2nd Edition- 2016

Clinical guidelines for the pre and post operative

physiotherapy management of adults with lower limb
amputations

British Association of Chartered

Physiotherapists in Amputee Rehabilitation

NICE has accredited the process used by the British Association of Chartered Physiotherapists in Amputee Rehabilitation
Accreditation is valid for 5 years from 10 January 2017 and is applicable to the guideline processes described in Clinical
guidelines for the pre and post-operative physiotherapy management of adults with lower limb amputations.
Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
About this document: This document presents the updated, evidence based, clinical guidelines for
the pre and post operative physiotherapy management of adults with lower limb amputations as
described in the literature and expert opinion.
This document will update: Broomhead P, Dawes D, Hancock A, Unia P, Blundell A, Davies V (2006).
Clinical guidelines for the pre and post-operative physiotherapy management of adults with lower
limb amputations. Chartered Society of Physiotherapy, London.
Please refer to the guideline process document for full details of all methodology and processes
undertaken in the development of these recommendations.
All appendices referred to will be found in the process document.

Citing this document: Smith S, Pursey H, Jones A, Baker H, Springate G, Randell T, Moloney C,
Hancock A, Newcombe L, Shaw C, Rose A, Slack H, Norman C. (2016). Clinical guidelines for the
pre and post-operative physiotherapy management of adults with lower limb amputations. 2nd
Edition. Available at http://bacpar.csp.org.uk/

About BACPAR: The British Association of Chartered Physiotherapists in Amputee Rehabilitation

(BACPAR) is a professional network recognised by the Chartered Society of Physiotherapy (CSP).
BACPAR aims to promote best practice in the field of amputee and prosthetic rehabilitation,
through evidence and education, for the benefit of patients and the profession.

Comments on these guidelines and the additional documents should be sent to:
Sara Smith, BACPAR Guidelines Coordinator, Douglas Bader Rehabilitation Centre, Queen Marys
Hospital, Roehampton, London, SW15 5PN

Introduction
The first edition of this guideline was published in 2006. This evidence, the relevant recommendations and good practice
second edition seeks to integrate new scientific evidence and points (GPPs).
current best practice into the original recommendations and
create additional recommendations where new evidence has Throughout these sections the adults with lower limb amputation
emerged. may be referred to as individuals, amputees, patients or users.

These guidelines are not mandatory and BACPAR recognises Recommendations were developed and graded according
that local resources, clinician enthusiasm and effort, support to the level of evidence (Appendix 8). After each
from higher management, as well as the rehabilitation recommendation the letter in brackets refers to the evidence
environment in which the practitioner works, will influence the grade allocated (Appendix 13).
ability to implement recommendations into clinical practice.
Where a number of different evidence sources were used to
CPD activities: develop a recommendation, the grade is based on the highest
Examples of CPD activities and evidence can be found at level of evidence used. This grade reflects the quality of the
Health Professions Council (2010) Continuing Professional evidence reviewed and should not be interpreted as the
Development & your registration. www.hpc-uk.org/assets/ recommendations clinical importance.
documents/10001314CPD_and_your_registration.pdf
The table of the papers utilised in developing the
Guideline recommendations recommendations and their allocated level of evidence is in
Appendix 9.
The guidelines are divided into six sections for ease of
reference: The full list of references follows the recommendations.
1. The role of the physiotherapist within the MDT
2. Knowledge Key to the guideline update:
3. Assessment Where recommendations have been amended or added for
4. Patient and carer information this update symbols are displayed next to the recommendation
5. Pre operative management numbering for ease of identification.
6. Post operative management
New recommendations in this guideline update are marked **.
Each section includes an introduction, a summary of the Amended recommendations are marked ~~.

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations

Section 1 - the role of the physiotherapist within the 1.3 The physiotherapist contributes, as part of the MDT, to the
multidisciplinary team prediction of prosthetic use. B(42)

1.4 A physiotherapist specialised in amputee rehabilitation

Introduction (Appendix 16) should be responsible for the management of
A specialist multidisciplinary team (MDT) achieves the best physiotherapy care. C(3, 41)
rehabilitation outcome.(38, 39, 40)
1.5 When it is possible to choose the level of amputation the
To provide an effective and efficient service the team physiotherapist should be consulted in the decision making
work together towards goals agreed with the patient. The process regarding the most functional level of amputation for
physiotherapist plays a key role in coordinating patient the individual. C(45)
rehabilitation.(41)
1.6 The physiotherapist should be involved in producing
The Chartered Society of Physiotherapy (CSP) Core Standards(2) protocols to be followed by the MDT. C(45)
outline the role of the physiotherapist within an MDT. These
standards emphasise the need for physiotherapists to be 1.7 There should be an agreed procedure for communication
aware of the roles of other members of the MDT and to have between the physiotherapist and other members of the MDT.
clear protocols and channels of referral and communication C(45)
between members.
1.8 Within the MDT the role of the physiotherapist includes
To rehabilitate people who have had an amputation, the compression therapy. C(45)
core MDT may include: specialist physiotherapist, specialist
occupational therapist, surgeon, specialist nurse and social 1.9 A physiotherapist experienced in amputee rehabilitation
worker. Additional MDT members include: diabetic team, can, as part of the MDT, be responsible for the decision to start
dietician, general practitioner, specialist nurses, housing and using the early walking aid having liaised with other members
home adaptation officer, podiatrist, counsellor, psychologist, of the MDT as necessary. C(45)
social services team, social worker, pain control team,
wheelchair services, rehabilitation consultant prosthetist, 1.10 The physiotherapist, along with other professionals,
orthotist and community services. should contribute in the management of residual limb wound
healing. C(45)
Evidence
1.11 The physiotherapist, along with other professionals
The multidisciplinary team approach to rehabilitation following should contribute to the management of pressure care. C(45)
amputation is recognised internationally as the rehabilitation
mode of choice; however there is little published literature to 1.12 The physiotherapist, along with other professionals,
support this. Campbell et al(42) concluded from a case series of should contribute to the management of wound healing on
61 people with an amputation that the MDT can reasonably the contra lateral limb if applicable. B(8)
predict prosthetic outcome 85% of the time in predicted users
and 65% of the time in predicted non users. Ham et al(41), in 1.13 The physiotherapist, as part of the MDT, should
a case controlled study, suggested that vascular amputees contribute to the management of pain as necessary. C(45)
benefit from care by a specialist MDT resulting in reduced
hospital stay and out-patient re-attendance. 1.14 The physiotherapist, as part of the MDT, should be
involved in making the decision to refer the patient for a
In addition to Ham et al , two other papers support the
(41)
prosthetic limb. C(45)
role of the physiotherapist within the MDT. Condie et al(43)
found that in a cohort of Scottish people with a lower limb 1.15 The physiotherapist should contribute to the decision on
amputation, the time from surgery to casting was reduced which MDT outcome measures are to be used. C(45)
when the patients received physiotherapy. Klingenstierna(44)
concluded from eight case studies that exercise improves 1.16 The physiotherapist, along with other professionals,
thigh muscle strength in people with a transtibial should contribute to the patients psychological adjustment
amputation. following amputation. C(45)
In the absence of other evidence on the role of the 1.17 The physiotherapist should be able to refer directly to a
physiotherapist consensus opinion was sought to further clinical psychologist/counsellor if appropriate. C(45)
inform this section.(45)

