Stepwise Rehabilitation of the Triple Amputee Combined With Dysfunction of the Sound Limb
A 36-year-old man, who had splenectomy history due to trauma when he was 10 years old, visited the emergency room due to abdominal pain and vomiting on November 15th, 2010. He developed septic shock, so norepinephrine was applied for 5 days and peripheral ischemia of four extremities occurred. The patient underwent right knee disarticulation, left trans-femoral amputation and right elbow disarticulation on December 21th, 2010 (). He underwent skin flap operation of the right knee and left hand skin defect area on January 10th and 24th, 2011, and joint range of motion exercise and isometric exercise were performed. After the operation wound healing, he was admitted to the Severance Rehabilitation Hospital for prostheses measurement and rehabilitation on March 5th, 2011.\nConsidering the patient's young age, we set the final goals as gait, independency of ADL and going back to work. During the initial stage of the rehabilitation program, we focused on upper extremity function improvement and independency improvement on wheelchair level activity. After this short-term goal had been reached, gait training and car training were planned. Finally, before discharge, we planned to do computer training since he used computer a lot for his marketing business.\nBefore admittance to our hospital, the patient had a psychiatric consultation due to depression. There was no objective data for the depression score, but he showed clinically meaningful level of depression, so he took antidepressant medication. After symptoms improved, medication was stopped, and he no longer took the pills after being admitted to our hospital. Since his limb was amputated when he was on shock status, he finally recognized amputation after recovering from the shock. This made him feel negative body image of himself, and thus he went through anorexia and sociophobia. But, after admission to our hospital, he accepted his situation and got over with negative body image and wanted active rehabilitation. We helped him get actively involved in the rehabilitation program by inspiring a sense of accomplishment from stepwise functional recovery. Sometimes he felt the depression, but he did not want to take the medication. Continuous support from his family and inducing motivation made him feel better, so he could actively participate in the rehabilitation program. The patient's motivation was increased particularly by setting short-term goals that considered the patient's condition and by sharing the rehabilitation program with the patient. When he was admitted, the stump sites were relatively fine: right elbow disarticulation site was club shape and stump length from acromion was 32 cm; right knee disarticulation site was cylindrical shape and stump length from great trochanter was 44.6 cm; and left trans-femoral amputation site was conical shape and stump length from great trochanter was 33.3 cm. Skin condition and soft tissue shrinkage of all three amputation sites were relatively fine with no bony spurs or neuroma. There had been phantom pain and phantom sensation on stumps, but they decreased during gait training with the prostheses. Also, his left hand was 2nd, 3rd, 4th, and 5th distal interphalangeal joint disarticulation status, skin flap site was fragile, and there were blisters due to friction during the rehabilitation program. This condition of the sound limb made the rehabilitation program more difficult for the patient. At first, passive range of motion of the left wrist joint flexion was 40° and extension was 30°. In addition, 1st web space length was 2 cm, but we could achieve 4 cm of 1st web space after left hand stretching exercise (). Due to the contracture and weakness of the left hand, he could not do opposition before intensive training, however, he was finally able to do tip pinch using thumb and 2nd finger when he picked up something like a tissue. Manual muscle power test (MMT) of upper extremities on admission showed grade 4 on both shoulder joints in terms of flexion, extension, abduction and adduction, grade 3 on the left elbow and wrist joint in terms of flexion and extension, and grade 2 on the left hand in terms of flexion and extension. MMT of lower extremities on admission showed grade 3 on both hip joints in terms of flexion, extension, external rotation and internal rotation. After strengthening exercise, the left hand muscle power improved to grade 3, and the hip joint muscle power improved to grade 4 together with strengthening exercise and Cybex (Cybex 770+TMC) isokinetic training. Since he had stayed in the intensive care unit (ICU) for a long time, deconditioning and impaired pulmonary function also made his rehabilitation program more difficult. Vital capacity (VC) on admission was 3,480 mL (75.9% of predictive value) and peak cough flow (PCF) on admission was 450 mL. We guided him to buy an Ambu bag and trained him to do air stacking exercise, and finally, VC/PCF reached to 5,300 (115%)/650.