BACKGROUND AND PURPOSE
Approximately 185,000 amputations occur annually in the United States.1 In 2005, an estimated 1.6 million people were living with limb loss in the United States; by 2050, the rate is expected to rise to 3.6 million.2 Combined illness burden may have a stronger impact than single disease process on an individual's risk of amputation.3 Recent literature reviews concluded that national surveys are needed to determine the current data on incidence, prevalence, impact on disability, and cost of limb loss.4,5
With these statistics in mind, it is important to consider the role of the physical therapist (PT) in collaboration with the prosthetist in the rehabilitation of patients with amputations. According to Harvey et al.,6 the goal of physical therapy for a patient with multiple limb amputations is to assist the patient in returning to physical function at the highest level. This is accomplished by concentration on proximal and core muscle strengthening regardless of amputation level.6 Physical therapy includes cardiovascular conditioning and gait training.6 With respect to management of a patient with multiple limb amputations, Davidson et al.7 found that overheating was very common. Their recommendation is that patients with multiple limb amputations be referred to a specialized rehabilitation center to address prosthetic options and rehabilitation requirements over their lifetime.7 Of special importance is to maintain full hip and knee range of motion and to advocate daily prone lying. In this connection, a primary goal of the PT is to facilitate early ambulation of the patient.7
Limited evidence exists for patients with multiple limb amputations with regard to functional gains as measured by the FIM Instrument, previously the Functional Independence Measure (FIM).8 Stineman et al.9 found that patients undergoing early rehabilitation made greater motor FIM gains than those admitted from home or from a long-term facility who had later rehabilitation. Early rehabilitation was defined as rehabilitation immediately postoperatively on a rehabilitation unit. However, after adjusting for illness burden and severity of disability, the benefits disappeared. Leung et al.10 conducted studies to determine if the FIM could be used as a prognostic indicator for use of lower limb prosthetics, finding that admission FIM was not useful. Motor subscore at discharge had a correlation with prosthesis use as well as level of amputation and comorbidity. Major et al.11 found that the Berg Balance Scale (BBS) is a reliable and valid clinical instrument to assess balance for people with lower limb amputations, although it lacks the ability to discriminate between low and high fall risk. For this population, it can be useful in identifying challenges to balance due to limitations on prosthetic range of motion and control. Raya et al.12 found that the Amputee Mobility Predictor (AMP)-Bilateral and the AMP have a strong correlation with the 6-minute walk test (6MWT) for people with amputation that are higher functioning. Zidarov et al.13 found that quality of life for patients with lower limb amputations not only was high during inpatient rehabilitation (IR) but also remained stable at 3-month follow-up after discharge.
Based upon the current literature, there are a notable number of individuals with amputations, and cost to the health care system for their care is expected to continue to rise.2–5 Patients with multiple limb amputations should seek out specialized rehabilitation for their care that includes functional mobility, prone lying, gait training, and balance. This will make a substantial impact on the patient's recovery. In the current case, the complexity of multiple limb amputations should be considered within the context of Legionnaires' disease (LD) to have a better understanding of what led to amputation.
Legionnaires' disease is a potentially fatal pneumonia caused by inhalation of the bacterium Legionella pheumopheila typically found in aquatic environments.14 Symptoms include malaise, lethargy, and anorexia. The most common complications include shock and respiratory, renal, and multiorgan failure.14 Approximately 8,000 to 18,000 people in the United States are hospitalized with LD annually.15
A thorough literature review yielded only one report linking LD and physical therapy rehabilitation. This article explored aquatic pools in relation to L pheumopheila.16 The authors recommend that preventative measures should be taken to monitor for contamination of pool water with L pheumopheila to prevent the risk of spreading.
The primary purpose of this case report is to describe a patient with multiple limb amputations due to medical complications resulting from LD. The PT evaluation, examination, diagnosis, interventions, outcomes, and collaboration with the prosthetist are reviewed in detail. The patient's course of interdisciplinary IR program over a 2-month (9-week) length of stay will be discussed along with changes in functional status and progression to safe discharge home.
