The Diabetic BK Amputee
This article describes the care process and basic concepts used in below-the-knee amputation in clinical practice. The hospital is the Regent Park Community Health Centre. This is a specialized multidisciplinary office and health promotion center in downtown Toronto. Those who live in. Regent Park includes low-income immigrants and refugees who are not status individuals and the homeless. As such, the health center’s clients face significant health inequalities and access barriers.
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- Demographics: 64-year-old retired man’s anger at being a non-status immigrant
- Medical diagnosis: diabetes mellitus (poorly controlled) diabetic gangrene
- Comorbidities: anemia decreased ear hearing smoking daily alcohol
- Previous care or treatment: left 4th toe amputation 2014 continuous wound care single point cane
- HPI: Short L BKA March 30 2015; home d/c April 4 2015. Used 2ww indoors w help from family.
- Currently relies on family for shopping meal prep & assistance w ADL (bathing toileting dressing).
- Report a phantom sensation. Denies residual limb pain but c/o some pain in sound limb w WB. Surgical incision treatment effectively f/u w surgeon’s plan. Skin of sound limb intact.
- PMH: DM, and DM; use of PVD; L 4th toe amputation 2014; L transmetatarsal amputation February 2015; ischemic gangrene L foot March 2015; decreased hearing L ear.
- SHx: Moved to Canada in 2014. Retired. Lives in apt w wife son dtr mother-in-law & granddaughter. Wife & son able to help. No hobbies/interests have been identified. He doesn’t drive; son-in-law who is able to provide car or family use of taxi. Currently using loaner w/c back apt.
- Drug therapy: Gabapentin metformin ramipril Crestor iron fumarate tekta ducosate sodium ASA.
- Self-Report Outcomes: Not used d/t significant language barrier.
- Physical Performance Measures: 2MWT TUG Berg AMP.
- Subjective: He is there to interpret; client does not speak English. There are no barriers to the apt. Client is not left unattended at home.
- Chief complaints: Isolation (lack of self-mobility); fatigue; decrease in strength.
- Current jobs: Family physician and nurse in this area.
- Goals: Walk independently home perform ADL (bath toilet basic meal prep) independently turn into and out of car independently. Physical Examination
A 64-year-old man 10 days after a below-the-knee amputation due to diabetic gangrene exhibits decreased muscle strength in all other motor organs and bilateral upper limbs and decreased range of motion. Poor use of the other organs has resulted in a bulbous appearance. Client would benefit from ongoing PT interventions to address energy flow and phantom sensitivity; to provide education to client and family; and maintain the remaining organs in preparation for prosthesis. This PT will refer client to specialty amputee service for prosthetic rehabilitation during health insurance is covered.
- Instructions from the client’s father and son: bandage the residual limb; provide packing supplies.
- Education provided include: Hallucination Positioning Residual Massage and Scar Release. PT residual limb massage.
- Prone stretching of L hip flexors.
- Gait training using 2ww. T/f training.
- Bilat LE strengthening exercises including modified bridging hip abd and addition prone hip ext seated bilat hip abd knee ext supine SLR R ankle DF; SLS standing strengthening with R w UE support.
- A home program with instructions is available (Strengthening Exercises Stretching Stump Massage Scar Massage Wraps).
- Referral to 3 local physical rehabilitation services. Discuss referral and preferred rehab center with client and son.
- Apply for the Ontario Health Insurance Plan. Liaise with GP RNs and surgeons for rehabilitation referrals.
- Follow up with coordinators in various rehabilitation services, arrange client admissions and update status. Arrange for accessible public transportation to access daily rehab appointments.
- Client withdraws from community PT services after receiving a rehabilitation program and giving a start date.
The client is progressing well with lower body strength and flexibility. The shape and stability of his stump have also improved with the treatment. When he was discharged from the hospital for rehabilitation services, the limb was suitable for a prosthetic. Activity Tolerance and Standing Balance Also going well.
In hindsight, upper body strength training was a valuable addition to this client’s treatment plan . Specific upper body strengthening increased his ease of transfer and walking; improved his gait with a two-wheeled walker; improved safety By reducing the risk of falls; and contributing to an overall positive outcome. Overall, however, the treatment provided prepared this client for prosthetic use.
This patient is at increased risk of amputation of the remaining sound limb within the next 5-10 years . Special attention is required to protest and observe the right leg and foot to prevent any minor wounds that could lead to gangrenous infection and eventual amputation . Any wound on the remaining extremity must be treated promptly and aggressively . Safety must be paramount in this client’s continuation of care, as a fall could have had a devastating effect on his state of health . Steps should also be taken to quit smoking as this puts the client in a Increased risk of complications .
- The Diabetic Amputee – http://www.physio-pedia.com/The_Diabetic_Amputee
- Diabetic Amputation Rates in Canada: Not Good News, http://www.themayerinstitute.ca/diabetic-amputation-rates-in-can ada-not-good-news/ 5. Izumi, Y., Satterfield, K., Lee, S. and Harkless, L., 2006, Risk of Reamputation in Diabetic Patients Stratified by Limb and Level of Amputation: 10-year observation, http://care.diabetesjournals.org/content/29/3/566.long
- Diabetes Care, March vol. 29 no. 3 566-570 6. Pecoraro RE, Reiber GE, Burgess EM., 1990, Pathways to diabetic limb amputation. Basis for prevention., Diabetes Care. 1990 May;13:513-21. – See more at: http://www.physio-pedia.com/The_Diabetic_Amputee#sthash.NfsK SqmB.dpuf
- Reducing the Risk of Complications – Diabetes, http://www.phac-aspc.gc.ca/cd-mc/diabetes- diabete/complications-eng.php
- Diabetes Mellitus – Ontario Wound Care, http://www.ontariowoundcare.com/diabetes.htm