10-Week Physical Activity Program for a

Hypertensive Obese Adult

Abstract
Obesity is a chronic health problem affecting increasing numbers of people
worldwide and is now recognized as a global epidemic. Many serious medical
problems, including hypertension which is a predisposing factor for
cardiovascular disease, are associated with obesity. In adults, the occurrence
of hypertension rises with increasing body weight. [1] This study outlines the
case of a hypertensive obese man with BMI of 30 kg/m 2. The BMI test was
used to measure the percentage of his body fat. [2] [3] His blood pressure was
under good control using medication.
Both aerobic (endurance) and muscle strengthening (resistance) exercises
were included in his physical activity program. [4] [5] [6] Before and after each
exercise session, a sphygmomanometer was used to measure blood pressure
(BP) in order to avoid the risk of a hypertensive event by stopping exercise if
BP became too elevated. [7] Exercise programs of this type have been shown to
result in beneficial effects for the obese adult. After ten weeks of matched,
evidence-based intervention, Mr X demonstrated a loss of weight and
improved cardiorespiratory and muscular fitness. He no longer had pain in his
back or knees because of his weight loss.

Introduction 

Client Characteristics
Mr X was a 45-year-old man with a history of hypertension that was under
good control using medication. He worked as a taxi driver for eight hours per
 day. He smoked one and a half pack of cigarettes per day and had done so for
over 20 years. His father died from a heart attack at age 60. He had no signs or
symptoms of cardiorespiratory disease. He had just completed a medical
check-up and the report showed body height of 173cm and body weight of
88kg, total cholesterol of 8 mmol/L and fasting glucose of 5.4 mmol/L. His
BMI was 30 kg/m2, his hip circumference was 40 inches (102 centimeters) and
his waist girth was 47 inches (119 centimeters). [2] [3] [8] 

Case Presentation
Mr X had many risk factors; [8] [4] [5] 

 Cigarette smoking
 Hypertension (even though his blood pressure was under control with
medication)
 Hypercholesterolaemia
 Obesity - his BMI had recently been calculated as 30 kg/m 2 and was
regarded to be obese according to the WHO’s International Classification.  [2] [3]
 Sedentary because of the non-physical nature of his job and daily
activities
Mr X did  not have a family history of heart disease that require specific
screening because his father’s heart attack occurred after the age of 60. His
fasting glucose was normal. Although he was considered young at less than 45
years old, he was in the moderate risk category because he did not have any
signs or symptoms of cardiorespiratory disease but was sedentary. He was
concerned about his body shape and about the symptoms of the overweight
such as joint pain. [8] [9] 

Management and Outcomes

Mr X was started on a program of regular aerobic and muscle strengthening
exercises as a primary preventative measure against cardiovascular events.
[8]
 To start him on low- to moderate- intensity physical activity, further medical
work-up and exercise testing was not necessary (although a sub-maximal
exercise test of his cardiovascular fitness would have providded a
comprehensive appraisal of his condition). Before embarking on a vigorous
exercise program after completion of the initial ten week program, however,
he would need further medical clearance from specialists according to the
recommendations from the American College of Sports Medicine: Prescribing
Exercise to Obese Adult Program. [8] [10] [4] [11] [5] [12]
Mr X was sedentary therefore he had to build up his physical activity targets
over several weeks, starting with 10-20 minutes of physical activity every other
day during the first week or two in order to minimise potential muscle
soreness and fatigue (which could negatively affect compliance with the
program). If he had demonstrated difficulty completing the initial level, the
physiotherapist would have reduced the intensity/duration. If Mr X had found
the initial level very easy, the physiotherapist would have increased the
intensity/duration until it felt somewhat hard.
Walking is the most commonly recommended type of physical activity.
Weight-bearing physical activity may be difficult for an obese man, however.
Gradually increasing moderate-intensity physical activities was therefore
encouraged. [4] Based upon Mr X's information, the program was designed to be
of moderate intensity. This meant he exercised for at least five days a week at a
moderate intensity. Considering he had four risk factors and had led a
sedentary lifestye up to that point, his target heart rate was kept at about 40%
of his VO2R.[11] [5] To calculate this, his resting HR and age-predicted HR max were
put into the Karvonen equation and the desired intensity was between 40%
and 50% of that number. [13] From this equation, Mr X's target HR was
calcualted and then monitored throughout his workouts to determine if an
increase or decrease in intensity of any exercise component was required.

Program
 Aerobic Exercise -  Five times per week for 20 minutes. [4] [5]

 Warm Up: 5-10 minutes of dynamic stretching of the entire body in order
to increase Mr X's heart rate 
 Walking on a track or treadmill for 20 minutes [10] Mr X was instructed to
walk for one minute on an incline to be increased followed by one minute at a
leisurely walking pace. He was not able to jog because of the pain in his joints.