Good practice points

Recommendations
The MDT agrees its approach to rehabilitation.(45)
1.1 Within the MDT the role of the physiotherapist includes
exercise therapy. B(2, 44) Roles and responsibilities are agreed within the MDT.(45)
1.2 Within the MDT the role of the physiotherapist includes Patient and public involvement should underpin service
assessment and treatment with early walking aids. B(43) delivery and development.(45)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
Cognitive deficit affecting memory and executive function is
Establish channels of communication between: the MDT, predictive of functional limitations.
stakeholders, commissioners, professional networks.(45)
Czerniecki et al(52) report that average subjects did not regain
Education, audit and research should be undertaken on a pre-amputation levels of mobility within the first year post
regular basis by the MDT.(45) surgery. In addition to this, increased age and previous arterial
reconstruction are factors associated with a reduced rate of
Documented pathways of care should be used.(45) ambulatory recovery.

Contact details of MDT members should be readily available to In a 1997 pilot study of 10 patients (seven with abnormal
the patient and carers.(45) resting ECG) with peripheral vascular disease, Bailey et
al(53) investigated ECG abnormalities during walking with
Access to other stakeholder agencies should be understood a pneumatic post-amputation mobility aid. They found
and agreed to facilitate discharge planning and transfer of care normal blood pressure elevation in nine patients and a group
e.g. Intermediate Care Teams, Social Services etc.(45) mean age-predicted maximum heart rate of less than 70%,
suggesting appropriate exercise levels. However, five patients
A summary of the patients treatment and status at transfer or reached over 70% of age-predicted maximum heart rate. They
discharge should be documented in the patients record, with suggest that physiotherapists need to pay close attention to
details of future management plan e.g. details of package of patients cardiac status during rehabilitation.
care, community therapy, prosthetic referral.(45)
Czyrny and Merrill(54) concluded that amputees on renal dialysis
Section 2 Knowledge admitted to acute rehabilitation had similar functional outcomes
and rehabilitation costs to amputees with peripheral vascular
disease without renal failure. In a prospective case series of 16
Introduction healthy males Rush et al(55) found that there is an increased risk
To provide effective rehabilitation the physiotherapist needs of osteopenia in the femur of the amputated limb.
a good understanding of the factors that may influence the
outcome of rehabilitation.(45) In a prospective cohort of 21 diabetic patients with unilateral,
transtibial amputations Jayatunga(56) found that the use of
The physiotherapist also needs to have an understanding orthoses/appropriate footwear reduced the risk of contra-
of prosthetic prescription principles and the prosthetic lateral foot damage due to diabetic neuropathy.
rehabilitation process to successfully plan and deliver
rehabilitation.(45) Factors affecting wound healing include smoking, malnutrition,
previous surgery, gangrene, level of amputation, antibiotics,
Knowledge of the complications that may arise following diabetes, surgical technique, dressings and drains. No single
amputation of the lower limb and how members of the MDT factor can be considered in isolation(46).
may deal with these complications is essential in order that the
rehabilitation process may be adapted to accommodate these Two case series(57, 58) have looked into the relationship between
factors.(46, 47) amputation level and rehabilitation outcome. These studies
show that patients with a transtibial amputation have a greater
An understanding of the psychological implications of chance of succeeding with a prosthesis than those with a
amputation is necessary and the physiotherapist should trans-femoral amputation(57, 58).
be aware of how these issues may be dealt with by the
physiotherapist and other members of the MDT.(48) Ward and Meyers(59) in their review found evidence that the
energy cost of ambulation is greater with ascending levels of
The physiotherapist is responsible for keeping up to date with amputation. They also describe that with daily exercise people
developments in amputee rehabilitation. This should include with an amputation consume significantly less oxygen (i.e. use
awareness of published guidance and recommendations. less energy).

Evidence Use of an early walking aid to facilitate assessment and

rehabilitation is well documented.(7, 59, 60, 61, 62, 63, 64)
Concurrent conditions will influence rehabilitation potential
and the physiotherapist should be aware of these(45). In a non- Vanross et al(60) demonstrate that in the presence of a large
systematic overview of 71 studies Pernot et al(39) suggest that open residual limb wound, early use of the pneumatic post
concurrent conditions along with increasing age are prognostic amputation mobility (PPAM) aid may still be appropriate and can
of a low level of function. In a systematic review Sansam et facilitate healing. An MDT protocol was considered essential.
al(49) found that poorer health status can impact negatively
on walking ability particularly given the increased energy Mazari et al(63) concluded there is no difference in clinical and
requirements to walk with a prosthesis. quality of life outcomes between articulated and non-articulated
early walking aids in the rehabilitation of transtibial amputees.
Hanspal et al(50), in a retrospective case series, found that
outcome is affected by cognitive and psychomotor function. Three studies agree that exercise plays an important part in a
In a literature review Coffey et al(51) identify that a range of functional rehabilitation programme following amputation.(44,
strategies should be used in the rehabilitation of amputees. 65, 66)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
The BACPAR guidelines on the management of residual limb 2.10 ~~The physiotherapist understands the factors affecting
oedema reference the different approaches to inform best the healing of residuum wounds. B(7, 46, 60)
practice.(7)
2.11 ~~The psychosocial issues that may affect patients
Discharge data for amputees in Scotland over a three-year following amputation and the cognitive and psychomotor
period(23) (1998) shows that the use of compression socks aspects affecting the rehabilitation potential of the amputee
to control oedema of the residuum can reduce the time to are understood by the physiotherapist. B(48, 50, 51, 78)
prosthetic rehabilitation. Lambert and Johnson(67) in an audit
of physiotherapists working in artificial limb units found that 2.12 ~~The risk of damage to the remaining diabetic/
compression socks are widely used. neuropathic foot is understood by the physiotherapist. B(8, 30, 56, 80)

