physical therapy management of the obese …

PHYSICAL THERAPY MANAGEMENT OF OBESE DYSVASCULAR PATIENT

PHYSICAL THERAPY MANAGEMENT OF THE OBESE DYSVASCULAR PATIENT WITH AN AMPUTATION: A CASE REPORT

_______________________________________________________________________

A Case Report

Presented to

The Faculty of the Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

_______________________________________________________________________

By

Michael Gregory Ballough

2017


APPROVAL SHEET

This Case Report is submitted in partial fulfillment of the requirements for the degree of

Doctor of Physical Therapy

____________________________________ Michael Ballough

Approved: April 2017

____________________________________ Verner Swanson, MSPT

Committee Chair

____________________________________ Ellen Donald, PhD, PT Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standard of scholarly work in the above mentioned discipline.


Acknowledgements

I would like to thank my academic committee for guiding me through the

process of this case report and my independent studies learning activities, as well as the

entire faculty of the physical therapy department. Without the established clinical

relationships and personal connections of this department, I would not have had the

opportunity to observe patients in the rehabilitation setting, observe prosthetic

manufacturing and fitting, attend required continuing education at a discounted rate, or

locate my case report.

PHYSICAL THERAPY MANAGEMENT OF OBESE DYSVASCULAR PATIENT 1

Table of Contents

Abstract ............................................................................................................................... 2

Introduction ........................................................................................................................ 4

Background and Purpose ................................................................................................ 4

Body Mass, DM, and Amputation .............................................................................. 6

Case Description: Patient History and Systems Review ................................................... 10

Clinical Impression #1 .................................................................................................... 12

Examination ................................................................................................................... 13


Interventions ................................................................................................................. 14


Outcome ........................................................................................................................ 20

Discussion.......................................................................................................................... 24

References ........................................................................................................................ 29


Abstract

Background and Purpose: The rising number of obese and overweight Americans, along

with the rising incidence of diabetes mellitus type 2 is causing an increase in the

prevalence of dysvascular amputation in the United States. Due to the interrelated

nature of elevated body mass and dysvascular amputation, an understanding of the

management and a review of current literature guiding the rehabilitation potential of

the obese, dysvascular patient with a lower extremity amputation is an increasingly

relevant topic in physical therapy practice. As the primary contributor to the discharge

destination and the primary provider of mobility training, a physical therapist should be

able to intelligently advocate for and deliver appropriate physical therapy early in the

patient’s plan of care to maximize rehabilitation potential.

Case Description: The patient was a 57-year-old male with an anthropomorphic profile

of 72 inches of height, a body weight of 145 kg, and a body mass index of 43.3. He was

admitted to the hospital for a non-healing wound on the plantar aspect of his right foot

and diagnosed with sepsis of the right foot. The patient’s past medical history was

significant for diabetes mellitus type 2, progressive Charcot foot on the right lower

extremity, hypertension, and a 30 pack-year history of smoking. The patient underwent

a staged amputation of the right lower extremity to allow for resolution of the sepsis

before the final below knee amputation procedure was completed.

Outcomes: Following the right below knee amputation, the patient received one-month

of acute and subacute physical therapy before being discharged home. In the one-

month time period between amputation and discharge from the hospital, the patient’s


open kinetic chain exercise tolerance improved markedly. However, ambulation

distance plateaued early in his care, and he was discharged to home with a Functional

Independence Measure: Locomotion: Walk score of 5/7 after ambulating 80 feet with a

rear-wheeled walker. After discharge to home, the patient fell onto the suture of his

residual limb and experienced delayed wound closure secondary to diabetes mellitus.

It was nearly six months before prosthetic training began. Upon discharge from

outpatient therapy, the patient’s elevated body mass index and general deconditioning

were the primary factors in assigning him K2 ambulation status.

Discussion: As the healthcare practitioner most closely involved with determining the

mobility status of a patient, physical therapists play an important role in deciding

discharge destination of the obese, dysvascular patient. Furthermore, we are often

intimately involved in residual limb management, restoring functional independence,

and prosthetic training. By tailoring physical therapy interventions in the acute phase of

physical therapy to the specific patient and identifying barriers to rehab, we can better

determine the appropriate discharge destination for our patients to reduce morbidity

and mortality associated with amputation.


Introduction

Background and Purpose

It is estimated that there are 2 million people with at least one amputation living

in the United States, and that number is projected to be 3.6 million by 2050 (Ziegler-

Graham, MacKenzie, Ephraim, Travison, & Brookmeyer, 2008). Approximately 54% of

the estimated persons with an amputation population in the U.S. received their

amputation secondary to vascular disease (Ziegler-Graham et al., 2008). Over two-

thirds of people who have had an amputation secondary to vascular disease were

comorbid for diabetes mellitus (DM) (Ziegler-Graham et al., 2008). It has been

estimated that 60% of all lower extremity (LE) amputations in the U.S. are secondary to

DM; as well, 42% of persons living with LE limb loss are 65 years of age or older (Centers

for Disease Control and Prevention, 2014; Ziegler-Graham et al., 2008). The country’s

aging population and the rising incidence of DM have contributed to the increase in

amputations and will continue to drive to the rise.