As his fitness improved, the duration and intensity of the walking were
increased progressively in a variety of ways
 Cool Down: 5-10 minutes of slow walking to gradually decrease his
elevated heart rate but still keep his muscles moving to avoid cramping
 Stretching: 10 minutes of a variety of static stretches that engage the
whole body, especially his legs
Resistance Training:[4] [6] Two times per week after the aerobic exercise. The
goal was to improve Mr X's muscular endurance and technique. Each exercise
required approximately one minute of rest in between each set. The program
was designed so that while one muscle group was resting, another could be
worked by alternating the exercises in each set.

 Leg extension: 3 x 10
 Leg curls: 3 x 10
 Bench Press: 3x12
 Row: 3x12
 Dumbbell Shoulder: 3x 12
 Tricep kickbacks: 3x 12
 Bicep curls: 3x 12
 Abdominal crunches: 4x 10
 Side crunches: 4x 10
 Back extensions: 3x10
 Cool Down/Stretch: A variety of static stretches focusing on the muscles
that were exercised

Outcome
After ten weeks of the above exercise program, Mr X demonstrated some
weight loss with the BMI test showing a loss of 5 kg/m 2. His cardiovascular
endurance had improved and his responsiveness to antihypertensive
medications and increased. [4]

Discussion
Studies have shown that physical activity provides many health benefits. Being
physically active and fit reduces obesity-related chronic diseases and decreases
the risk of premature death. In this case study, Mr X demonstrated a loss of
weight after ten weeks of physical activity.
The authors of several systematic reviews have consistently reported a
decrease in Systolic Blood Pressure (SBP) of about 1 mmHg per kg of weight
loss with follow-up of 2 to 3 years. [14] [15] [16] [17] There is also attenuation in the
longer-term with a decrease of about 6 mmHg in SBP per 10 kg of weight loss.
Intervention programs appropriate for obesity-hypertension combine diet,
physical activity and behavioural modification, aiming to achieve long-term
changes in health-related behaviours. Aerobic exercise can reduce weight and
BP. In a meta-analysis that included assessment of ambulatory BP, it was
reported that in programs lasting 4 to 52 weeks (with physical activity as the
only intervention) aerobic exercise reduced BP by 3/2.4 mmHg. [18]
The effects of resistance training on BP have also been studied. [18] The
estimated decrease in was similar to the effects of aerobic exercise, although
not statistically significant for SBP and without statistically significant weight
change.
In conclusion, a moderate intensity exercise intervention produced
improvement in body weight, BMI, waist and hip circumferences and blood
pressure.
Related articles
Mr C: Amputee Case Study - Physiopedia Title Mr C: Amputee Case Study Abstract
Mr. C is a 56-year-old Caucasian male who underwent a left TTA. He sustained an anterior
myocardial infarction (MI) while in recovery after the amputation and was also newly
diagnosed with Factor V clotting disorder. His amputation occurred in another facility and
he was transferred to our hospital for rehabilitation. Mr. C worked very diligently in
physical therapy both pre prosthetic and during prosthetic gait training. Mr. C also had
very strong emotional issues with the loss of his limb but in the end he was able to accept
his amputation and was a successful prosthetic user. Key Words Trans-tibial,
cardiovascular, grief, instability, crutches, prone lying Client Characteristics Demographic
Information: Mr. C is a 56-year-old Caucasian male who is newly widowed, his wife
expired one month ago from an MI. He was married for 33 years. He has two children,
twin sons who are 29 years of age. His parents are deceased and he has two brothers and a
sister. He is a Methodist and is very involved in his church. Primary language is English.
He is unemployed and is a retired Private Investigator. He graduated from Virginia Tech
and has a Bachelors degree in Business Administration. Co-morbidities/Medical history:
DM, PVD, osteoarthritis and HTN, knee surgery for cartilage repair, with chronic
instability right knee, LBP, left ulnar nerve transposition in 2001, Hyperlipidemia, CAD
with ejection fraction of 25-30%, cardiac catheterization and stent placement. Previous
functional status and treatment: Mr. C was independent in all self-care activities prior to
his amputation. He ambulated without an assistive device and used his knee brace. He was
seen previously for Low Back Pain (LBP) with a successful treatment series. Examination
Findings He stated he is worried about not being able to perform the same activities after
his amputation, like helping out with the Boy Scouts. Long term goal: Independent using a
prosthesis with forearm crutches 500' in 12 weeks. Short term goals: Independent ace
wrapping, transfers in 1 wk. Prone lying for 2 hours/day, amputee exercise program x 30
reps, improve lower extremity MMT by one half grade, ambulate 25' with standard walker
with contact guard assist in 2 wks. Self Report Outcome Measure: Houghton Scale of
Prosthetic Use-Initial score 0 and discharge a 7 [1] Physical Performance Measure:
Functional Independence Measure-initial score 81 discharge score 105 Body Functions:
Cardiovascular Blood pressure 117/78 Pulse 67 Pain residual limb pain-2 occ phantom
sensations. Integumentary Residual limb healing, staples intact, bilateral dog ears.