McCartney et al(68) concluded from his cross sectional 2.13 The physiotherapist should have an understanding of the
study that 10% of patients had their quality of life affected pathology leading to amputation. C(45)
by phantom pain/sensation. Two studies found that it was
not uncommon for amputees to experience phantom limb 2.14 ~~The physiotherapist should have knowledge of medical
sensation/pain influenced by a number of factors (69, 70). investigations commonly undertaken prior to amputation and
Mortimer et al (71) suggests in a well conducted qualitative their significance. C(45,52)
study that accurate information on phantom limb pain/
sensation should be provided by an individual with 2.15 The physiotherapist should have knowledge of surgical
appropriate knowledge and training. A range of techniques used in amputation. C(45)
modalities have been identified in the management of
phantom limb pain (69, 72, 73, 74). 2.16 ~~The physiotherapist should have knowledge of the
principles of prosthetic prescription. C(31, 45)
In a retrospective cohort of 254 lower limb amputees, Meikle
et al(75) found that interruptions to rehabilitation are common 2.17 The physiotherapist should be aware of the possible
and result in longer periods of rehabilitation but the outcome psychological effects that may occur following amputation. C(45)
is not adversely affected.
2.18 ~~The physiotherapist should have basic knowledge
A study into psycho-educational intervention by Delehanty(48) of the principles of counselling and should know when it
concluded that psychological support is beneficial. is appropriate to refer a patient to a clinical psychologist/
counsellor. C(45)
Recommendations
2.19 The physiotherapist should be aware of the socio-
2.1 ~~The use of early walking aids as an assessment and
economic impact of lower limb amputation. C(45)
treatment tool is understood by the physiotherapist. A(7, 61, 64)
2.20 The physiotherapist should be aware of the systems in
2.2 The physiotherapist is aware that level of amputation, pre-
place to refer for assessment for a prosthesis. C(45)
existing medical conditions and social environment will affect
rehabilitation. B(39, 45, 49, 51, 52, 57, 76, 77, 78)
2.21 ~~The physiotherapist should have basic knowledge of
Who prescribes wheelchairs
2.3 ~~The role of exercise therapy as an essential part of the
How they are provided
rehabilitation process is understood. B(44, 53, 59, 65, 66, 79)
Any accessories including pressure-relieving seating. C(45)
2.4 ~~The impact of the level of amputation on rehabilitation
2.22 ~~The physiotherapist should have basic knowledge of
potential is understood by the physiotherapist. B(45, 57, 58, 59)
the provision of equipment that can facilitate activities of daily
living. C(45)
2.5 ~~The physiotherapist has an understanding of the
predisposing factors to successful (and unsuccessful)
rehabilitation. B(31, 45, 51, 52, 53, 54)
Good practice point
There should be opportunities for CPD and lifelong learning.(45)
2.6 ~~The physiotherapist has an understanding of the
management of residual limb oedema. B(7, 43, 67) Section 3 Assessment
2.7 ~~The physiotherapist is aware that pain (of the residuum,
phantom or lower back) may affect the quality of life of the
Introduction
amputee. B(68, 69, 70) Sufficient information should be gathered from all sources including
the clinical record and other members of the MDT before carrying
2.8 ~~Methods of pain relief for the post-operative out a full subjective and objective examination of the patient. This
treatment of phantom pain/sensation are understood by the should take into account the emotional and cognitive status and
physiotherapist. B(71, 72,73,74) co-morbidities e.g. cardiac and/or renal disease, diabetes, arthritis
or previous stroke, which may affect the patients motivation,
2.9 ~~The physiotherapist has an awareness of the long term exercise tolerance, skin condition or sensation. The social situation,
effects of amputation. B(52, 55, 59) including available support, occupation and hobbies, together with
the home environment of the patient, should also be considered.(2)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
Realistic goals and a rehabilitation programme Section 4 Patient and Carer Information
should be discussed and agreed with the patient (and
carers).(2)
Introduction
An outcome measure should be used to evaluate change in The CSP Quality Assurance Standard(2) 4.3 states that
functional level as part of continual assessment. information [should be] provided to enable service users to
participate fully in their care. This promotes understanding
Evidence of the process and reasoning behind treatment. The
Collin et al(23) in 1995 concluded from a case series of poorly rehabilitation process should have an educational element that
defined elderly individuals that a wheelchair should be empowers patients and carers to take an active role in their
routinely provided following a lower limb amputation. In 1992, present and future management. This will assist with problem
Collin et al(76) highlighted the importance of environmental solving and awareness of when to seek professional help.
factors in determining functional outcome.
Due to the number of recommendations in this section it has
Studies that gave evidence supporting the need to examine been sub-divided into four sections for ease of use. These sub-
specific pathologies include a cohort study by Potter et sections are:
al(77). They noted that in patients with diabetes, peripheral
neuropathy is nearly always present in the intact limb and 4.1 Patient journey
that it is also present in two thirds of non-diabetics. This 4.2 Informed goal setting
demonstrates the need to ensure sensation is routinely 4.3 Care of the remaining limb
checked at assessment. 4.4 Care of the residual limb

The care of the contra-lateral limb guidelines evidence the 4.1. Patient journey
importance of assessing skin condition(8) This is also relevant
when assessing patients who have undergone previous Evidence
amputation of the contra-lateral limb. The importance of skin In the absence of published literature this sub-section is
checks is reinforced by a descriptive cohort study carried out supported by consensus opinion.(45)
by Levy in 1995(81).
Recommendations
Coffey et al(51) in a systematic literature review found
that impaired cognitive skills such as memory and 4.1.1 ~~The physiotherapist should give patients information
executive function negatively affect independence. A further about the expected stages and location of the rehabilitation
paper by Hanspal(78) suggested that the results of a cognitive programme suited to their individual circumstances. C(2, 45)
assessment soon after amputation can predict the level of
mobility likely to be achieved. This was based on a cohort 4.1.2 ~~With the patients consent, the physiotherapist should
study of 32 elderly patients but no specific results were give carers information about the expected stages and location
published on level of mobility and links with cognitive status. of the rehabilitation programme suited to the patients
individual circumstances. C(2, 45)
Recommendations
4.1.3 The physiotherapist should offer patients the opportunity
3.1 ~~There should be written evidence of a full physical to meet other adults with lower limb amputations. C(45)
examination and assessment of previous and present function.
B(2) 4.1.4 Where appropriate, and with the patients consent, the
physiotherapist should offer carers the opportunity to meet
3.2 ~~The patients social situation, psychological status, goals other adults with lower limb amputations. C(45)
and expectations should be documented. B(50, 76, 78)
4.1.5 The physiotherapist should provide information about
3.3 ~~Relevant pathology including diabetes, previous arterial the prosthetic process to those patients likely to be referred
reconstruction, impaired cognition and skin condition should for a prosthesis. C(45)
be noted. B(78, 51, 81, 77, 52)
4.1.6 The physiotherapist should offer to show demonstration
3.4 ~~A problem list and treatment plan, including agreed goals, limbs to those patients likely to be referred for a prosthesis.
should be formulated in partnership with the patient. B(2) C(45)
4.1.7 The physiotherapist should know where to refer patients
Good practice points for information about benefits. C(45)
A locally agreed amputee specific physiotherapy assessment
tool should be used.(45) 4.1.8 The physiotherapist should know where to get advice on
arrangements available to support carers. C(45)
Names and contact details of the MDT members involved
in the patients care should be recorded to facilitate 4.1.9 The physiotherapist should be able to refer the patient to
communication.(45) other agencies as necessary. C(45)
The principles of the Single Assessment Process (SAP) should
be considered to improve MDT communication.(45) 4.1.10 ~~Where possible all verbal information/advice given
should be supplemented in written form. C(2, 45)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
4.2. Informed goal setting 4.3.4 Physiotherapists should ensure that patients are under
the care of a specialist MDT, including a diabetic specialist,
Evidence podiatrist and foot care specialist. B(8)
The CSP Quality Assurance Standard 8.5 states that goals
4.4. Care of the residual limb
[should be] agreed with the service user and multi-disciplinary
team, including outside agencies and wider carers and family.
Evidence
A prospective cohort study by Czerniecki(52) summarised that In a review by Eneroth(46) multiple factors were found to
co-morbidities (including cognitive and physical factors) will affect wound healing in vascular patients with an amputation.
impact on levels of ambulation post-operatively. This is further Oedema control is considered essential in preventing this
supported by a systematic review by Coffey et al(51) which delay. BACPAR guidelines found robust evidence to support
states that cognitive impairment, particularly memory and the use of rigid dressings, pneumatic post amputation mobility
executive function, is predictive of functional limitations over (PPAM) aids, compression socks and wheelchair residual
time. These factors should be considered when undertaking limb support boards in the management of oedema and
the goal-setting process. discouraged the use of elastic bandage wrapping(7).