\nDuring the 2nd week of the program, he was fitted with the right elbow disarticulation prosthesis. Elbow disarticulation socket, elbow flexion device control unit, elbow lock control cable, outside locking hinge, constant friction wrist unit, and figure of 8 harness were used. Artificial hand was used for cosmetic reasons during work, and bimanual activity training was performed. Even though he was originally right handed, we planned to make sound left hand as the dominant hand at first. His left hand function test was impossible due to the contracture and weakness on admission, but after training, pinch power showed 1.8 kg and Box and Block Test showed 33 points. However, there still remained some limitations to using the left hand as the dominant hand. First, the motion of the left wrist was limited as flexion 50° extension 50°, and skin condition was still thin and fragile. Second, due to remaining contracture, it seemed hard to bear his weight with the left hand, even though the left hand function was recovered. So, we changed our plan and decided his right hand as the dominant hand and trained each hand the same proportionally. Before intensive gait training, we measured wheelchair (MIKI U2; MIKI Korea, Daegu, Korea), did ADL training with prosthesis on wheelchair level, and made him improve independency and use walking aid more efficiently after. Sitting balance was good on admission but ADL training had not been done; so Functional Independence Measure (FIM) score of self care subunit was 6 points. So intensive ADL training was done and he finally could don upper prosthesis by himself using pull over sweater method. But, since dressing, eating and grooming still needed minimal assistance due to the impaired hand fine motor function, ADL training was done consistently until discharge. On occupational therapy, ADL training, such as spoon use, drinking with a cup, and buttoning and unbuttoning, was done and as a result, follow-up FIM score improved to 12 after 1 month and 25 on discharge. He was able to do upper dressing by himself, although it took 2 minutes and 30 seconds. We decided on the dominant leg as the right leg because of the longer stump length on the right side. We also decided on the height of 162 cm, which is shorter than his original height of 167 cm, to improve stability by lowering the center of gravity. The patient was fitted with right knee disarticulation prosthesis with end bearing socket, polycentric knee, endoskeletal shank and dynamic solid ankle cushion heel (SACH) foot on the 6th week of the program. In addition, he was fitted with left trans-femoral amputation prosthesis with quadrilateral socket, polycentric knee, endoskeletal shank and dynamic SACH foot on the 8th week of the program. Parallel bar weight shift training was started on the 9th week of the program. On the 10th week of the program, he started gait training with anterior walker without wheels, and he finally could walk 100 m using anterior walker without pause (). After starting intensive gait training, we analyzed the gait pattern and found that the left leg was dragged on swing phase. We shortened the left leg by a quarter inch and it improved the gait pattern. During rehabilitation program, doctor, physical therapist, occupational therapist, and prosthetist regularly met twice a week and discussed the prostheses fitting, hand function recovery, and gait pattern. This multidisciplinary team approach made the patient more motivated and rehabilitation program more efficient.\nCane gait seemed to be difficult for him due to the left hand contracture and weakness. We decided to gait with a walker indoors and use an electronic wheelchair outdoors. Family education, such as stump site management, was done and occupational rehabilitation program, such as ADL training and computer training, was done for going back to work. We rented a car for disabled people and trained him to move to the driver's seat and drive short distance with electronic wheelchair. And we also gave him information about repair costs of a car for the disabled. He could use a computer mouse by himself, but since the typing speed was too slow, a universal cuff was used for faster speed. On discharge, ADL independency was increased up to 90 point of FIM score and 56 point of Modified Barthel Index score, which were 48 point and 20 point on admission, respectively ().\nFunctional level status also improved. He was at absolute bed rest status on admission, but at the time of discharge, he could come to sit by himself and gait with anterior walker. After discharge, we follow up on him constantly. He is successfully goes back to work using an electronic wheelchair and performs almost all of ADL by himself without help on wheelchair level.