Sensation intact residual limb, Right leg to Semmes Weinstein monofilament.
Musculoskeletal Height 5'11" Weight 204lbs BMI is 28.5-overweight. Manual muscle test
NL except:Left shoulder abd 4+,Right wrist ext 4+ Bilat Hip flx 4- Left knee ext 4+ ROM
NL including Thomas Test. Neuromuscular Sitting balance good Standing balance poor.
Stand pivot transfers,contact guard assist. Bed mobility independent.Gait not tested.
Impairments-Motor Function,Locomotion and Balance Associated W/Amputation.[2]
Activity Limitations- Right knee instability,recent MI Participation Restriction- none
Environmental Factors-2 story home,bath,bedroom on 2nd floor,steps to enter Clinical
Hypothesis Mr. C is a 56-year-old diabetic with a recent left TTA (trans-tibial amputee)
with a newly diagnosed clotting disorder. He presents as an excellent rehabilitation and
prosthetic candidate. He is cooperative and motivated despite his very recent loss of his
wife of 33 years. In general he is overweight, doesn't exercise regularly but has good
glucose control. He needs to improve overall strength and endurance, heal and shape his
residual limb to prepare for the prosthetic fitting. Due to his recent MI, he will need blood
pressure and pulse monitoring while performing pre-prosthetic and prosthetic activities.
Intervention Treatment began with amputee exercises as Mr. C did not have his right knee
brace and was unable to ambulate. Prone lying, gradually increasing the time. Upper body
strengthening and UBE for aerobic conditioning. Ace wrapping his residual limb.
Progression by adding repetitions, weights or time to the activity. Patient education in:
glucose control, weight loss and aerobic exercise. An intervention that is not commonly
performed by physical therapists but was crucial to Mr. C, was talking about his losses. He
was a very verbal person and more than one session was spent listening to him and
actually letting him cry. Losing his limb, his wife and discovering that he has a clotting
disorder was very stressful and venting was an important intervention for this particular
patient. A fellow amputee provided additional support by visiting him during therapy.
Prosthetic training began as an outpatient. He was fitted with a Triple S (silicone suction
suspension) total contact socket with audible locking pin and a College Park Tribute foot.
He quickly mastered the balance, weight shifting and step in place preliminary exercises
with the prosthesis. Gait began in the parallel bars, using a three-point gait pattern and
progressing to a four-point and then two point pattern. He used forearm crutches in a two-
point gait pattern outside the parallel bars. He achieved independence on ramps and stairs
and floor transfers. Outcome Mr. C achieved all of the established goals and after intensive
gait training was seen every two weeks for follow up sessions for 3 additional visits. Gait
training on uneven terrain was accomplished and he then progressed to a single crutch.
Currently he is a community ambulatory and wears his prosthesis all day, but continues to
ambulate with a straight cane due to his knee instability on his contralateral limb. He can
walk short distances or in his home, without the cane. He has had no skin break down on
his residual limb. Mr. C continues to volunteer with the boy scouts and participates in
weekend camping trips. Discussion Mr. C was a very motivated patient and despite all his
medical issues conquered his impairments, worked through the grieving process and is a
functional community prosthetic wearer. I think the most notable difference as compared
to all my other amputee patients was his need to discuss his amputation and actually cry
and show his feelings while in physical therapy. This was difficult for me as I had never
had such an expressive patient and I learned to work on my listening skills! In the
literature the Amputee Coalition has the most in depth discussions, services and education
about grieving after limb loss. They offer support groups throughout the country and
provide an excellent magazine with helpful articles.[3] The impact on clinical practice
would be to draw awareness to be sensitive to the loss that all our amputees experience but
to provide hope and encouragement that they can improve and function in the
community.Healthy Mom, Healthy Family (Exercising with Multiple
Morbidities) - Physiopedia Abstract A patient with asthma, Type II diabetes,
hypertension and obesity presented with right lower limb cellulitis. Multiple surgeries
were performed and she was left with two large wounds medially and laterally extending
from her ankle up to her mid-calf region, a stiff ankle and an oedematous foot. It was
initially presumed that this was the type of patient that would not be very physically active
and that she would be difficult to motivate to participate in regular exercise. This
assumption was completely incorrect. Once this patient understood the clear health
benefits of physical activity to each of her different conditions and realized that being
healthy would keep her out of hospital and with her children, she did not need any other
input and was able to successfully push herself to exercise harder as the program
progressed with marked results. Introduction First impressions and judgement of a
patient’s motivation to exercise can often be incorrect. A patient’s internal motivation can
come from many different areas rather than one specific source. Case Presentation Mrs. X
was a 46 year old female patient presenting with right lower limb cellulitis. She underwent
four incision and drainage surgeries and was transferred for rehabilitation two weeks later.