In the absence of other evidence, consensus opinion was In the absence of other evidence, consensus opinion was
sought to further inform this section.(45) sought to further inform this section.(45)

Recommendations Recommendations
4.2.1 ~~Patients/carers should be made aware that concurrent 4.4.1 Advice should be given to the patient/carer on the
pathologies and previous mobility affects realistic goal setting factors affecting wound healing. B(46)
and final outcomes of rehabilitation. C(52)
4.4.2 ~~Advice should be given to the patient/carer on the use
4.2.2 ~~Patients/carers should be made aware that the level of of compression socks. B(3, 7, 43)
amputation affects the expected level of function and mobility.
B(52, 82) 4.4.3 Instruction should be given to the patient/carer on
methods to prevent and treat adhesions of scars. C(45)
4.2.3 ~~Patients/carers should be made aware that they will
experience lower levels of function than bipedal subjects. B(52) 4.4.4 The physiotherapist should give on-going advice about
residual limb care. C(45)
4.2.4 ~~The physiotherapist should use appropriate outcome
measures for rehabilitation goals. C(2, 3) Good practice points
Names and contact details of the MDT members involved in
4.2.5 ~~The physiotherapist should use a range of strategies
the patients care should be given to patients and carers.(45)
to assess and consider the impact of cognitive impairment on
goal setting. B(51)
Information leaflets/booklets should be developed locally for
patients and carers to supplement information given verbally.(45, 71)
4.3. Care of the remaining limb
Physiotherapists should be aware of the BACPAR Guidelines
Evidence entitled Risks to the contra-lateral foot of unilateral lower
A body of work was carried out by BACPAR in 2009 limb amputees and Guidance for the multi-disciplinary team
recommending that care of the remaining/contra-lateral on the management of post-operative residuum oedema in
limb is included in therapeutic practice. These guidelines are lower limb amputees.(7, 8, 45)
intended to be a practical resource for therapists working with
lower limb amputees and should be used alongside other Section 5 Pre-op Management
current, published guidelines.(8) Rerkasem et al(80) also support
the education of patients in regards to risk factors for foot care
and ensuring that the patient is under the care of appropriate
Introduction
MDT foot care specialists. Early assessment and planning of rehabilitation can
commence at this stage and helps to prepare the patient for
Recommendations rehabilitation. A pre-amputation consultation also enables
the physiotherapist to give appropriate advice, information
4.3.1 ~~Vascular and diabetic patients and their carers should
and reassurance; issues such as phantom limb sensation
be made aware of the risks to their remaining foot and
and avoidance of falls may be discussed.(83) However, it
educated in how they can reduce them. B(8, 80)
is acknowledged that patients who require emergency
amputation may not have the opportunity for pre-amputation
4.3.2 ~~The patient/carer should be taught how to monitor the
consultation, assessment and treatment.
condition of the remaining limb. B(8, 80)

4.3.3 Physiotherapists should establish links with their local

Evidence
podiatry/chiropody services to ensure that information and This section is supported by consensus opinion in the absence
education given to patients and carers is consistent. C(45) of any published literature.(45)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
Recommendations ~~Setting of care
5.1 Where possible the physiotherapist should reinforce In 2000 a retrospective cross sectional study of 146 traumatic
information given by other MDT members about the general amputees by Pezzin et al(85) found that their physical
surgical process (not technique). C(45) function and vitality were increased by having longer in-
patient rehabilitation. Schaldach(84) found in a retrospective
5.2 Where possible the patient and carers should be given before and after case control study of 71 trans-femoral
advice, information and reassurance by the physiotherapist and transtibial patients that in-patient rehabilitation is
about rehabilitation. C(45, 83) more effective in terms of cost and time when a clinical
care pathway is followed. Meikle et al(75), in a retrospective
5.3 The physiotherapy assessment should be commenced pre- cohort study, found that interruptions to rehabilitation due
operatively, if possible. C(3, 45) to co-morbidity are common, but do not adversely affect the
outcome of rehabilitation despite lengthening the process. In
5.4 Where possible rehabilitation/discharge planning should a case control study Cutson et al(86) observed that in-patient
commence pre-operatively. C(45) rehabilitation reduced the time from surgery to prosthetic
ambulation among male dysvascular transtibial patients.
5.5 Where appropriate and possible the patient should be **There are, however, known issues with accessibility to
instructed in wheelchair use pre-operatively. C(45) inpatient rehabilitation.
5.6 A structured exercise regime should be started as early as For ease of description, this section has been divided into the
possible. C(45) following sub-sections:
5.7 Bed mobility should be taught where possible. C(45) 6.1 ~~Immediate post-operative care
6.2 Environment and equipment
5.8 Where appropriate and possible transfers should be 6.3 Compression therapy
taught pre-operatively. C(45) 6.4 Mobility
6.5 Early walking aids (EWAs)
5.9 If indicated, the patient should be assessed for 6.6 Falls management
physiotherapy respiratory care. C(45) 6.7 Wheelchairs and seating
6.8 Prevention/reduction of contractures
5.10 If indicated, the patient should be given appropriate 6.9 Exercise programmes
physiotherapy respiratory treatment. C(45) 6.10 Management of phantom sensation and pain
5.11 Pain control should be optimised prior to physiotherapy Evidence
treatment pre-operatively. C(45)
~~This section is supported by consensus opinion in the
5.12 If appropriate, and with the patients consent, carers absence of relevant published literature.(45)
should be involved in pre-operative treatment and exercise
programmes. C(45) Recommendations
6.1.1 ~~Physiotherapy assessment and rehabilitation should
Good practice point ideally start on the first day post-operatively. C(45)
The physiotherapist should be involved with the MDT decision
to proceed with amputation and level selection.(10, 45) 6.1.2 Pain should be considered and adequately controlled
prior to every treatment. C(45)
Where this is not possible, a procedure for prompt referral
to physiotherapy following decision to amputate should be 6.1.3 Respiratory care should be given if appropriate. C(45)
developed.(10)
6.1.4 ~~A physiotherapist should use their assessments
Section 6 Post-op Management to inform the MDT regarding interventions and discharge
planning. C(45)
Introduction 6.2 Environment and equipment
The rehabilitation process should commence as early as
possible, preferably following a suitable care pathway(84). Evidence
Patients should be assessed and a rehabilitation plan discussed **Environment and equipment should be considered in
and agreed. Advice and information should be given regarding relation to the individual, the intervention and both the
bed mobility, to avoid complications such as contractures and rehabilitation setting and discharge destination.
pressure sores. Appropriate advice and assistance with transfers
should be given. Following assessment, a problem list should be A questionnaire cross sectional survey carried out by White(87)
made, with both short and long term goals considered, taking in 1992 concluded that residual limb support boards are well
into account the patients psychological, emotional and physical accepted for use with patients with a lower limb amputation,
status, pain management and the broader issues surrounding but that therapists are not always confident about their use.
social and home environment. The evidence based guidelines for occupational therapy with