CASE DESCRIPTION: PATIENT HISTORY AND REVIEW OF SYSTEMS
The patient was a 55-year-old healthy man who worked full time as a banker with the goal “to be able to golf again.” Informed consent was obtained for participation in this case report. He was admitted to IR after a complicated acute care course including septic shock, respiratory and renal failure, multiple strokes, ischemic liver disease, bilateral ischemia/necrosis of feet and hands, and critical illness myopathy. Eventually, he underwent left transradial and bilateral transtibial amputations because of hypotension-induced ischemia from sepsis. Upon admission to IR, he was severely deconditioned after a prolonged acute care stay and was dependent for all mobility. A FIM assessment, a manual muscle test, and pain and skin assessment occurred upon admission to IR; however, ambulation and standing were not possible. The BBS and AMP were not completed. The patient's multiple strokes had left him with deficits in memory, abstract reasoning, and organization. He was seen by a speech language pathologist to address these areas and ensure he had the ability to learn new information throughout the rehabilitation process.
Upon admission to IR, the patient was found to be alert and oriented to person, place, and time at baseline assessment. Table 1 includes a comprehensive list of examination items collected upon admission and throughout his stay. Baseline vitals included blood pressure of 118/77 mm Hg, 100% oxygen saturation on room air, and heart rate of 93 beats per minute. Pain was noted in bilateral hamstrings during stretching and active use because of limited length bilaterally, but he was unable to rate. Hip flexion was 3−/5 bilaterally and hip abduction was 2+/5 bilaterally. Static sitting balance required moderate assistance with one upper limb support. Left and right protective and righting reactions were present. Rigid dressings were on bilateral lower limb residual limbs. Skin assessment revealed a stage II sacral ulcer.
His short-term goals included the ability to function at a maximal assist level for mobility and to direct transfers with moderate verbal cues. Long-term goals included supervision for bed mobility/transfers and minimal assistance for ambulation with the least restrictive assistive device and prosthesis.
Functional Mobility. The 18-item FIM Instrument is used to measure level of functional mobility in the cognitive and motor domains (Table 1).8 The motor FIM includes 13 items that focus on activities of daily living and mobility (range, 13-91). The five cognitive items focus on communication and functions of cognition (range, 5–35). With this instrument, lower scores represent greater disability and higher scores indicate a lesser degree of disability. The FIM has been found to have excellent test-retest reliability in elderly adults (intraclass correlation coefficient, 0.98 for total FIM, 0.95 and 0.89 for motor FIM and cognitive FIM, respectively).17 In terms of validity, the admission motor FIM scores (β = 0.55) and admission cognitive FIM scores (β = 0.38) of patients with neurological disorders had the highest impact on discharge total FIM scores.18
Pain. The 0-to-10 Numeric Pain Rating Scale (NPRS) is used to rate pain, with 0 meaning none, 5 meaning moderate, and 10 meaning the worst imaginable.19 In the inpatient setting, the patient's pain was assessed upon admission and during every therapy session. The NPRS has adequate test-retest reliability for a single pair of assessments taking place during week 1 and 2 (r = 0.63).20 It has not been specifically examined in patients with amputations.
10-Meter Walk Test. The 10-meter walk test enables clinicians to assess speed in meters per second.21 With this measure, a patient walks a total of 10 m. The initial 2 m is for acceleration, the middle 6 m is timed, and the final 2 m is for deceleration. Although it has been used in patients with lower limb amputations, no minimally clinically important differences have been established. Test-retest reliability in healthy adults has been found to be excellent for comfortable gait speed (r = 0.75–0.90).22 When looking at construct validity in healthy adults, the measure has been found to have poor correlation with the BBS (r = 0.052) and adequate correlation with the Functional Reach Test (r = 0.307).23
Timed Up and Go Test. The purpose of the timed up and go test is to assess fall risk in older adults along with assessing balance, mobility, and walking ability.21 With this measure, a patient sits in a chair and then is timed to get up out of the chair, walk 3 m, turn around, and return to sitting in the chair. Patients with lower limb amputations can be tested, but no minimally clinically important differences have been established for this population at this time. Hofheinz and Schusterschitz24 found excellent interrater reliability and correlation with BBS for community dwelling elderly.