DM is a systemic pathology that is associated with development of ischemic

heart disease, peripheral vascular disease (PVD), and cerebrovascular disease (Cade,

2008). Patients who have undergone amputation related to DM are at risk of

cardiovascular sequelae, additional future amputation, and the high rate of mortality

associated with dysvascular amputation. Dysvascular amputation is any amputation

related to poor vascularity in the extremity due to a disease process. This term includes

PVD, loss in circulation related to DM, and venous insufficiency, and it excludes


amputations caused by trauma, cancer, or congenital malformations (Dillingham, Pezzin,

& MacKenzie, 2002).

Mortality after all-cause dysvascular LE amputation from the level of the great

toe to the mid-foot has been reported as 25% within 1 year, and 50% for patients who

underwent initial transfemoral or any-level bilateral amputation (Dillingham, Pezzin, &

Shore, 2005). Three-year survival for patients with DM who underwent a LE amputation

has been reported at 50%, with 5-year survival rates between 39% to 68% (Rieber,

Boyko, & Smith, 1995). A more recent Veterans Health Administration (VHA) study of

patients who underwent a LE amputation at a mean age of 66.9-years-old found 46%

mortality (54% survival) at three-years (Kurichi et al., 2015). The VHA study is applicable

to the larger discussion of LE amputation given that the VHA study participant mean age

of 66.9-years-old reflects the aging population of the United States, not wartime or

combat related amputation, and the three-year mortality rate of 46% is consistent with

past research.

Patients who received an amputation from the level of the great toe through the

transtibial level, secondary to complications of DM, have a revision rates of between

17.6%-24% within 1 year (Dillingham et al., 2005; Lim et al., 2006). In their conclusions,

Dillingham et al. stressed that mortality and need for revision should not be viewed

purely as a failure of surgery but also as an indication that dysvascular disease is a

progressive systemic process (Dillingham et al., 2005). After a unilateral amputation,

instruction for regular inspection and preservation of the intact limb is practiced. With

such poor results once amputation is indicated, researchers are coming to the


conclusion that prevention of diabetic ulceration or critical limb ischemia is the most

effective way to reduce mortality (Limb Loss Task Force/Amputee Coalition, 2012;

Lusardi, Milagros, & Nielsen, 2013).

Body Mass, DM, and Amputation.

The interaction between body mass indexes (BMI), DM, and amputation is

complex. BMI is strongly correlated with an individual’s lifetime risk of developing DM.

Epidemiological studies have shown that an 18-year-old male with a BMI of 35+ has a

70% lifetime chance of developing DM, type 1 or type 2, while men with BMIs of 30 to

<35, 25 to <30, 18.5 < 25, and < 18.5 have risks of 57.0, 29.7, 19.8, and 7.6 percent

respectively (Narayan, Boyle, Thompson, Gregg, & Williamson, 2007). Body Mass Index

calculated by static body weight and a measure of height is not a precise measure of a

person’s body fat. Dual-energy x-ray absorptiometry (DEXA) scans, skin fold

measurements, and hydrostatic measurements all have the advantage of differentiating

adipose tissue from lean muscle (Hu, 2017). However, BMI is a valid field measure to

gauge a person’s habitus and is useful in epidemiology scale studies where more

involved measurements would be time and resource prohibitive.

Male patients whose amputations are due to DM and who are obese or

overweight at the time of surgery have been shown to have decreased mobility over

normal-weight patients (Rosenberg et al., 2013). Male patients whose amputations are

due to DM and are obese or overweight are also more likely to use an assistive device

with prosthetic limb ambulation at 12 months post-operative date (Rosenberg et al.,

2013). In a study of dysvascular patients with LE amputations being treated in a


comprehensive inpatient rehabilitation unit (CIRU), it was found that normal-weight

patients were among several subgroups more likely to achieve short-term rehabilitation

goals (Czerniecki, Turner, Williams, Hakimi, & Norvell, 2012). These studies suggest that

BMI is tied to incidence of DM, DM is tied to incidence of amputation, and higher

pre-surgical BMI is associated with poorer mobility at four and 12 months

post-operative. Decreased mobility after amputation paints a bleak picture of

rehabilitation potential for the overweight, dysvascular patient with an amputation, but

there is conflicting data on the link between BMI and post-amputation outcomes.