She had multiple co-morbidities such as obesity (BMI = 30), asthma, Type II diabetes and
hypertension. Medication She used an inhaler as needed, was on a sliding scale for insulin
injection and was on medical treatment for her blood pressure. She had a myocardial
infarction in 2011 but no complications or complaints since that time. Tests and
investigations Doppler of right lower limb – Nil of note Social History Mrs X was married
with five children. She lived in a four room house with electricity and running water and a
toilet outside the house. She was the sole breadwinner of the family and her work entailed
walking to a school our hour from her home to sell food. Clinical presentation Mental
state: Alert and responsive Chest: Clear Blood Pressure: 140/80, Pulse 90 and Respiratory
rate: 20 Wound on medical and lateral side of ankle extending 15cm up leg ROM: Full
except for Right ankle 0° – 91° Muscle strength: Grade V except for right ankle Grade III
Oedematous right foot – pitting The patient was independently mobile with a pair of elbow
crutches and also independent in all ADLs Endurance was fair Management and Outcomes
The care plan was to increase Mrs X's physical activity levels gradually, introduce strength
exercises as well as endurance training.[1] Her fitness was assessed using a modified Two
Minute Step in Place test as her ankle and mobility with elbow crutches made other tests
difficult to implement. She was unable to reach the recommended tape height due to
difficulty weight bearing on her right ankle so the height was lowered to a more
comfortable level. She was able to achieve a score of 80. Exercise plan A daily walking
exercise program was introduced.[2] The distance and speed of walking was adjusted over
the 2.5 weeks of treatment [3] and stairs and ramps were included.[4] By the end of the 2.5
weeks, Mrs X was exercising for 30 minutes five days per week.  [2] She did a warm up of
marching on the spot as comfort allowed.[5] Strengthening exercises of the upper limb
were done using 2 kg then 3 kg weights. [4] [5] Exercises included bicep curls and elbow
extensions, 2 sets of 20 repetitions (increased from one set initially). The quads bench for
quadriceps and hamstring strengthening exercises was used instead of squats and lunges
due to the patient's stiff ankle. [4] [5] Hip abduction with ankle weights was done in side
lying. She was given two 2 kg ankle weights to use at home. The strengthening program
was done 2 – 3 times per week.[4] All weights added were low so as not to add too much
stress with regards to her blood pressure and were only added after her blood pressure was
stable for 2-3 days. A motivational interview was done with Mrs X during which she easily
identified where exercise could be added to her day. She was even able to come up with a
solution for making her own weights for her upper limb exercise program at home. She
was determined to continue and was keen to include her husband and children in the
program. Outcome Before starting the exercise program, Mrs X's systolic blood pressure
would regularly spike to 140–150mmHg. After 3-4 days of the walking program her blood
pressure stabilized and for two weeks, she maintained a systolic pressure of 110–
120mmHg. Her fasting blood sugar levels were initially spiking between 15 and 20
mmol/L. This was always corrected prior to exercise. Following exercise, her blood sugar
levels were more stable, maintaining a level of between 7-10 mmol/L. Normal fasting
blood sugar levels for a diabetic person are 5–7.2 mmol/L.[6] There was also a report from
Mrs X regarding the fact that she hadn’t needed to use her insuin pump and that prior to
this program, she usually needed to use it in the type of weather we had been having. Her
score for the modified Step in Place Test increased from 80 to 120 steps. Her level of
breathlessness went from a level two to a level one. Discussion Mrs X was initially assumed
to be a difficult patient to implement an exercise program with because she was obese and
had more than two co-morbidities. However, once she started the program, she quickly
responded to the exercise and the health benefits were clear. She was able to feel and see
the benefits and became well-motivated internally. She had many reasons for changing her
habits, including the fact that she needed to care for her family and was unable to do so in
hospital. She also saw the need to include and motivate her family to participate in the
exercises with her. Even in her low income setting, she easily came up with a solution for
adding her own weights by taking empty 2-litre bottles of water or soda and filling them
with sand. Thus, given the right motivation at the right time, patients may only need
minimal advice and input to change their own lives. Mr. T. (right BKA): Amputee Case
Study - Physiopedia Title Mr. T. (right BKA) Abstract Mr. T. is a 64 year old male who
attended 2.5 months of intensive rehabilitation to learn to walk again after being immobile
for more than a year. Mr. T. was a diabetic whose right foot became infected after having a
wound on his fifth toe. Mr. T. as a result had a below knee amputation which resulted in
poor wound healing and another infection in his residual limb. He required debridement
of the wound and 3 months after his surgery his incision site had healed so that he could
begin walking again. Key Words Transtibial amputation, diabetes, multiple co-morbidities,
poor functional mobility prior to surgery Client Characteristics Mr. T. is a 64 years old
male who is on long-term disability. He was previously a heavy machine operator. He lives
in a two storey house with his wife and has no intention of moving. Mr. T's wife works full-
time and is not at home during the day. For the last year Mr. T. has been house bound and
falling several time a day. He was mostly sitting in his lazy boy chair at home on the main
level and even sleeping in it as he was too afraid to do stairs. Essentially he has been non-
ambulatory for about a year previous to his admission to hospital. In February 2015 Mr. T.