6-Minute Walk Test. The 6MWT is a measure of aerobic capacity/endurance for ambulating a total of 6 minutes.21 In ideal testing environments, patients are asked to ambulate without assist. Harada et al.25 found excellent test-retest reliability and concurrent validity with standing balance and gait speed in a geriatric population. However, no normative data exists for patients with amputations.
Amputee Mobility Predictor. The AMP is used to assess functional mobility of individuals with lower limb amputations.26 It can be completed either with or without a prosthesis. With this measure, 21 items test functional mobility. This enables the clinician to track changes in balance during functional mobility, in sitting, or in standing. It has excellent test-retest reliability for patients with all levels of lower limb amputations, as well as concurrent validity with 6MWT.27
A number of interventions were implemented during treatment sessions, with selection based on the patient's varying level of pain, fatigue, and strength. During the initial weeks of IR, the patient received dialysis 3 days per week. This took time and caused fatigue, making a substantive impact on his ability to participate in intensive therapy promoting functional mobility.
At the beginning of the patient's stay, bed mobility activities were prioritized to enable him to gain some independence in bed. Rolling training with the use of side rails helped him learn how to reposition in bed to prevent skin breakdown. It also allowed for assistance with toileting and hygiene as well sling placement for a hydraulic lift transfer. Transition to a prone position was then incorporated to promote a prolonged hip flexor stretch to facilitate prosthetic training. The patient and his significant other were trained so they could gradually increase prone tolerance in the evenings. Supine to sit was addressed to enable a change of position in bed and to prepare for lateral transfers when the patient's strength improved. Skin protection education was also provided to monitor his residual limbs, to prepare for his prosthesis, and to prevent worsening of buttock pressure ulcers. Core and lower limb strengthening subsequently occurred to prepare for integration of prosthetic training and functional mobility.
Also important was to teach the patient safe change of position throughout the day. Initially, transfers occurred with a hydraulic lift. The patient was educated on directing the transfer, and over time he began to increase his endurance and tolerance to upright position in the wheelchair. He experienced occasional orthostatic hypertension and initially was fit into a high back recliner wheelchair to gradually increase his tolerance to a 90° upright sitting position. As his upright tolerance and strength improved, he progressed from hydraulic lift transfer to transfer training with a transfer board. The scooting motion involved in this type of transfer facilitated core and hip strengthening. Additional focus on sitting balance was also incorporated to improve protective reactions in all planes to prepare for the progression of transfers.28
During the early phase of IR, the patient had rigid dressings on his bilateral residual limbs. He was not ready to begin gait training until 5 weeks after admission. His primary mode of locomotion was a manual or power wheelchair. Manual wheelchair mobility included teaching the patient how to position himself properly in wheelchair with bilateral residual limb supports. The patient was educated on making sure the antitippers were facing down each time he was transferred into the manual wheelchair. This safety feature prevented the chair from tipping backward because of his posterior center of gravity. The manual wheelchair also had the rear axle placed posteriorly to increase stability.
To increase his autonomy on the IR unit, power wheelchair mobility using a right-hand control was integrated into sessions. The patient was fit into a midwheel drive power wheelchair with an increased back angle. Given the patient's multiple limb amputations, this accommodated his posterior center of gravity. Because he had lost a significant amount of weight during his hospitalization, he was at high risk for pressure ulcer progression. Consequently, he was fit with a Roho Quadtro Select High profile cushion to assist with his sitting balance and allow for optimal pressure relief.29
Pressure-relief education was provided in both types of wheelchairs. The pressure relief technique used in the manual wheelchair was a lateral lean or dependent tilt back. The tilt in space feature was used in the power wheelchair. Left lateral lean pressure reliefs were more difficult owing to his transradial amputation. As a result, if he was in his manual wheelchair, he required a caregiver to perform a 2-minute dependent tilt back pressure relief to ensure a thorough pressure relief.