It has been conversely reported that normal-weight, overweight, and obese

patients who underwent amputation for peripheral artery disease showed no

statistically significant trends in mobility after amputation at three-years postoperative

(Kalbaugh et al., 2006). A possible confounding variable in the Kalbaugh et al. study is a

disproportionate percentage of BKAs in the obese cohort (61.9%) and a

disproportionate percentage of above knee amputations (AKA) in the underweight

cohort (59.3%) (Kalbaugh et al., 2006). Taken together, the mobility outcomes may

reflect the level of amputation rather than BMI status (Kalbaugh et al., 2006). It has also

been found that normal-weight, overweight, and obese individuals who had undergone

amputation showed no statistically significant differences in 2 Minute Walking Test

(2MWT) distances or in length of stay for inpatient rehabilitation (Vivas, Pauley, Dilkas,

& Devlin, 2017). An interesting finding of the three previously cited rehabilitation

studies is that underweight individuals have consistently been shown to have decreased


mobility and poor amputation rehabilitation outcomes (Kalbaugh et al., 2006;

Rosenberg et al., 2013; Vivas et al., 2017).

Within the studies attempting to tie BMI to rehabilitation potential, multiple

authors reported net weight gain, after adjusting for gross weight loss of the amputated

limb. Male patients undergoing their first dysvascular LE amputation show a weight

gain of approximately 6 lbs at 12-months post-operative (Rosenberg et al., 2013). This

phenomenon has also been observed in males who underwent any cause amputation,

with reported values of 16-18 lbs of weight gain at 24-months post-operative, and

greater weight gain associated with more proximal amputation (Littman et al., 2015).

The finding of weight gain with all-cause amputation, along with the systemic nature of

dysvascular amputation stresses the importance of physical activity and vigorous

rehabilitation for possible improvements in the patient’s cardiovascular,

musculoskeletal, and body weight status.

Research comparing LE dysvascular amputation outcomes by hospital discharge

destination found that discharge to inpatient rehabilitation yielded lower disability index

scores and greater self-reported overall health then a discharge to a skilled nursing

facility (SNF) or to home (Sauter, Pezzin, & Dillingham, 2013). The authors speculated

that inpatient therapy may provide a more intense therapeutic environment than a SNF

or home health care. They also speculated that the multidisciplinary team, the intensity

of rehabilitation, stabilization of underlying pathologies, weekly team meetings, patient

involvement in goal setting, regular access to a psychologist, and the environment of a

rehabilitation unit may be a more supportive environment for rehabilitation to take


place (Sauter et al., 2013). Total contact time with rehabilitation staff was not found to

be a significant predictor of success across rehabilitation environments (Czerniecki et al.,

2012). Otherwise stated, three hours of therapeutic exercise in the home health

environment may not be as effective as three hours of inpatient rehabilitation exercise

(Czerniecki et al., 2012) . Furthermore, comprehensive inpatient rehabilitation at any

point in the first 12 months after a LE dysvascular amputation has been shown to

increase chance of mobility by 17% as compared to patients who underwent home

health or outpatient physical therapy (Czerniecki et al., 2012). Inpatient care versus

home health, skilled nursing, or outpatient physical therapy has also been found to

decrease mortality, decrease incidence of readmission to the hospital, decrease

subsequent amputation, and increase the chance of prosthetic fitting (Dillingham &

Pezzin, 2008).

Short-term rehabilitation outcomes may also be better predictors for

rehabilitation success than BMI. Prosthetic fitting is an important milestone in

amputation rehabilitation. It has been found that prosthetic fitting after dysvascular

amputation in patients with a mean age of 66.9 reduced three-year post operative

mortality from 46% to 25%; prosthetic fitting in this context can be seen as a measure of

good health and also as a motivational tool that encouraged the patients toward

mobility (Kurichi et al., 2015).

The physical therapy management of an obese patient recovering from a

dysvascular amputation requires a number of medical specialties working in concert.

The close proximity of the medical team, rehabilitation team, and nursing in the


inpatient environment is a proposed benefit of inpatient rehabilitation (Czerniecki et al.,

2012). The inpatient environment allows for control of modifiable risk factors within the

first 12 months, including weight management, protection of the residual limb, and

psychosocial support.

This case report of a 57-year-old male with an anthropomorphic profile of 72

inches of height and a body weight of 145 kg (BMI 43.3) reflects many of the challenges

a physical therapist will face when working with this population and presents current

evidence on the optimal discharge destination, prevention of sequelae, and

optimization of rehabilitation outcomes. The demonstrated rise in the number of

amputations in the United States, as well as projected growth in the future, makes

physical therapy management of patients with amputations an increasingly relevant

topic of scholarship for emerging professionals and practicing physical therapists.