was admitted to hospital for a diabetic foot, which then became gangrene and as a result
he had a right below knee amputation at the beginning of March 2015. Mr. T. also has the
following co-morbidities: Diabetes Chronic Kidney disease (pre-dialysis) Obesity
Hypertension Hypertensive nephrosclerosis Peripheral vascular disease BPH Recurrent
falls CHF COPD Peripheral neuropathy Strokes (2008, 2014) Ex-smoker (50 pack year
history) Left rotator cuff tear (as a result of his falls at home) Previous to Mr. T's
admission to hospital he was receiving home care nursing to address his leg wounds
including the ones on his right foot. When he became febrile and the wound was becoming
worse the home care nurse suggested he go to hospital. Examination Findings As a result
of one year of immobility and a right BKA it took 3 people and a hoyer to transfer MR. T.
Patient was totally dependent on nursing staff for his self-care. The patient reported that
his goal was to be able to independently toilet himself, independent bed mobility,
ambulate with a rollator, be able to go up and down his stairs and to get onto his deck so
that he could BBQ. No contracture of his knees Decreased active range of motion of his left
shoulder Unable to sit unsupported Ax4 to stand with High Wheel walker, initially able to
stand 10 seconds. Patient was not able to hop on his unaffected leg. Poor healing of wound.
The prosthetist provided the patient with a gel liner that he was able to tolerate and it
helped to shape his residual limb) Strength testing demonstrated upper and lower
extremity strength as a 3/5 ICF Findings[1]: Body Function and Structures Primary: Lower
limb below knee Decrease strength and mobility Activity Limitations: Decreased bed
mobility Decreased ability to transfer bed to wheelchair Unable to ambulate Unable to
perform basic self care activities Unable to get in/out of house, unable to perform stairs
Participation Restrictions Unable to BBQ on outdoor deck in backyard Unable to get out of
home to visit friends in neighborhood Environmental Factors/Personal Factors The
patient wanted to return home asap. Not working. Clinical Hypothesis The patient had
multiple co-morbidities decreased mobility function prior to his amputation. Although the
patient according to the guidelines[2] is not a prosthetic candidate his motivation and his
realistic goals were worth pursing the possibility of him becoming an indoor ambulatory.
Therefore the team including the patient despite the difficulty of re-learning to ambulate
would proceed with have the patient fitted for a prosthesis. Intervention Mr. T. 1 to 2
hours of physiotherapy daily (5x/week) which consisted of: Wheelchair with amp board.
Transfer training Unable to lie prone due to his obesity. Exercises. Upper and lower
extremity and trunk strengthening, Stand with a high wheeled walker. Initially he could
not extend his hips and had a flexed posture and mainly was weight bearing through his
arms with the walker. Eventually he was able to maintain an upright posture and stand for
5 minutes. Prosthetic and stair training,[3] Mr. T. he didn't want to practice ambulating
outside He said his balance was poor after his 2 strokes and was going to rely on his
scooter, he was happy that he could walk indoors and did not want to progress his ability
to ambulate outdoors. Education including taking care of his prosthesis and socks,
don/doffing his prosthesis, home exercise program, residual limb care and proper foot
care of his left foot. Mr. T was morbidly obese and as a result education on getting up from
the floor was not attempted. It was felt that due to left shoulder injury and the patient
being overweight that he would not be able pull himself up to sit or stand should he fall. It
was suggested that he get a life line however the patient was only willing to carry a cell
phone on himself when he was home alone so that he could call 911 should he fall.