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
people who have had lower limb amputations recommend Recommendations
the provision of residual limb support boards for all transtibial
amputees.(88) 6.4.1 ~~Ideally, bed mobility should be taught on the first day
post-operatively. C(45)
In the absence of other evidence consensus opinion was
sought to further inform this section.(45) 6.4.2 Sitting balance should be re-educated if needed. C(45)

Recommendations 6.4.3 Standing balance should be re-educated if needed. C(45)

6.2.1 ~~The physiotherapist should have knowledge of the 6.4.4 Safe transfers should be taught as early as possible. C(45)
provision of equipment that can enhance the rehabilitation
process and facilitate activities of daily living. C(45) 6.4.5 ~~Mobility post-operatively should be in a wheelchair
unless there are specified reasons to teach a patient to use
6.2.2 ~~Physiotherapists should be familiar with the correct crutches/zimmer frame/rollator. C(45)
use and availability of specialist amputee equipment, e.g.
slings, hoists, residual limb boards. C(45, 87, 88) 6.4.6 ~~The physiotherapist should help the patient gain
maximum mobility post-operatively. C(45, 89, 90)
6.2.3 The physiotherapist should be involved in home visits
where necessary. C(45) 6.5 Early walking aids (EWAs)

6.3 Compression therapy Evidence

Evidence **Pollock et al(62) found in a randomised controlled trial
that using EWAs reduced the incidence of post-operative
~~A cross sectional survey of physiotherapists(67) showed complications, and resulted in faster and more successful
that compression socks are widely used, but that their use rehabilitation. Schon et al(91) demonstrated in a before
varies greatly. Discharge data from all Scottish amputees over and after case control study that prefabricated prostheses
a three-year period showed that all forms of compression may reduce complications, falls, revisions and time to first
therapy resulted in quicker progression to prosthetic prosthesis. **This is further supported by Vanross(60) with
rehabilitation(43). Recent guidelines by BACPAR have the use of an EWA as part of an unhealed wound protocol.
demonstrated that available evidence is against the use of Lein(92) carried out a cross sectional survey in 1992, and
elastic bandages due to it being unreliable and dangerous in concluded that the pneumatic post-amputation mobility
regards to pressure distribution **BACPAR oedema guidelines (PPAM) aid provides a valuable tool for assessment and
recommend compression therapy is commenced within 10 treatment, provided it is used correctly. In 1998, Condie et
days post-operatively.(3,7) al(43) found from a cohort of all the Scottish amputee discharge
information that use of compression therapy, including EWAs,
In the absence of other evidence, consensus opinion was resulted in quicker progression to prosthetic rehabilitation.
sought to further inform this section.(45)
Recommendations
Recommendations
6.5.1 EWAs should be considered as part of the rehabilitation
6.3.1 ~~A compression sock should be used in preference to programme for all lower limb amputation patients as an
elastic bandages for reducing limb volume. D(7) assessment tool. B(43, 60, 61, 91, 92)

6.3.2 The physiotherapist should use compression therapy as 6.5.2 EWAs should be considered as part of the rehabilitation
appropriate. D(7) programme for all lower limb amputation patients as a
treatment tool. B(43, 60, 61, 91, 92)
6.3.3 **The timing of compression therapy application should
be discussed with the MDT at an early stage. C(7, 45) 6.5.3 EWAs should be used under the supervision of therapists
trained in their correct and safe application and use. C(3, 92)
6.4 Mobility
6.6 Falls management
Evidence
A longitudinal cohort study by Stineman et al(89) found that Evidence
even a small improvement in dependency levels resulted **Three studies have reported an increased risk of falls
in improved mortality rates at six months. i.e. through following lower limb amputation(93, 94, 95). Kulkarni(93) concluded
progression of transfers and functional ability. that instruction on how to get up from the floor should be
part of rehabilitation. Pauley(95) states that older age, greater
**According to Kirby et al(90) in a qualitative study, number of co-morbidities, cognitive impairment and the use of
the seated stair handling method is a generally a greater number of medications predict a greater likelihood of
effective, safe and well-tolerated method for people falling. **BACPAR guidance for the prevention of falls in lower
with unilateral lower limb amputations to ascend and limb amputees(6) further supports this evidence by identifying
descend the stairs. a number of risk factors along with appropriate assessment
In the absence of other evidence, consensus opinion was tools and multi-factorial falls prevention interventions.
sought to further inform this section. (45)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
Recommendations identified. This should be reviewed and progressed as
appropriate. C(45)
6.6.1 ~~The patient, carers and the MDT should be made
aware that the risk of falling is increased following lower 6.9.2 ~~An exercise regime should be given relevant to the
limb amputation. B(6, 93) patients goals and reviewed on a regular basis. C(45)
6.6.2 ~~Rehabilitation programmes should include education 6.10 Management of phantom sensation and pain
on preventing falls. B(6, 93, 96)
Evidence
6.6.3 Patients and carers should be given instructions on
how to get up from the floor in the event of the patient **52% of patients experience phantom limb pain and/or
falling. B(6, 93, 96) sensation immediately following surgery(70). ~~Mortimer et
al(71) in 2002, found from a well conducted qualitative study,
6.6.4 Advice should be given in the event that the patient is using focus groups, that patients need accurate and timely
unable to rise from the floor. B(93, 96) information about phantom limb pain, and this should be
provided by individuals with appropriate knowledge and
6.7 Wheelchairs and seating training.