Current literature reflects that discharge destination has a significant impact on

mortality and mobility for patients with dysvascular amputation and that weight status

is an inconsistent predictor of rehabilitation outcome. As the primary contributor to the

discharge destination and the primary provider of mobility training to patients, a

physical therapist should be able to intelligently advocate for and deliver appropriate

physical therapy early in the patient’s plan of care to maximize rehabilitation potential.

Case Description: Patient History and Systems Review

The patient was a 57-year-old male with an anthropomorphic profile of 72 inches

of height and a body weight of 145 kg (BMI 43.3). He was admitted to the hospital with

sepsis of his right foot secondary to a non-healing diabetic ulcer on the plantar aspect of


the foot. The patient’s past medical history included diagnoses of hypertension (HTN),

obesity, gastroesophageal reflux disease, DM type 2, a 30 pack-year history of smoking,

and use of constant positive airway pressure device. The patient’s right foot had been

treated with progressive casting for a “rolled ankle,” Charcot foot, for approximately 18

months. The patient had also undergone conservative treatments for the non-healing

wound including local wound care by a podiatrist and hypobaric oxygen therapy. Upon

admission to the hospital, visual exam revealed cellulitis to the right mid-shin and

Charcot foot, with the patient reporting chills and pain of 7-8/10. Physical exam

revealed fever, diminished sensation in bilateral LEs, intact dorsal pedis pulse bilaterally,

and expiratory wheezing in lungs bilaterally. Imaging revealed diffuse cellulitis and

“extreme Charcot, essentially obliterating the ankle and hind foot.” The patient was

scheduled for right ankle guillotine disarticulation, broad spectrum antibiotics (IV

Vancomycin, Cefepime, and Flagyl), and a below knee amputation (BKA) closure of the

right LE when the infection was controlled.

Two days after the initial right ankle disarticulation, the patient demonstrated

5/5 LE strength in all available planes, pain of 4/10, modified independence for bed

mobility, and Functional Independence Measure (FIM): Transfer scores of 4/7. The FIM

has been shown to be a valid measure of functional independence and mobility in the

inpatient phase of rehabilitation, and it has been shown to be sensitive to change

during the inpatient phase of rehabilitation for patients with amputations (Panesar,

Morrison, & Hunter, 2001). The measures taken after the initial amputation were used

to develop a short-term plan of care that included LE strengthening and increasing


standing tolerance until the final BKA surgery took place. The endocrinology report

after ankle disarticulation showed blood glucose levels between 220-250 mg/dL.

Elevated blood glucose during a systemic infection can be a direct result of the body’s

immune system, and not necessarily uncontrolled DM. Control of the infection and

sliding scale insulin administration lowered the patient’s blood glucose to 160-165

mg/dL, and the secondary surgery was scheduled for five days later. Only one physical

therapy session was completed between the ankle disarticulation and BKA closure

consisting of bridging x 1 set x 10 reps, alternating straight leg raise (SLR) x 1 set x 10

reps, transfer training, and static standing balance for three minutes in a rear-wheeled

walker. The BKA surgery was completed as scheduled, five days after the initial ankle

disarticulation and seven days after admission to the hospital.

Clinical Impression #1

The patient was an ideal candidate for physical therapy intervention after the

initial ankle disarticulation and after the BKA closure. Early physical therapy

intervention allows a patient undergoing an amputation to increase single limb balance

on the unaffected limb, increase activity tolerance, and prevent known sequelae of LE

amputation such as hip contracture, knee contracture, and formation of venous

thrombus. Single limb balance time has been identified a strong predictor of amputee

mobility after prosthetic fitting (Raya, Gailey, Fiebert, & Roach, 2010). The patient

presented with a number of factors that are commonly seen with LE amputation: DM,

history of tobacco use, and obesity. Examination of both feet revealed diminished

sensation and intact dorsalis pedis pulses. Reduced sensation is a risk factor for diabetic


(neuropathic) ulceration, but the presence of pedal pulses is not a sensitive indicator of

wound healing potential (American Diabetes Association, 2003). With the infection

controlled, DM was identified as the patient’s greatest barrier to rehabilitation and no

mention of body weight status or functional level was yet made.

Examination

The physical therapy evaluation completed on BKA post-operative day one

showed manual muscle testing of 5/5 in bilateral upper extremities (UE) except for 3+/5

in the left triceps secondary to a past rotator cuff injury. The patient also showed 5/5 in

all planes of left LE, 3+/5 in right LE hip flexion, and “unable to assess due to pain” in all

other right LE planes. Mobility was assessed using subjective rating by the physical

therapist and the FIM tool. The patient needed supervision for bed mobility and

recorded a 3/7 for FIM: Transfers. The residual limb was dressed in a rigid removable

dressing (RRD) that immobilized the knee. Gait training was withheld until the right

sciatic nerve block was removed. On day two, the patient began describing phantom

toe pain and was subjectively reported as needing minimum assistance (min assist) with

gait in a rear-wheeled walker. He remained at 1/7 in the FIM: Locomotion Walk

category due to a distance travelled of <50 feet. On day two, the patient was able to

begin bed exercises: one set of ten repetitions of bilateral active assisted range of

motion (AAROM) straight leg raises (SLR), hip abduction and adduction, gluteal set,

quadriceps set, and intact limb ankle pumps. Endocrinology reported fasting blood

glucose levels at 140 mg/dL demonstrating control of the infection and glycemic control.