GAIT AND BALANCE TRAINING
Sit-to-stand training was introduced 4½ weeks after IR admission once the patient's rigid dressings were removed and he was fit with his initial pair of lower limb prosthesis. The integration of static standing was prioritized to improve balance and comfort. This also increased awareness of the prosthesis on bilateral residual limbs.28 Dynamic standing balance training, with a focus on balance reactions and fall prevention, was integrated into his interventions. Gait training worked toward refinement of his gait pattern to progress from a step-to pattern to step-through gait pattern. The patient initiated gait training in the parallel bars with moderate assistance and progressed to using a left platform rolling walker with minimal assistance. The platform walker was used because of his multiple limb amputations, ability to weight bear through his elbow, and inability to weight bear through his distal end of his residual limb. Use of the platform walker assisted in his ability to stabilize and maintain his balance. However, long-term use of a platform walker would be difficult because of the eventual use of his body-powered upper limb prosthesis.
A step-to-stair negotiation pattern was used with a right handrail ascending and provision of moderate assistance by one person. This pattern was adopted because of having bilateral prostheses and inability to demonstrate the hip flexor and extensor strength to complete a reciprocal step-over-step stair negotiation pattern. Fall recovery was not addressed during the patient's inpatient stay.
PREPROSTHETIC AND PROSTHETIC TRAINING
Rigid dressings added more weight to the patient's residual limbs. He was non–weight bearing on his residual limbs while his incisions healed and limb volume reduced. The rigid dressings promoted healing, reduced edema, and increased participation in therapy.
As standing activities were integrated into sessions, prosthetic training occurred concurrently to educate the patient on how to don/doff his lower limb prosthesis. He was provided with a supracondylar suspension patella tendon bearing socket with a solid ankle cushioned heel (SACH) foot. This allowed for a very stable surface to begin prosthetic training, considering he had bilateral amputations. The SACH feet were outset by the prosthetist to promote a wider base of support. A torsion unit was not used for this patient with new amputations because of the fact that it would allow for too many planes of movement and reduce his stability. He was educated by the PT in collaboration with the prosthetist to determine the appropriate number of socks of varying ply levels and thickness to wear with his prosthesis for an effective fit. The assessment of sock ply was important to ensure the prosthesis would enable the patient to maximize performance of functional mobility. It also helped to minimize skin redness as the patient was exposed to more challenging activities. The ply of socks varied with temperature, medical changes, and other factors impacting the size of his residual limbs. The patient was educated on wearing his shrinker when he did not have his prosthesis on to minimize fluctuations in residual limb size. Vacuum and suction were not recommended by the physician and prosthetist. As a result, he did not have a seal-in liner owing to being on dialysis and having significant fluctuations in his limb volume. While he was using his preparatory prosthesis, the prosthetist wanted to have the most amount of adjustability to accommodate volume fluctuations.
For his transradial amputation, he was fit with a body-powered prosthetic device once proper healing had taken place. To balance the rehabilitation goals for the upper limb prosthetic training, the occupational therapist took the primary role in training the patient on the body-powered prosthetic device. Their primary focus was on fine motor skills and activities of daily living.
Pain management strategies were integrated into therapy sessions by providing intermittent rest breaks. Collaboration with the physician took place to modify pain medications based upon the patient's tolerance for participation. The patient was educated on phantom limb pains. He also participated in desensitization of his residual limbs. Owing to the nature of his bilateral transtibial amputations, the patient may have been inclined to fully extend his knees to promote stability during gait as he was gaining comfort with the prosthesis. The increased knee flexion of the prosthesis was to promote a more normal gait pattern. This may have caused increased pressure on his distal shins and resulted in shin pain despite the absence of redness.
Before discharge from IR, equipment assessment took place to ensure safe discharge home. Identified durable medical equipment included a hospital bed, platform rolling walker, manual rental wheelchair with a pressure-relieving cushion (until his definitive power wheelchair was fabricated), padded tub bench, padded drop-arm commode, and a transfer board. Family/caregiver training on all functional mobility was completed to promote carryover of techniques used in IR to home after discharge. Verbal, hands-on, and return-demonstration education ensured the patient and his caregiver were proficient in all aspects of care.