Evidence ~~McCartney(68), in a cross sectional study of 40 subjects from

Scotland, found that pain after amputation is common and
~~This section is supported by consensus opinion in the affects quality of life in 10% of the population.
absence of any published literature.(45) In the absence of other evidence, consensus opinion was
sought to further inform this section.(45)
Recommendations
6.7.1 **Patients should routinely be provided with a Recommendations
wheelchair and appropriate accessories to include residual 6.10.1 ~~As early as possible, patients should be made aware
limb support (as appropriate) footplates, anti-tips and they may experience phantom limb sensation or pain post-
appropriate pressure management devices. C(45, 88) operatively. B(68, 70, 71, 72)
6.7.2 Where necessary the physiotherapist should be able 6.10.2 ~~Information and treatment regarding phantom
to assess a patients suitability for a wheelchair or have limb sensation and pain should be given by clinicians with
knowledge of the referral process. C(45) appropriate knowledge and training. B(71, 72, 97)
6.7.3 ~~The physiotherapist as part of the MDT should be 6.10.3 **Techniques for the self-management of phantom
able to teach the patient and carer how to safely use the sensation and/or pain should be taught. C(45, 72)
wheelchair, including all accessories. C(45, 87)
6.10.4 ~~Appropriate information and treatment should be
6.8 Prevention/reduction of contractures given for residual limb pain. C(45)
Evidence Good practice points
This section is supported by consensus opinion in the absence Information leaflets/booklets should be developed locally
of any published literature.(45) for patients and carers to supplement information given
verbally.(45)
Recommendations
6.8.1 ~~Contractures should be prevented by education of Information on self management/home exercise following
appropriate positioning. C(45) discharge should be provided to the patient.(45)

6.8.2 ~~Contractures should be prevented by education of Patients requiring ongoing outpatient treatment should have
stretching exercises. C(45) this arranged prior to discharge.(45)

6.8.3 Where contractures have formed appropriate treatment A summary of the patients treatment and status at transfer
should be given. C(45) should be sent to the physiotherapist providing on-going
treatment.(45)
6.9 Exercise programmes
Contact names, telephone numbers and addresses of
Evidence relevant MDT members should be supplied to patients prior to
discharge.(45)
~~In the absence of other evidence consensus opinion was
sought to further inform this section.(45) **Physiotherapists should be aware of the BACPAR guidance
entitled Guidance for the prevention of falls in lower limb
Recommendations amputees and Guidance for the multi-disciplinary team on
6.9.1 **Following on from the initial assessment, an exercise the management of post-operative residuum oedema in lower
program should be provided to address the problems limb amputees.(45)

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
**Physiotherapists should be aware of the well established 16. Health Professions Council (2010). Continuing
PIRPAG exercise program.(45) Professional Development & your registration.
Available from: www.hpc-uk.org/assets/
**Physiotherapists should consider the option of ascending documents/10001314CPD_and_your_registration.pdf.
and descending the stairs using a seated method.(45) Accessed 17/2/11.
17. Liberating the NHS: www.gov.uk/government/
**Physiotherapists should be aware of other relevant publications/liberating-the-nhs-white-paper Accessed
guidelines including AGILE and the OT guidelines.(45, 96) 13/6/14.
18. Brouwers, M., Kho, M.E., Browman, G.P., Cluzeau, F.,
List of references as they appear in the text Feder, G., Fervers, B., Hanna, S., Makarski, J. on behalf
of the AGREE (2010). Next Steps Consortium. AGREE
1. Broomhead, P., Dawes, D., Hancock, A., Unia, P., Blundell,
II: Advancing guideline development, reporting and
A., Davies, V. (2006). Clinical guidelines for the pre and
evaluation in healthcare. Can Med Assoc J. 182:E839-842;
post operative physiotherapy management of adults with
doi: 10.1503/cmaj.090449Agree II Tool
lower limb amputation. London: Chartered Society of
19. Grieve, A and Lankhorst, G (1996). Functional outcome of
Physiotherapy.
lower limb amputees: a prospective descriptive study in a
2. Chartered Society of Physiotherapy (2012). Quality
general hospital. Prosthet Orthot Int, 20: 79-87
Assurance Standards. London: Chartered Society of
20. Nicholas, J.J, et al (1993). Problems experienced and
Physiotherapy.
perceived by prosthetic patients. Jour Pros and Orthot,
3. British Society of Rehabilitation Medicine (BSRM) (2003).
Vol 5 (1) : 16-19.
Amputee Rehabilitation: Recommended Standards &
21. Rybarczyk, B.D., et al. (1992). Social discomfort and
Guidelines. 2nd ed. London: BSRM.
depression in a sample of adults with leg amputations.
4. Atwal, A., McLaughlin, J., Spiliotopoulou, G. (2011).
Arch Phys Med Rehabil, Vol 73 (12) : 1169-73.
Occupational therapy with people who have had lower
22. Thornberry, D.J., Sugden, J. and Dunford, F. (1994). What
limb amputation. London: The College of Occupational
happens to patients who have amputations for peripheral
Therapists.
vascular disease? ISPO Blackpool.
5. Jarvis, V., Verrall, T. (eds) (2011). Prosthetic Best Practice
23. Colin, C., and Colin, J. (1995). Mobility after lower limb
Guidelines. Leeds: RSL Steeper.
amputation. Br J Surg, 82 (8): 1010-1.
6. Blundell, R., Bow, D., Donald, J., Drury, S., Hirst, L.
24. Frykburg, R.G., et al. (1998). Functional outcome in the
(2008). Guidance for the prevention of falls in lower limb
elderly following a lower extremity amputation. J Foot
amputees. Available from www.BACPAR.org
Ankle Surg, 37(3): 181-5; discussion 261.
7. Bouch, E., Burns, K., Geer, E., Fuller, M., Rose, A.
25. Pell, J.P., et al. (1993). Quality of life following lower limb
(2012). Guidance for the multi-disciplinary team on the
amputation for peripheral arterial disease. Eur J Vasc
management of post-operative residuum oedema in
Surg. 7(4): 448-51.
lower limb amputees. Available from www.BACPAR.org
26. NHS choices: http://www.nhs.uk/conditions/amputation/
8. Brett, F., Burton, C., Brown, M., Clark, K., Dugiud, M.,
Pages/Introduction.aspx
Randall, T., Thomas, D. (2012). Risks to the contra-lateral
27. Audit Commission National Report (2000) Fully Equipped:
foot of unilateral lower limb amputees: A therapists
The provision of equipment to older or disabled people
guide to identification and management. Available from
by the NHS and social services in England and Wales.
www.BACPAR.org
Available from www.audit-commission.gov.uk . Accessed
9. Associative Parliamentary Limb Loss Group (APLLG)
13/6/14.
(2008). Helping deliver patient Led prosthetic
28. Scovell ,R.P., Condie ,M.E., Treweek, S.P. (2000). A survey
services with the support of this patients charter.
of the lower limb amputee population in Scotland. 1997
APLLG+NI+charter+MAR+2008.pdf.
ReTis, SPARG report, NCTEPO, Glasgow.
10. NCEPOD Lower limb amputation (2014). Working
29. Stokes, D., Curzio, J., Bacon, E., Barker, L., Berry, A. (2008).
together. A review of the care received by patients who
A UK survey of therapists perspectives on post-amputation
underwent major lower limb amputation due to vascular
hopping. Int J. Ther & Rehab. 15 (12): 551-560.
disease or diabetes. NCEPOD
30. NICE (2013). Process manual for accrediting producers
11. Field, M.J., Lohr, K.N. (1992). Guidelines for clinical
of guidance, advice and recommendations for practice: a
practice: from development to use. Washington DC:
guide for producers and stakeholders. www.nice.org.uk/
National Academy Press.
guidelines manual Accessed 26/1/14.
12. Graham, I.D., Logan, J., Harrison, M.B., Strauss, S.E.,
31. Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert,
Tetroe, J., Caswell, W., Robinson, N. (2006). Lost in
A., Quinlivan, D., Randell ,T., Shepherd, R., Withpetersen,
knowledge translation: Time for a map? J of Cont
J. (2012). Evidence based clinical guidelines for the
Education in Health Professions. 26 (1); 13-26.
physiotherapy management of adults with lower limb
13. NHS Centre for Reviews and Dissemination (1999).
prostheses. 2nd edition. London: Chartered Society of
Getting Evidence into Practice. Effective Healthcare. 5 (1).
Physiotherapy.
Royal Society of Medicine Press.
32. CASP appraisal tools available from www.
14. Francis report www.gov.uk/government/uploads/
caspinternational.org.
system/uploads/attachment_data/file/279124/0947.pdf
33. Scottish Intercollegiate Guidelines Network (SIGN) (2008).
Accessed 13/4/14.
SIGN 50: A guideline developers handbook Revised
15. Department of Health (2008). Framing the contribution
edition. www.sign.ac.uk/guidelines/fulltext/50.html
of Allied Health Professionals: Delivering high quality
Accessed 8/4/14.
healthcare. Available from: www.dh.gov.uk/publications
(Report No.291126). Accessed 13/6/14.