Based on findings from post-operative day one and two, inpatient goals of

independence with transfers, increase ambulation distance with an assistive device, and

increase balance to maintain independence with activities of daily living were

established. The patient’s prior level of function and BMI status were identified as a

limiting factors in progression of mobility and therapeutic exercise. Upper extremity

strength and intact LE strength were good, and the therapist recorded post-operative

day two transfers and gait as min assist. However, hopping gait in the rear-wheeled

walker was limited to within the hospital room. The disparate transfer ability and

ambulation distance of the patient reflected the differences in the patient’s LE muscular

strength and endurance, as well as the difference between the patient’s left UE strength

and endurance. He could easily press his body weight up from a bed or chair, but

extended hopping gait placed repeated pressure through the left UE. The patient’s

prior level of function over the past several years had been limited by the progressive

Charcot foot on the right LE and more recently by the painful, septic wound that

prompted his hospital admission. Therefore it was to be expected that he would be

globally deconditioned and unaccustomed to prolonged bouts of activity.

Interventions

The functional goals established after post-operative day two were addressed by

daily physical therapy treatment including mobility training and isolated movements

aimed at strengthening the residual limb for eventual prosthetic gait. Table 1 outlines


the initial daily physical therapy program followed by step-down to sub-acute status and

progressively longer physical therapy sessions every other day.

Table 1 Acute Care and Subacute Physical Therapy Progression

Plan of Care Day

Physical Therapy Intervention

Day 1 (Post Operative Day 2)

Transfer training. Residual limb SLR AAROM, hip abd/add, glute set, quad set x 10. Intact limb, ankle pump x 10. Min assist “hopping” ambulation in RW.

Day 2 Transfer training. Residual limb SLR, hip abd/add, glute set, quad set x 10. Intact limb, ankle pump x 10. CGA “hopping” ambulation in RW.

Day 3 Transfer training. Residual limb SLR, hip abd/add, glute set, quad set, bridging x 10. CGA “hopping” ambulation in RW of 7’.

Day 4 Step Down to Subacute

Day 5 Transfer training. SBA ambulation in RW. Forward and backward ambulation training 5’.

Day 6 All transfers SBA. Residual limb SLR, hip abd/add, glute set, quad set, bridging x 10. SBA ambulation in RW.

Day 7 (Reevaluation)

All transfers SBA. SBA ambulation in RW, approx. 50’

Day 8 Ambulation in parallel bars, bridging over bolster x 10 x 2, R LE Ext in side-lying x 10 x 2, R hip abd/add x 10 x 2, balance, abdominal bracing, ambulation in RW 40’, w/c pushups x 5 x 2.

Day 10 Ambulation in parallel bars, bridging over bolster x 10 x 2, R LE Ext in side-lying x 10 x 2, R hip abd/add x 10 x 2, balance, abdominal bracing, ambulation in RW 40’, w/c pushups x 5 x 2.

Day 12 Ambulation in parallel bars, bridging over bolster x 10 x 2, R LE Ext in side-lying x 10 x 2, L LE Ext in side-lying w/ 4lbs x 10 x 3, Bilat Hamstring Curls w/ green band x 10 x 2, R hip abd/add x 10 x 2, balance, abdominal bracing, ambulation in RW 40’, w/c pushups x 5 x 2. PT lasting 60 mins


Table 1 continued Acute Care and Subacute Physical Therapy Progression

Plan of Care Day

Physical Therapy Intervention


Day 16 Patient issued bariatric walker for home use. Gait, transfer, and curb training initiated.



Day 24 (Discharge)

Patient indep with transfers, able to ambulate household distances, able to maintain static standing for 10 secs, able to navigate curbs, able tolerate 10 mins of physical activity.

Bed Mobility – Independent FIM: Transfers 6/7 FIM: Locomotion: Wheelchair 6/7 FIM: Locomotion: Walk 5/7 (Household Exception) Distance of 80’ in RW)

Note. SLR = straight leg raise; ARROM = active assisted range of motion; abd = abduction; add = adduction, glute = gluteal; quad = quadriceps; CGA = contact guard assistance; RW = rear-wheeled walker; w/c = wheelchair; R = right; L = left; w/ = with; LE = lower extremity; Ext = extension; Bilat = bilateral; PT = physical therapy.