Outcome Mr. T. was able to get in/out of bed independently without assistance He learned
to don/doff his prosthesis independently, including understanding when to add socks. He
is still learning to take care of his prosthesis and socks (his wife has taken over this duty)
He was able to sit to stand independently He was able to ambulate 20 meters with a 2
wheeled walker and 10 meters with a rollator. He has a 2 WW on the second floor of his
home and a rollator on the main level so he can use the seat as a tray to carry drinks/food
for himself when he is home alone. Indpendent going up and down stairs using two
handrails (13 steps) Mr. T was discharged home July 10, 2015 with CCAC supports:
Personal support worker (PSW) 2x/day (maximum service provided) OT for home safety
and home PT to progress mobility, strength and balance. His lower and upper extremity
strength increased to 4/5 and his left shoulder range of motion for flexion and abduction
was 110 degrees. Discussion Mr. T had a total of 4.75 month stay in the hospital, 2.5
months of which were spent in intensive rehabilitation. If the guidelines were followed for
determining if Mr. T were a candidate for a prosthesis then Mr. T would have gone home is
a wheelchair and would have become depressed. His main goal was to get outside onto his
back deck and BBQ. I was not able to ascertain this however, in my discharge note to the
CCAC PT I communicated the patient's goal so that they could ensure that the patient was
indeed able to BBQ. Instead Mr. T was able to transfer independently and ambulate short
household distances which was his main goal. During the patient's stay in hospital he
became quite angry and combative with the therapist. Mr. T was also saying that he would
not be able to get back home and was depressed by this notion. Once a discharge date was
set concrete goals made his mood became better. It was requested by the team for Mr. T to
see a psychologist [4] while in hospital, however the doctor did not feel this was necessary
and since the referral can only be made by the doctor Mr. T did not receive this service. In
reviewing the literature it was certainly evident that a rigid or semi-rigid dressing is the
best evidence for reducing edema after surgery. [5]Our vascular surgeons currently use
tensor bandaging or compression bandages. Our prothetist uses the gel line to help with
the shaping process. I am currently unsure how to go about changing this. The Diabetic
Amputee 1: Amputee Case Study - Physiopedia   Title The Diabetic Amputee 1
Abstract An estimated 350,000 diabetics live in Jamaica, of which, approximately 350
amputations of diabetic feet done each year 5. Mr X, a 63 year old male diabetic to the
hospital’s physiotherapy department after undergoing a transtibial amputation. He 8
weeks rehabilitation programme: education, strengthening, balance training and gait
training with crutches. Poor and prolonged wound healing delayed prosthetic fitting. Mr. X
gained independence in ADLs with the use of crutches. Mr. X unfortunately defaulted for
management, but plan of prothesis is discussed. Key Words Transtibial Diabetic Balance
Endurance Ambulation Wound Client Characteristics Mr. X is a sixty-three year old male
patient who is known to have diabetes mellitus for greater than twenty year. Mr X is also
known to have hypertension for a similar duration of time. He is currently managed oral
medication. Mr X works as messenger for a large corporate organization. He carries out his
function as a messenger by driving a car. He sometimes operates as taxi as well. Mr. X
lives with his consort and 15 year old son in a 2 story home with modern conveniences. The
lower level of the house consisted of a bedroom, bathroom and kitchen which meant Mr X
did not need to go upstairs in the early stages post amputation Examination Findings Due
to poor wound healing and vascular compromise, and after developing gangrene of the
right foot, he had transtibial amputation in 2014. Complaints: Inability to use crutches,
pain and sensitivity at end of stump, poor wound healing and inability to work and
function independently. Objective: He ambulated with walker but tired easily and lost
balance. Nil contractures noted. Stump oedematous. Sitting posture normal. Dressing was
soiled. Residual stump length from inferior pole of patella to end of the stump was 25.5
cm, with a circumference of 41cm, ROM: actively within normal movement MMT: 4/5
throughout both lower limbs. Sensation – Sole (L) foot – impaired to light touch, pin prink
Proprioception - intact Balance: Sitting dynamic balance – Fair, Static standing balance –
poor. Endurance: required seated rested period after ambulating with the walker
approximately 8 metres and RPE of 15. ICF Body Structure & Function: Musculoskeletal
system: Decreased Muscle strength, Impaired balance, Pain Activity Limitation: Inability
to stand unsupported, inability to walk with crutches, unable to drive Participation
Restrictions: Unable to participate in instrumental ADLs such as cooking, cleaning,
gardening. Unable to work Contextual Factors Personal: +ve : Lives with wife and son who
are supportive +ve: Motivated to return to a vocation -ve: Frustrated about current status
Environmental: +ve home modern, -ve 2 story home, no ramps Clinical Hypothesis Patient
identified problems Inability to walk/climb stairs Inability to drive Inability to cook, clean,
wash at home Non-patient identified problems Pain Reduced muscle strength Impaired
balance Impaired cardiovascular endurance Poor wound healing Anticipated Problems:
Due his reduced muscle strength, and impaired balance may have difficulty using a
crutches effectively. He also has delayed wound healing delaying the time it takes to have
Mr. X use a prosthesis. He may required to use crutches for an extended period of time.
The possibility of a transfemoral amputation may become apparent due to delayed wound
healing. Intervention At the first session with Mr. X, he was educated on the intended
progression of rehabilitation. He followed a programme of strengthening for both lower
limbs and upper limbs starting with light resistance and progressing to heavier resistance.
Balance training was done using the parallel bars for static and dynamic work.