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
34. Linstone, H., Turof, F M. (eds). (1975). The Delphi Method: 55. Rush, P.J .et al (1994). Osteopenia in-patients with above
techniques and applications. Reading MA: Addison-Wesley. knee amputation. Arch Phys Med Rehabil 75(1): 112-5.
35. Thangaratinam, S., Redman, C.W. (2005). The Delphi 56. Jayatunga, U., Panagamua, B. and Lindsay, J. (1999).
Technique. The Obstetrician & Gynaecologist. 7: 120-125. What is our role in protecting good feet of unilateral
36. Herbert, R., Jamtvedt, G., Mead, J., Birger Hagen, K. diabetic amputees ? ISPO, South Normanton.
(2005). Practical Evidence Physiotherapy. Edinburgh: 57. Christiensen, B. et al. (1995). The effect of prosthetic
Butterworth Heinemann. rehabilitation in lower limb amputees Prosthet Orthot Int
37. Greenhalgh, T. (2006). How to read a paper: the basics 19(1):46-52.
of evidence based medicine. 3rd ed. Oxford: Blackwell 58. Houghten, A.D. et al (1992). Success rates for
Publishing. rehabilitation of vascular amputees: Implications for pre
38. Ham, R. (1995). Rehabilitation of vascular amputee one operative assessment and amputation level Br J Surg
method evaluated. Physiotherapy practice 1985 1:6-13. 79(8):753-5.
39. Pernot, H.F et al. (1995). Daily functioning of the lower 59. Ward, K.H., and Meyers, M.C. (1995). Exercise
limb extremity amputee: an overview of the literature. performance of lower extremity amputees. Sports Med
Clin Rehabil 11 (2): 93-106. 20(4):207-14.
40. Kurichi, J.E., et al (2009). Possible incremental benefits of 60. Vanross, E.R., Johnson, S. and Abbott, C.A., (2009). Effects
specialized rehabilitation bed units among veterans after of Early Mobilization on Unhealed Dysvascular Transtibial
lower extremity amputation. Medical care, 47(4), pp.457- Amputation Stumps: A Clinical Trial. Archives of Physical
465. Medicine and Rehabilitation, 90(4), pp. 610-617.
41. Ham, R.O., Regan, J.M and Roberts, V.C. (1987). 61. Scottish Physiotherapy Amputee Research Group
Evaluation of introducing the team approach to the care (SPARG). 2008. PPAM Aid Clinical Guidelines for
of the amputee: the Dulwich study. Prosthet and Orthot Physiotherapists. http://www.knowledge.scot.nhs.uk/
Int 11: 25-30. sparg/public-documents.aspx
42. Campbell, W.B. and Ridler, B.M. (1996). Predicting the use 62. Pollock, C. Jr., and Kerstein, M.D. (1985). Prevention
of prostheses by vascular amputees. Eur J Vasc Endovasc of postoperative complications in the lower extremity
Surg 12(3): 342-5. amputee. J Cardiovasc Surg (Torino) 26(3): 287-90.
43. Condie, M., Treweek, S.P., and Ruckley, C.V. (1998). Trends 63. Mazari, F.A.K., et al, (2010). Hull early walking aid for
in lower limb amputee management ; 3 year results from a rehabilitation of transtibial amputees - Randomized
national survey. British Journal of Surgery 85 (Suppl 1): 23. controlled trial (HEART). Journal of Vascular Surgery,
44. Klingenstierna, U. et al (1990). Isokinetic strength training 52(6), pp.1564-1571.
in below knee amputees. Scan J Rehabil Med 22(1): 39-43. 64. Scott, H. et al (2000). An evaluation of the amputee
45. Consensus. Opinion gained by the Delphi process. mobility aid (AMA) early walking aid. Prosthet Orthot Int
46. Eneroth, M. (1999). Factors affecting wound healing after 24(1);39-46.
major amputation for vascular disease: a review. Prosthet 65. Chin, T. et al (2001). Effect of endurance training
Orthot Int 23(3): 195-208. programme based on anaerobic threshold (AT) for lower
47. Fletcher, D.D. et al (2001). Rehabilitation of the geriatric limb amputees. J Rehabil Res Dev, 38(1):7-11.
vascular amputee patient: A population based study. 66. Moirenfeld, I. et al (2000). Isokinetic strength and
Arch Phys Med Rehabil . 82(6): 776-9. endurance of the knee extensors and flexors in transtibial
48. Delehanty, R.D and Trachsel, L. (1995). Effects of short amputee. Prosth Orthot Int 24 (3): 221-5.
term group treatment on rehabilitation outcomes 67. Lambert, A. and Johnson, J. (1995). Stump shrinkers: a
of adults with amputations. International Journal of survey of their use. Physiotherapy 81(4): 234-6.
Rehabilitation and Health 1(2): 61-73. 68. McCartney, C.J.L., et al (1999). Pain and disability
49. Sansom, K., et al (2009). Predicting walking ability following lower limb amputation a qualitative and
following lower limb amputation: a systematic review of quantitative study. The Pain Clinic 11(4):293-300.
the literature. Journal of Rehabilitation Medicine : official 69. Smith , D.G., et al (1999). Phantom limb, residual limb,
journal of the UEMS European Board of Physical and and back pain after lower extremity amputations. Clin
Rehabilitation Medicine, 41(8), pp. 593-603. orthop (361):29-38.
50. Hanspal, R.S. and Fisher, K. (1991). Assessment of 70. Giummarra, M.J., et al (2011). The menacing phantom:
cognitive and psychomotor function and rehabilitation of What pulls the trigger? European Journal of Pain, 15(7),
elderly people with prostheses BMJ 302(20): 940. pp.691.e1-691.e8.
51. Coffey, L. et al (2012). Cognitive functioning in persons 71. Mortimer, C.M ., et al (2002). Patient information on
with lower limb amputations: a review. Disability & phantom limb pain: a focus group study of patient
Rehabilitation, 34(23), pp.1950-1965. experiences, perceptions and opinions. Health Educ Res,
52. Czerniecki, J.M., et al. (2012). Mobility changes in 17(3): 291-304.
individuals with dysvascular amputation from the 72. Butler, D. and Moseley, L. (2015). Explain pain: 2nd Ed. Noi
presurgical period to 12 months postamputation. publications.
Archives of Physical Medicine and Rehabilitation, 93(10), 73. Liaw, M.Y., Wong, A.M., and Cheng, P. (1994).Therapeutic
pp.1766-1773. trial of acupuncture in phantom limb pain of amputees.
53. Bailey, M. and MacWhannell, C. (1997). Clinical American Journal of Acupuncture 22(3); 205-13.
monitoring of dysvascular lower limb amputees during 74. Mulvey, M.R., et al (2010). Transcutaneous electrical
initial gait training. Physiotherapy 83(6): 278-283. nerve stimulation (TENS) for phantom pain and stump
54. Czyrny, J.J., and Merrill, A. (1994). Rehabilitation of pain following amputation in adults. Cochrane database
amputees with end stage renal disease. Functional of systematic reviews (online), 5.
outcome and cost. Am J Phys Med Rehabil 73(5): 353-7.