After day seven of acute rehabilitation, reevaluation of the patient’s mobility

status allowed for increased duration of physical therapy in the gym setting with a


decrease in frequency to every other day. New short-term goals of household (HH)

distance ambulation and discharge to the highest level environment were established.

Rehabilitation movements preformed in the gym environment for the lower extremities

were modified for the residual limb. Bridging with the residual limb for patients with

amputations who are not yet placing weight through their incision entails placing a firm

roll of towels or a foam roll under the distal hamstrings of the residual limb and pressing

down into the roll. Hamstring curls on the residual limb can be performed in prone or

seated in a chair, and a band is wrapped around the posterior, distal LE. Table 2 outlines

the patient’s progress in subjective mobility level and the FIM. It should be noted that

at discharge, the patient’s FIM: Locomotion: Walk score remained at 5/7, which is

defined as “household” distance ambulation of > 50 feet but <150. By discharge the

patient was able to ambulate a consecutive 80 feet with a rear-wheeled walker.

Table 2 Acute and Subacute Mobility Progression

Plan of Care Day

Mobility Level

Day 1 (Post Operative Day 2)

Bed Mobility – Supervision FIM: Transfers 3/7 FIM: Locomotion: Walk 1/7 (Hopping gait in Rear-wheeled walker)

Day 3 Bed Mobility – Supervision FIM: Transfers 3/7 FIM: Locomotion: Walk 1/7

Day 4 Step Down to Subacute

Day 5 Bed Mobility – Supervision FIM: Transfers 4/7 FIM: Locomotion: Walk 1/7

Day 6 Bed Mobility – Mod Independent FIM: Transfers 4/7 FIM: Locomotion: Walk 1/7


Table 2 continued Acute and Subacute Mobility Progression

Plan of Care Day

Mobility Level

Day 7 (Reevaluation)

Bed Mobility – Mod Independent FIM: Transfers 6/7 FIM: Locomotion: Walk 2/7 (approximately 50 feet)

Day 8 Bed Mobility – Mod Independent FIM: Transfers 6/7 FIM: Location: Wheelchair 6/7 FIM: Locomotion: Walk 2/7

Day 10 Bed Mobility – Mod Independent FIM: Transfers 6/7 FIM: Locomotion: Wheelchair 6/7 FIM: Locomotion: Walk 3/7






Day 24 (Discharge)

Bed Mobility –Independent FIM: Transfers 6/7 FIM: Locomotion: Wheelchair 6/7 FIM: Locomotion: Walk 5/7 (Household Exception) Distance of

80’ in RW)


Regular prosthetist reassessment of the residual limb for swelling and wound

closure during this period also played a role in preparing the patient for discharge. After

the BKA, the patient was cast for two rigid removable dressings (RRD) to account for

residual limb volume changes and was issued an Adjustable Post-Operative Preparatory

Prosthetic System (APOPP) for discharge. The APOPP dressing is a prefabricated rigid

dressing that is easily adjustable to allow for shrinkage as the residual limb matures. It

can be progressively tightened to provide pressure and control edema, and it is easily

removable for woundcare or bathing (O’Sullivan, Schmitz, & Fulk, 2014). Among

patients who have undergone LE amputation, patients who are significant for obesity,

arterial disease, or tobacco use may experience greater residual limb volume lability

than other patients, requiring careful attention during the maturation phase of the

residual limb (Sanders et al., 2012). A podiatry consult for patient education on diabetic

foot inspection was performed, and physical therapy educated the patient on the

concept of energy conservation due to his limited ambulation tolerance.


The patient progressed steadily through acute and subacute care. Interventions

were primarily focused on LE strengthening and short distance ambulation, with

wheelchair press-ups included to improve sit-to-stand mobility and the UE strength

needed to perform hopping gait in a rear-wheeled walker. With the patient’s weight

and conditioning limiting ambulation distance, earlier UE conditioning through light UE

resistance training or use of the UE ergometer may have been beneficial in increasing

caloric expenditure without further stressing the LE or endangering wound healing. The


UE ergometer has been shown to have cardiovascular carryover in dysvascular patients

suffering from critical limb ischemia and to help control serum glucose levels in patients

with DM type 2 (Jeng, Chang, Chen, & Tseng, 2002; Saxton et al., 2011). Despite steady

progress, Days 12-22 described in Table 1 and Table 2 show a contrast in the amount

physical therapy the patient was able to tolerate and his ability to increase ambulation

distance. The treating physical therapist recorded that the patient was able to

ambulate household distances, though the patient plateaued at 80 feet of ambulation.

