Therapeutic skills case study 9
This is a draft as Jill said we will be going through this scenario in a seminar soon so I will add to this then.
You are a physiotherapist working on a vascular surgical ward. A 65 year old gentleman has recently had a left below the knee amputation as a result of peripheral vascular disease and diabetes mellitus.
Demonstrate a post operative physiotherapy management plan to prevent post operative secondary complications and promote functional recovery of this patient (prior to out of bed mobilization).
Teach this patient to transfer from bed to wheelchair
With an emphasis on the shoulder (glenohumeral joint) and the elbow of the leading arm, analyse the above transfer.
Notes on this case:
Peripheral vascular disease:
Peripheral vascular disease (PVD), also known as peripheral artery disease (PAD) or peripheral artery occlusive disease (PAOD), is a collator for all diseases caused by the obstruction of large peripheral arteries, which can result from atherosclerosis, inflammatory processes leading to stenosis, an embolism or thrombus formation. It causes either acute or chronic ischemia (lack of blood supply), typically of the legs. One of the causes is diabetes mellitus.
Diabetes mellitus
Diabetes mellitus, often referred to as diabetes, is a syndrome resulting in abnormally high blood sugar levels (hyperglycaemia).Blood glucose levels are controlled by chemicals and hormones in the body, including the hormone insulin. Diabetes mellitus refers to the group of diseases that lead to high blood glucose levels due to defects in either insulin secretion or insulin action. All forms of diabetes are treatable with insulin but there is no cure. Injections deliver insulin, which is a basic treatment of type 1 diabetes. Type 2 is managed with a combination of dietary treatment, medications and insulin supplementation.
Below the knee amputations
This is called a transtibial amputation and is one of the most common types of amputation. Surgeons try to preserve the knee joint whenever it is practical to do so and will fashion the stump at the lowest practical level. Very short stumps make fitting a prosthesis extremely difficult and very long below-knee stumps are prone to circulation problems.
Things to consider:
A rigid dressing will be in place on the stump for 10-14days after surgery.
Exercises are important to prevent contractures.
Also certain posititions should be avoided to prevent contractures,
Such as- hanging the stump over the side of the bed, sitting in a wheelchair with the stump flexed, placing pillows under the hip or knee, placing a pillow under the back and curving the spine, lying with knees flexed, placing a pillow between thighs and crossing legs over.
Introduce yourself to the patient
Wash hands if you are going to touch the patient
Explain to the patient that exercises need to be done in order to increase circulation and prevent muscle shortening (contractures).
Gain the consent on the patient to go ahead
Section one
Post operative exercises:
The unaffected leg-
Exercises need to be done on the unaffected leg as the patient has not been able to get out of bed so needs to maintain strength and circulation in this leg.
Exercises would include:
Plantar and dorsiflexion of ankles (10 times)
Flexing knees and hips towards the trunk (10 times)
Tense hamstrings and push knee down against the bed (10 times)
Straight leg raises (5-10 times)
Tense glutes to relieve pressure exerted on buttocks (10 times)
The affected leg-
(I asked Jill what the patient would be able to do with the amputated leg and she said we would go through it in class)
My research has found that since the amputation is below the knee that the usual quad and hamstring exercises would apply
I.e straight leg raises,
tensing hamstrings,
lying on front and stretching the quads by raising the stump,
adduction and abduction stretches of the affected leg,
attempting to bend the knee
(However, I will revise this list once we have gone through it in class.)
Section two
Teaching the patient to transfer from bed to wheelchair
(Again I am unsure if these transfers are correct so I will alter them accordingly)
Transfer 1
Using a leg pivot transfer
A single-leg pivot shift transfer involves having the new amputee stand on the sound limb and turn their body in order to comfortably sit onto the wheelchair. Often, especially if the individual is weak or unsteady, this type of transfer needs to be done with the assistance of a therapist or nurse.
Transfer 2
Using a sliding board to transfer
As shown in the diagram
Ask the patient to slide/shuffle to the edge of the bed
Put the sliding board in place, ensuring the bed is at the same level as the wheelchair, and teach the patient to take their weight on the unaffected leg and the arm that is on the bed and then slide over on the board into the wheelchair reaching for the wheelchair arm for support. Then lower themselves down into the wheelchair.
Section three
Functional analysis
The shoulder and elbow of the leading arm during the transfer from bed to wheelchair
As I am unsure which transfer Jill and Anne will be teaching us I do not know what action the arm will be doing so cannot do the functional analysis until we have gone through this in class.
Structure for the functional analysis:
describe the starting position
break the movement down into phases
discuss muscle activity, planes, mechancial principles and forces
describe the finishing position
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