BACPAR clinical guideline (2016) Amputee rehabilitation

Clinical guidelines for the pre and post operative physiotherapy
management of adults with lower limb amputations
75. Meikle, B., Develin, M., and Garfinkel, S. (2002). 95. Pauley, T., Devlin, M. and Heslin, K., (2006). Falls
Interruptions to amputee rehabilitation. Arch Phys Med sustained during inpatient rehabilitation after lower limb
Rehabil 83(9):1222-8. amputation: prevalence and predictors. American Journal
76. Collin, C., Wade, D., and Cochrane, G. (1992). Functional of Physical Medicine & Rehabilitation. 85(6), pp.521-32;
outcome of lower limb amputees with peripheral vascular quiz, 533-5.
disease. Clin Rehabil 6(1); 13-21. 96. Goodwin, V., and Briggs, L. (2012). Guidelines for the
77. Potter et al (1998). Incidence of peripheral neuropathy physiotherapy management of older people at risk of
in the contralateral limb of persons with unilateral falling. AGILE, Falls guidelines working group.
amputation due to diabetes. J Rehabil Res Dev 35(3):335-9. 97. Richardson, C., et al. (2006). Incidence of phantom
78. Hanspal, R.S., and Fischer, K. (1997). Prediction of phenomena including phantom limb pain 6 months after
achieved mobility in prosthetic rehabilitation of the major lower limb amputation in patients with peripheral
elderly using cognitive and psychomotor assessment. Int J vascular disease. Clinical Journal of Pain, 22(4), pp.353-8.
Rehabil Res 20(3):315-8. 98. NHS Scotland (2005) Available from www.
79. Sapp, L. and Little, C.E. (1995). Functional outcomes in a lower clinicalgovernance.scot.mhs.uk/section2/definition.asp.
limb amputee population. Prosthet Orthot Int 19 92-96. 99. Scally, G., and Donaldson, L.J. (1998). Clinical Governance
80. Rerkasem, K., et al (2008). Reducing lower extremity and the drive for quality improvements in the new NHS in
amputations due to diabetes: The application of England. BMJ 317(7150): 61-65.
diabetic-foot protocol in Chiang Mai University Hospital.
International Journal of Lower Extremity Wounds, 7(2),
pp. 88-92.
81. Levy, S.W. (1995). Amputees: skin problems and
prostheses. Cutis 55(5) 297-301.
82. DeFrates, A., Boonstrar, A.M., and Vos, L.D.(1994).
Functional outcome of rehabilitated bilateral lower limb
amputees. Prosthet Orthot Int 18(1): 18-24.
83. Quon, D.L., et al (2011). A qualitative study of factors
influencing the decision to have an elective amputation.
Journal of Bone & Joint Surgery, American Volume,
93(22), pp.2087-2093.
84. Schaldach, D.E. (1997). Measuring quality and cost of
care: Evaluation of an amputation clinical pathway. J Vas
Nurs 15(1): 13-20.
85. Pezzin, L.E. et al (2000). Rehabilitation and the long term
outcomes of persons with trauma related amputations.
Arch Phys Med Rehabil 81(3): 292-300.
86. Cutson, T.M. et al (1994). Early management of elderly
dysvascular below knee amputees Journal of Prosthetics
and Orthotics 6(3): 62-66.
87. White, E.A. (1992). Wheelchair stump boards and
their use with lower limb amputees. British Journal of
Occupational Therapy 55(5): 174-178.
88. Atwal, A. et al (2011). Occupational therapy with people
who have had lower limb amputations: Evidence based
guidelines. London: College of Occupational Therapy.
89. Stineman, M.G., et al (2009). Survival analysis in
amputees based on physical independence grade
achievement. Archives of Surgery, 144(6), pp. 543-551.
90. Kirby, R.L., et al (2009). Handling stairs in the seated
position for people With unilateral lower-limb
amputations. Archives of Physical Medicine and
Rehabilitation, 90(7), pp.1250-1253.
91. Schon, L.C. et al (2002). Benefits of early prosthetic
management of transtibial amputees: a prospective
clinical study of a prefabricated prosthesis. Foot Ankle Int
23(6): 509-14
92. Lein, S. (1992). How are physiotherapists using the Vessa
Pneumatic Post amputation mobility aid? Physiotherapy
78(5): 318-322.
93. Kulkarni, J. (1996). Falls in patients with lower limb
amputations prevalence and contributing factors.
Physiotherapy 82(2): 130-6.
94. Yu, J.C., et al. (2010). Incidence and risk factors of falling
in the postoperative lower limb amputee while on the
surgical ward. PM and R, 2(10), pp.926-934.

BACPAR clinical guideline (2016) Amputee rehabilitation

BACPAR clinical guideline (2016) Amputee rehabilitation