With the patient’s wishes to be discharged home and his prescribed assistive devices, it

was the conjecture of the therapist that the patient would be safe in his home with a

wheelchair, rear-wheeled walker, and the ability to ambulate short distances while his

wound healed. With the goal of household ambulation met, a maximum ambulation

distance was not attempted as a precaution to protect the intact LE, the residual limb,

and the weakened left rotator cuff. It was also recorded by the therapist that the

patient showed outward physical signs of fatigue during gait such as flushed skin and

heavy sweating. Given the outward signs of exertion with ambulation and lower

extremity exercise, as well as the 60 minute length of the physical therapy sessions, it

may have been the conjecture of the treating physical therapist that additional

cardiovascular conditioning was not warranted or advisable at the time.

Outcome

In the short time the patient was undergoing acute and subacute physical

therapy, the documented exercise progression showed a precipitous increase in exercise

tolerance for open kinetic chain movements with an ambulation distance that plateaued


at 80 feet. Table 3 outlines exercise progression and mobility progression as

documented by the same physical therapist on corresponding days.

Table 3 Acute and Subacute Physical Therapy and Mobility Progression

Plan of Care Day

Physical Therapy Progression Mobility Progression


Bed Mobility – Mod Independent FIM: Transfers 6/7 FIM: Locomotion: Wheelchair 6/7 FIM: Locomotion: Walk 3/7



Day 16 Patient issued bariatric walker for home use. Gait, transfer, and curb training initiated.





Table 3 continued Acute and Subacute Physical Therapy and Mobility Progression

Plan of Care Day

Physical Therapy Progression Mobility Progression



Day 24 (d/c)

Patient indep with transfers, able to

ambulate household distances, able to

maintain static standing for 10 secs,

able to navigate curbs, able tolerate 10

mins of physical activity.

Bed Mobility – Independent FIM: Transfers 6/7 FIM: Locomotion: Wheelchair 6/7 FIM: Locomotion: Walk 5/7

(Household Exception) Distance of

80’ in RW)

Note. R = right; LE = lower extremity; Ext = extension; L = left; w/ = with; Bilat = bilateral; abd = abduction; add = adduction; x 10 x 2, RW = rear-wheeled walker; w/c = wheel chair; PT = physical therapy; d/c = discharge.

Per the initial established goal of physical therapy, the patient was discharged to

the least restrictive environment, his home. Discharge occurred 37 days after entering

the emergency room with sepsis of the right foot and 30 days after receiving the BKA.

The patient was discharged home with a wheelchair, bariatric rear-wheeled walker, and

APOPP to control edema and protect his incision.

The patient was readmitted to the hospital one day after discharge home due to

a fall on his residual limb and incision. The patient reported slipping in his bathroom

while not using the walker or having his residual limb covered by the APOPP. There was


minimal dehiscence of the wound after the fall, and the patient returned home with

referrals for nursing while his residual limb healed and matured.

Approximately one month after discharge from the hospital, the patient incision

still showed small, superficial open wounds and the patient was recommended to begin

using limb shrinkers. Approximately six weeks after the patient received his shrinkers,

he received a temporary, below knee endoskeletal prosthetic socket. The prosthetic

socket was a total contact, expulsion valve model with liner and sleeve suspension and a

K2 foot. The patient had instructions to wear the device for one hour per day.

Prosthetic training and outpatient physical therapy began six weeks later. This timeline

allowed for nearly six months from the BKA closure to outpatient gait training with the

temporary prosthetic. Amputation rehabilitation progression is largely tied the status of

the residual limb and wound closure, so it is expected that a patient with DM who

suffered a fall onto the limb would have an extended timeline (Uustal, 2009).

Outpatient therapy was initiated three times a week for one month. The patient was

discharged from outpatient able to ambulate 450 feet with a cane, move laterally within

the parallel bars, and don and doff his own prosthetic.

Upon discharge from outpatient physical therapy, it was recorded by the treating

therapist that the patient was ambulating at a K2 level. Due to difficultly with changes

in speed, difficulty in ambulation with variable surfaces, the exertion level with

ambulation, and BMI status the patient could not be subjectively classified as a K3

ambulator at discharge. K-level determination at this facility was guided by the patient’s

prior level of function and the clinical judgment of the department physiatrist and


physical therapist, and no formal K-level assessment, such as the Amputee Mobility

Predictor (AMP), was administered.

Discussion

The care of the case patient required the treating physical therapists to work

with many factors in addition to the recently amputated limb. As the provider of

mobility training, the provider who prescribes assistive devices, and the provider who

recommends discharge destination, a physical therapist should be able to intelligently

advocate for the most appropriate discharge destination and deliver appropriate

physical therapy to maximize rehabilitation potential.