Purtubations in sitting and standing. Reaching outside his base of support in siting and
standing. Resistance bands were used following a progression from light to medium
resistance. Gait training using a walker was done, initially with minimal support of a gait
belt to just standby assist. Verbal cues were given to correct deviations. Distances walked
using the walker was gradually increased with each session to improve his cardiovascular
endurance. A Cycle ergometer was used to facilitate endurance training. When safe
ambulation was achieved using the walker, he was progressed to ambulation with axillary
crutches. This was done on level surfaces with assistance of a gait belt and progressed to
just standby assist. This took quite some time before a progression to using crutches up
and down stairs with assistance of a gait belt and standby support. Mr. X required
prolonged rest periods between exercises. Throughout the treatment sessions, Mr. X still
had problems with wound healing and superimposed infection. He was receiving dressings
three times weekly. Though not the purview of the physiotherapist, this was monitored and
the wound checked. Outcome After eight weeks of physiotherapy management, Mr X
showed improvement in many areas. He reported less pain in the residual stump and
increased ability to tolerate tactile stimulation at the end of the stump. There were
significant improvements in manual muscle testing of both upper extremities which
recorded a 5/5 on reassessment. The unaffected left lower extremity improved to grade 5/5
in knee extension, ankle dorsiflexion and plantarflexion. All left hip movements improved
to grade 5/5 except left hip abduction and adduction. There was also improvement in hip
flexion on affected right limb. All other muscle groups remained at grade 4. His
cardiovascular endurance showed marked improvement with Mr. X now being able to
ambulate greater distances. He would ambulate approximately 15 metres before needing to
rest, indicating an RPE of 13. Sitting balance at reassessment was good and standing static
balance improved to good. He was completely independent with the axillary crutches but
still standby assistance when using the axillary crutches up and down stairs. Mr X reported
improvements in some activities at home such as standing in kitchen to prepare meals,
bathing self and minimal house chores. He also reported that he had started to ambulate
in the community using the crutches. Discussion This 63 year old male who lives with wife
and 15 year old son. Mr X work includes driving and is the primary breadwinner of his
family. He presents with deficits in strength and balance and poor cardiovascular
endurance. Impaired wound healing and infection requiring antibiotic treatment affected
rehabilitation, delaying fitting of appropriate prosthesis, with the possibility of a
progression of the amputation to transfemoral[1]. Improvement in most parameters
including his independence with crutches, were noted. Mr X started to show signs of
depression. He withdrew from the community, became non-compliant with his home
exercise programme and missed some days to get the wound dressed[2]. Mr. X eventually
defaulted from therapy. This highlights two challenges. One being the complications of
uncontrolled diabetes and two, the lack of financial aid as hospital care is not free nor are
the prosthesis. Early walking aid devices [3] are beneficial but are not available here. Had
the opportunity presented for prosthetic fitting and subsequent post fitting rehabilitation,
Mr. X would have been recommended for a patella tendon bearing socket rather than a
total surface bearing socket to prevent direct pressure contact to the end of stump and
directly into the wound. The PTB is cheaper to manufacture and also easier to don and
duff, ideal for Mr. X [4]. Following fitting, corrections and alignment, he would have been
progressed to gait training in various environments. [5] Mr. H: Amputee Case Study -
Physiopedia Title Mr. H: Amputee Case Study Abstract This case study will focus on an
elderly gentleman Mr. H, a 92yo man admitted for inpatient rehab post left AKA for
critical ischaemia of the left foot. Mr. H initially was not for prosthetic rehab but during
the course of his admission he made significant gains in strength and functional
independence and broached the topic with the team. When considering the factors
necessary for prosthetic rehab as detailed in the Physiopedia 'Assessment of the amputee'
[1]resource, Mr. H met the criteria and despite the opposing factors of age and
comorbidity went forward with prosthetic fitting. Key Words Transfemoral, elderly, pre-
prosthetic, cardiac, comorbidities, equal-opportunity Client Characteristics Mr. H is a 92
year old retiree. Medical diagnosis: L trans-femoral amputation due to critical ischaemia
with distal tissue loss. Previous 4th and 5th toe amputations 3 months earlier with slow
wound healing. Comorbidities: Previous L 4th and 5th toe amputations, L popliteal bypass
and femoral endocardectomy, hypertension, type 2 diabetes mellitus, chronic obstructive
pulmonary disease, ex smoker, aortic stenosis. Previous care/treatment: Mr. H presented
to the emergency department of one of the large acute hospitals in our region with a
painful, reddened L foot that he was unable to weight bear on. He was assessed by medical
staff and was admitted for surgical review. Due to the acute nature of Mr. H's limb
deficiency the decision to amputate was made quickly with little chance to prepare Mr. H
for the reality of the amputation. Post-operatively Mr. H received standard care and his
wound healed well with no complications. Examination Findings Prior to his admission to
hospital, Mr. H was living alone in a unit he owned. Retiree, Scottish migrant and
widower, he had 3 supportive sons. He was independent with all PADLs and received
cleaning assistance and meals on wheels (meal delivery service). He was independent with
shopping. Despite his functional independence prior to his most recent hospital
admission, Mr. H had made the decision to enter residential aged care. Mr. H reported his
current issues to be difficulties in transferring, moving around in bed and managing daily
tasks. He did not complain of any pain in his stump, phantom pain or stump sensitivity.
