High-level rehabilitation: Amputee Case Study

Title

High-level rehabilitation: Amputee Case Study

Abstract

This is a case study of a young patient with a traumatic amputation who presented at a limb-fitting clinic I worked at as a physiotherapist. The patient required a more suitable socket for their prosthetic limb and it was identified that this was a patient who with high level rehabilitation had potential to increase their physical fitness and engage in sporting activity. A multidisciplinary team approach and person centered care were utilised in order to set achievable goals with an aim to improve quality of life and increase social integration.

Key Words

transtibial, traumatic, high level, sport, rehabilitation, prosthetics

Client Characteristics

The patient discussed in this case study is a 23 year old male who suffered a traumatic amputation after having his left leg stuck between a train and a station platform at the age of 21. The patient had fallen whilst disembarking the train and had been unable to free himself before the train moved and crushed his leg whilst he was dragged along the platform. He was taken to hospital and had an emergency trans-tibial amputation. I began treating this patient 20 months after his amputation surgery in a limb-fitting clinic where the patient had come to have his patella tendon bearing supracondylar prosthetic limb reviewed. He had been supplied with his first prosthetic limb at 4 months after amputation and had a second socket supplied 6 months later. He had been involved in a walking rehabilitation programme run by physiotherapists in the hospital after receiving his first prosthetic for 10 weeks. He had returned to work as a carpet fitter and was keen to improve his physical fitness and gain a prosthetic limb, which would allow him to return to playing football recreationally and running track, if possible. Other than his amputation the only medical condition he suffered was mild asthma, which he used an inhaler for when required.

Examination Findings

The patient presented in the limb fitting clinic complaining of pain over the medial and lateral condyles, the head of fibula and the tibial tuberosity. He reported frequent pistoning of the prosthetic. He reported that he had returned to work part time working 4 hours per day as a carpet layer where much of his time was spent in a kneeling position. He reported this position to be very uncomfortable so he would remove the prosthetic if he was in this position for any length of time. He reported that it is his goal to be able to return to work full time along with improving his physical fitness to allow him to play football and run. He felt that his cardiorespiratory fitness had declined, as he had not participated in exercise since his amputation. He felt that a barrier to participating in exercise was that his prosthetic limb rubbed more on his stump and resulted in redness and grazed his skin. He had a manual wheelchair but reported no longer using this. On observation of gait pattern there was less time spent in single leg stance and evidence of vaulting and pistoning.
 A six minute walk test was used completing 910m with shortness of breath.
The patient also completed a 10 minute cycle on a stationary bike using the Borg perceived exertion scale with a score of 15 (hard) noted at 10 minutes.

Clinical Hypothesis

Poorly fitting prosthetic limb after his stump size shrinking over time and increased load bearing on the bony prominences of the stump. Decreased cardiorespiratory fitness due to deconditioning and sedentary lifestyle, which would benefit from a gym based exercise programme within the walking rehabilitation class run by physiotherapy. A discussion over a change in prosthetic limb and possibility of a running blade style prosthetic with the patient and prosthetist may be of benefit.

Intervention

With the prosthetist it was decided that the patient would benefit from a new socket and that a total surface bearing silicon suction socket (SSS) may be more comfortable for the patient. This design allows even weight bearing across the stump, reducing pressure peaks on bony prominence's. There would also be a pin inside the prosthesis preventing pistoning while mobilising. The patient was casted by the prosthetist who went on to design a new socket and the following week the patient was fitted with their new socket.
The patient was also fitted with a blade prosthetic at a specialist centre in a larger hospital in the nearest city and took several months to be provided.

The patient was also given several treatment sessions on a running track with physiotherapists where he was taught to use them and then was able to join an athletic club for disabled adults. The patient also attended walking rehabilitation every week for 12 weeks where they were able to use the hospital gym under supervision and instruction of physiotherapists. We worked on cardiovascular exercise on the stationary bike and treadmill where we began with walking at a normal pace and increased this to fast pace walking on a slight incline. An upper and lower limb weight programme was also utilised along with balance and coordination work on a gym ball.

Outcome

The patient’s stump was assessed after use with both his silicon suction socket and running blade prosthesis. It was found that there was no redness or abrasions to the skin with the silicon suction socket but that the running blade did leave redness on the stump after prolonged usage over 20 minutes. The patient was however able to comfortably run several laps of the 400 meter track using the blade after several months of practice. With the silicon suction socket a normal gait pattern was achieved with no vaulting or pistoning.


The patient was able to increase his hours at work eventually to 6 hour days rather than 4 hour. At the last clinic appointment with the patient he had not yet went back to playing football but was happy with running track one night a week at present.
 The 6 minute walk test was reassessed at 12 weeks after the baseline assessment and a distance of over 1200 meters was reached with no shortness of breath. In the 10-minute cycle test a borg scale measurement of 13 (somewhat hard) was noted at 10 minutes. Both of these outcome measures represent a significant improvement in the patients cardiorespiratory function.

Discussion

In this case effective multidisciplinary teamwork was used to set meaningful and realistic goals for the patient and to provide effective treatment in order to reach these goals. Person centered care was used to base the treatment around what mattered to the patient and resulted in improved physical fitness and quality of life for the patient as he was able to engage in social activity and increase his ability to work longer hours. The patient was very happy with the care he had received and felt that he was happier with both new prosthetics as he was able to mobilise comfortably. Cases of high-level rehabilitation if often more frequent among young amputees, especially those with traumatic amputations. In these cases it is the duty of the physiotherapist along with the rest of the multidisciplinary team to provide treatment beyond just mobilising but also to provide the opportunities to engage in sporting activity whither it be recreational or competitive.