up with her check up and follow up management and explains her experiences returning to work effectively.Client was reintegrated into her community/society.

Discussions

In summary, the case presented above is on prosthetic rehabilitation of a diabetic amputee. At the first three months of amputation surgery, client experienced Phantom Limb pain and sensation. This as summarized by Katz (2009) in the Therapy for Amputees textbook, can occur as a result of complex interaction of inputs from periphery and wide spread region of the brain sub-serving sensory, cognitive and emotional processes.
Also, the International Classification of Functioning, Disability and health (ICF)  by World Health Assembly was very helpful to describe, assess and compare function and disability of client.
Also, the outcome measure tool- The Amputee’s Mobility Predictor (AmpPro/AmpNoPro) was gainful in knowing what the client can do before and after prosthetic rehabilitation. Though it is my first case of using such tool but am glad I was able to use it for an outcome measure on the client.
Though in Nigeria, an interdisciplinary approach is not effectively practice but with the impact of knowledge I have gained in this course, I hope to get more involved with other health team practitioners especially the physiotherapists so as to successfully rehabilitate an amputee holistically.