Significant progress was made toward the goal of discharge to home and

functional use of the rear-wheeled walker. The strong intact limb and upper extremities

allowed the patient to achieve minimum assistance ambulation with a rear-wheeled

walker, but only with short distances. While not identified in the initial physical therapy

barriers to rehab, the patient’s ultimate level of function was limited by prior level of

function and body habitus. Patient education on glycemic control and the

biopsychosocial screening were initiated in the first days of his hospital stay, but no

mention of a regimented weight loss or lifestyle modification plan could be identified by

this researcher in the acute, subacute, or outpatient chart review of the patient. The

only barrier to rehab listed for the initial physical therapy evaluation was DM, which was

in reference to wound closure. With demonstrated good muscular strength but a lack of

endurance, the patient was exhibiting a finding commonly documented in children and


the general public: a high BMI is positively correlated to muscle strength and negatively

to muscular endurance (Hasan, Kamal, & Hussein, 2016; Kim et al., 2015).

The treating therapist also made note of the duration of PT intervention

beginning on Day 12. On Day 12, and for the rest of his care in the hospital, the patient

was able to tolerate 60 minutes of physical therapy. The standard for admission to

inpatient physical therapy, or “rehab”, from acute or subacute care is the ability to

tolerate three hours of rehabilitation every other day. However, in this case the patient

was discharged to home as his tolerance increased to one hour and he was able to

achieve household distance ambulation. The patient’s progress, what would benefit the

patient most, and the patient’s own wishes to return home complicate the decision of

discharge destination. There is evidence that patients with a dysvascular amputation

who are discharged to home after acute care suffer greater mortality and morbidity due

to a combination of poorer medical management of underlying disease processes and

all-cause re-hospitalization (Dillingham & Pezzin, 2008). As discussed in Outcomes, the

case patient fell onto his unprotected wound a day after discharge home and was briefly

re-hospitalized. The fall onto his residual limb supports the point that the patient

should have been discharged to inpatient care following the initial hospitalization, and it

has been found that a stay in a comprehensive inpatient unit at anytime during the first

year after dysvascular amputation is of benefit for mortality and mobility (Czerniecki et

al., 2012).

This case study demonstrates the administrative difficulty in managing the

obese, dysvascular patient with an amputation. After acquiring the stamina to perform


one hour of physical therapy per session, the patient was discharged home based on the

FIM household exception and his wishes, just as he was meeting the criteria for

admission to inpatient rehabilitation. The disconnect between his open kinetic chain

strength and ambulation tolerance demonstrates need for determining rehab potential

or barriers to rehab beyond tissue healing timelines. Upon discharge from outpatient

physical therapy, nearly six months after being admitted to the hospital, the patient’s

weight was still limiting K-level ambulation. Furthermore, the fall onto his exposed

residual limb while getting around his home with an assistive device one day after

release from the hospital should add scrutiny to the common goal of “discharge to the

highest level environment.” In cases where discharge to the optimal physical therapy

environment is challenged administratively, and negative health behaviors such as past

tobacco use, increased BMI status, and uncontrolled DM are part of the patient profile,

a greater emphasis on educational and lifestyle interventions in the acute or home

health setting may be appropriate to address the need for lifestyle modification.

Limitations of this case report include the retrospective chart review that

required reconciliation of notes from multiple specialties and notes from multiple

physical therapists. Documented interventions such as “balance”, “curb training”, and

“lateral movement” leave room for interpretation as to what specific intervention

occurred. While his plan of care across multiple specialties was documented during his

hospital and outpatient care, there was no information regarding his care at home other

than delivery of the prosthetic limb.


The conflicting evidence on BMI and its influence on the rehabilitation potential

of the patient with a dysvascular amputation is an important finding of this case report’s

literature review. Intuitively it is expected that body mass is tied to mobility, and that

assumption is true in the general public (Alley & Chang, 2007). However, a dysvascular

patient who has undergone a medically necessary amputation is now part of a smaller,

but still homogenous, group of individuals who are generally over 60 years of age,

demonstrate lowers levels of activity, and may have been suffering from cardiovascular

or other systemic disease for a long period of time. In this paradigm, it seems that

factors, other than BMI have a greater, more predictable impact on rehabilitation

potential.

Research identified for case report consistently shows that discharge to

comprehensive inpatient rehabilitation within the first year of amputation improves

mobility and mortality outcomes (Czerniecki et al., 2012; Dillingham & Pezzin, 2008). A

potential barrier to implementing this information is the tendency for patients to

request to return home and the level of medical acuity required to authorize inpatient

rehabilitation. Therefore, the physical therapist mindset for patients with amputations

needs to be similar to that with patients who have had a major medical event such as a

stroke. Rehabilitation decisions made immediately post hospitalization, and up to one-

year post amputation, may determine the ceiling of a patient’s rehabilitation and help

determine long-term mortality. As the primary contributor to the discharge destination

and the primary provider of mobility training to patients, a physical therapist can use


the existing body of research to advocate for and deliver appropriate physical therapy

intervention early in the patient’s plan of care and maximize rehabilitation potential.


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