He did however report phantom sensation of his amputated foot. From a psychological
perspective Mr. H scored low for depressive symptoms on the patient reported health
questionnaire. Main goals were for independent tfs and ADLs. Outcome measures DEMMI
27/100 (non-amp specific), AMPnoPro 14/43. Function: all bed mobility independent, SBA
for lie to sit using overhead bar, MA bed chair T/f to R, L=unable. Sit-stand 1xLA at rail.
OE: Mr. H had full AROM with 5/5 power bilaterally in his UL'S AND remaining limb. In
the amputated L limb Mr. H had 95° hip F, 30° Abd, 0° E, 10° Add. Distal his stump was
observed to be slightly bulbous but did not measure >5 cm increase in circumference.
There was no tenderness to palp of the scar which was fully healed and he was able to
tolerate end pressure without pain. There was some adhesion of the scar to the distal
femur. Clinical Hypothesis At the time of my initial assessment Mr. H presented quite well.
My main concerns were functional ones as Mr. H learned to rely on his remaining limb for
transfers and standing. His comorbidities were stable and he appeared to be dealing well
psychologically from the loss of his leg. When prosthetic rehab was broached I was initially
concerned with the increased energy expenditure for a man in his 90s with a history of
hypertension and vascular disease. My next thought was how we were going to be able to
prepare the stump to be able to fit a prosthesis. Intervention Mr. H was started with a
general strengthening program similar to those detailed in Engstrom [2]. He attended 2
hour long therapy sessions a day completing a mix of bed and functional exercises
including at least 15 mins of prone time. Mr. H commenced transfer training particularly
sit to stand and bed to chair. Initially Mr. H struggled with the anterior weight shift
necessary to complete a successful bed to chair pivot. Sitting and standing balance
training. After a few days of this Mr. H could complete 54 seconds standing without upper
limb support. After it was decided that Mr. H would be for prosthetic rehab he was
commenced with a stump bandaging routine then fitted with a shrink er (limited supplies
initially). We did not have access to an early walking aid but if I did this would have been
something I would have tried at this point to get an idea of Mr. H's ability to tolerate
weight through his residual limb. Throughout the whole process Mr. H was very receptive
and engaged in learning how to manage his stump. He was careful to wash his stump daily
and was diligent at checking his wound site especially once the shrinker was applied
Outcome I am currently still working with Mr. H and he will soon be discharged to a
residential care facility and will continue his prosthetic rehab in the outpatient setting Mr.
H is now able to complete all bed mobility, lie to sit, sit to stand and bed to chair transfers
independently. He is able to complete a full stand and pivot to the left and right when
moving from surface to surface and is able to get in and out of a car. Mr. H is hopeful of
returning to driving when he discharges however at this point he will need someone to
help get his wheelchair in and out of the car as he is unable to manage this independently.
Mr. H is happy with his discharge destination and feels that at his age that having support
around him is prudent. His family is very supportive of this decision as well as that to
explore prosthetic options. Mr. H did not have any falls or complications as an inpatient.
Mr. H has currently just been fitted by our prosthetist as is awaiting first fit Discussion Mr.
H's case is a relatively uncommon presentation in our rehab ward. Most of the patients we
have coming through with amputations are over 65 but most are trans-tibial and not as
physically able as Mr. H. Referring to the Physiopedia page 'Assessment of the
amputee'[1], most of these patients are fitted with prostheses purely to assist with
transfers. Mr. H was a difficult case as the drive for prosthetic fitting was patient centered
and would have significantly increased energy expenditure and overall physical demand
rather than lessened it. Keeping in mind the poor success rate of prosthesis use in older
amputees, 36% as reported by Ferry et Al 2013 via the 'Older people with amputations'
page on Physiopedia[3], the decision to support Mr. H in prosthetic rehab was even more
difficult. Coletta. E[4] also provides a good summary of the specific challenges of
prosthetic rehab for the elderly patient as well as detailing each stage of amputee
rehabilitation. Mr. H's case has highlighted the need for the use of more standardized
protocols and procedures in our rehabilitation unit.As a new service, documents and
guidelines are still being developed and as such each individual case has been considered
 in isolation from others. It would be more beneficial to draw on the wealth of resources out
there to create a standardized approach so that each patient is given equal opportunity

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