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.