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57-year-old Female, Post-Transtibial Amputation:

A Case Study

Mrs. Sandy Mays

sassy

Prognosis and Plan of Care

female

57 year-old

Examination

helper

SYSTEMS REVIEW

PROGNOSIS

Good/Moderate rehabilitation potential

+

-

African American

OMGWAPTTD

INTERVENTIONS

Diabetes - slow healing

Distracting support

Restrictions from edema

Obesity

Deconditioning

Motivation

Support

No complications post-op

THERE'S NO "I" IN TEAM

Ht: 5'7"

Wt: 252 lb.

HR: 65 bpm

BP: 128/85 mmHg

Respirations: 16 bpm

Integumentary: WNL, no other lesions present at this time.

Cognition: oriented x3

UE ROM: WNL

Mrs. Mays will be seen for 45 minutes

4-5x/wk inpatient for 6 wks

An ethical dilemma presented itself when Mrs. Mays refused treatment when visitors were present. We had to allow Mrs. Mays the autonomy to choose, but advised her that it's in her best interest to schedule visitors outside of physical therapy sessions. We also had to be careful not to jeopardize the support system she had in place.

widow, 20 years

HISTORY

• Confidentiality with visitors
• Church ramp surprise!

Upper Body Strength

Lower Body Strength

Core Strength

Gait Training

Balance Training

ROM

• Physicians
• Orthopedic Surgeon
• Diabetes Specialist
• PCP
• Nurses
• Occupational Therapists
• Orhtotist & Prosthetist
• Dietician
• Social Worker
• Chaplain

Mirror Therapy

Cryotherapy

Electric Stimulation

Edema Massage & Wrapping

Transfer Training

Past Medical Hx:

• IDDM, poorly controlled
• Hx of lower extremity ulcers
• Morbidly obese: BMI 39.5
• HTN

Medications:

• Insulin
• Lisinopril & HCTZ
• Tylenol 3

Patient Goals:

• Return to independent living status with use of a prosthetic
• Return to active lifestyle

one son, lives nearby

TESTS & MEASURES

PATIENT INSTRUCTIONS

Problem:

• Lt. below the knee transtibial amputation secondary to a non-healing infected foot ulcer
• 1-week post-op
• Pain - 4/10 at rest, 6/10 when active

Social:

• Widowed for 20 years, son lives nearby
• Lives independently in 2-story home
• Very active in her community
• Strong support system
• Spiritual

Previous Level of Fxn:

• Was able to complete IADLs and BADLs independently
• Antalgic gait

GOALS

Short-Term Goals

Long-Term Goals

• Diabetes Management
• Nutrition
• Integumentary Monitoring
• Independent Exercise Program

spiritual

active in the

community

MO MONEY, MO PROBLEMS.... Errrr NO MONEY, MO PROBLEMS

• Return home
• Prosthetic
• Ambulation
• Stairs

OUTCOMES

• Ambulation
• Edema
• Pain
• ROM
• Strength

neighborhood hero

• Palpation - pitting edema evaluation
• Girth Measurements
• AROM
• RROM
• One-legged Stance
• Diabetes Quality of Life Measure
• Lower Extremity Functional Scale
• Neurovascular Evaluation

Medicaid will only cover 4 weeks of stay in a subacute rehabilitation facility post-amputation. Because of this, the last two weeks had to be paid for out of pocket.

We also had to be cognizant of our coding and distribution of treatment sessions to accommodate Medicaid requirements .

• Mrs. Mays was discharged after five and a half weeks. At this point she was able to easily ambulate with a walker.
• She returned home to find that her church had built a ramp to make her home entrance more managable.
• Five months later she successfully obtained a prosthetic and fully returned to her involvement in the community.
• Other health benefits .

Evaluation/Diagnosis: Nagi Disablement Model

Demographic Factors

Biological Factors

• IDDM - Poorly Controlled
• History of Foot Ulcers

• 57 y.o.
• African American
• Female

Disability

Functional

Limitations

Impairment

Pathology

• Infected, non-healing foot ulcer
• Lt. transtibial amputation

• Inability to attend church.
• Inability to volunteer at elementary school or continue with other community involvement.

• Decreased LE ROM
• Decreased strength
• Decreased ambulation
• Balance deficit

• Mobility
• BADLs
• IADLs

Preferred Pratice Pattern: 4J

Impaired motor function, muscle performance, ROM, gait, locomotion, & balance associated with amputation

Comorbidities, Health Habits,

Personal Behaviors, Lifestyle

Psychological Attributes/Social Support

Physical & Social Environment

• Hypertension
• Obesity: BMI = 39.5

• Widowed - 20 years
• Lives independently in a two-story home
• 5 stairs with a handrail to enter
• Son lives across town

• Coping well after initial adjustment period.
• Strong support system through church and community.
• Very spiritual - Methodist
• Very independent - a little sassy, even!

REFERENCES

APTA. Guide to Physical Therapy Practice. 2nd ed. 2001

O'Sullivan SB, Schmitz TJ. Physical Rehabilitation: Assessment and Treatment. F A Davis Company; 5th ed. 2007

Shoemaker M. Professional Topics in Physical Therapy I. Notes. 2013

Lauren Smith, Emilee Anderson, Andrea Shefferly