Table 1 contrasts outcome measures at admission, midpoint, and discharge. Upon discharge, the patient was using a four-ply sock and gel sock with his left lower limb prosthesis and a one-ply sock on his right lower limb prosthesis. He required minimal assistance to don bilateral lower limb prosthesis. He continued to have 7 of 10 pain in bilateral shins with weight bearing in his prosthesis. Upon skin inspection, there were no increased areas of redness on his lower limb residual limbs. He completed a toilet transfer from an ambulatory level with minimal assistance using his prosthesis and a left platform walker. Using a left platform walker with bilateral lower limb and left upper limb prosthesis, he was able to ambulate a total of 137 m with standby assistance. He ascended/descended six steps with moderate assistance using a right rail with bilateral lower limb prosthesis. The AMP and BBS were not completed with this patient during IR.
This case report demonstrates progression from total assist to standby assist/minimal assist for mobility (excluding stairs, which required moderate assistance) during an IR episode of care. The patient's progress may have occurred at a slower rate than expected because of the critical illness myopathy. Owing to his extensive and complicated acute care course, this patient was significantly deconditioned and experienced other comorbidities that may have impacted the rate of his progress. Creative scheduling was required to ensure he met his inpatient requirement of 3 hours (180 minutes) of therapy 5 out of 7 days. He demonstrated significant fatigue and difficulty participating on the days he had dialysis. Because he had dialysis 3 days per week, he was scheduled for therapy on only one of the dialysis days. The remaining 2 days, he did not have therapy. This allowed him to rest and recover from the dialysis-related fatigue he experienced. The patient did not have therapy during the dialysis procedure.
A review of the current literature yielded no cases similar to the one discussed here. A limited number of studies exist with respect to PT interventions for patients with multiple limb amputations. This case report adds to the body of literature by describing the type of collaborative interventions that are integrated into the plan of care for a patient with multiple limb amputations. Future research may include a series of case reports. It may also include a study utilizing practice-based evidence (PBE), which would allow for more associations to be made regarding interventions. Practice-based evidence study methodology uses an observational cohort research design with clinicians from a variety of disciplines who are involved in direct patient care. It allows researchers to examine associations of various treatments and patient characteristics with outcomes.30,31 However, causation cannot be concluded from PBE. It would also be beneficial to have more studies on patients with multiple amputations to complete validity, reliability, and minimally clinically important differences for more outcome measures. This may include the 10-m walk test, 6MWT, and timed up and go test.
Insurance regulations may limit the type of upper or lower limb prosthesis that can be obtained for particular patients depending upon their K-level classification.26 This may have an impact on the functional outcomes and level of independence that can be obtained. A patient's ability to don/doff the prosthesis and appropriate fit impact functional level after any type of amputation. Insurance regulation also has an impact on the patient's length of stay. In this case, documentation and demonstration of progress on standardized outcome measures such as the 10-m walk test, 6MWT, and timed up and go test assisted in justifying additional time during IR.
In connection with outcome measures, a limitation was that the AMP and BBS were not completed to contribute to the objective process of monitoring for functional changes. Finally, this patient's next level of care─outpatient rehabilitation─was transferred to a facility outside our network of clinics. Consequently, follow-up data on outcome measures, definitive prosthesis, and overall functional capacity were inaccessible, limiting the focus of this report on the patient's inpatient stay.
Future research may include specifically looking at the amount of time in the prone position that should be integrated into the daily routine of a patient with a lower limb amputation. Davidson et al.7 recommended daily prone lying but did not provide dosing information. Specific guidelines for dosing, including duration and frequency, will be beneficial. This would ensure that patients are appropriately using the prone position to prepare for prosthetic training when the residual limbs are ready.
In conclusion, this case has an impact for clinical practice that includes a comprehensive list of physical therapy interventions that resulted in successful rehabilitation for a patient with multiple limb amputations. It also describes the collaboration with the prosthetist to optimize each session. Physical therapists and prosthetists have a key role in the rehabilitation of a patient with amputations by increasing the level of functional mobility, independence, and overall ability.
A special thank you to Sarra Mullen, CP, for her collaboration on this case, and Susan Moss, MA, LCSW, for her review of the manuscript.
I also thank the patient described in this case report for his active participation in the physical therapy and prosthetic plan of care during IR.
This case report was presented at the American Academy of Orthotics & Prosthetics Annual Meeting and Scientific Symposium: February 28, 2014, Chicago, Illinois.
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