Evidence based

management:lower limb
amputation

Submitted To : Dr Megha Nijhawan PT

Submitted By : Ankita Saraswat
Definition
• Amputation is defined as removal of the limb through a part of the bone.

• Disarticulation is the removal of the limb through the joint.

• Incidences
Age: Common in 50-75 years age group.
Sex: Seventy-five percent men, 25 percent women.
Limbs: 85 percent is through the lower limbs,
15 percent is through the upper limbs.
 Causes of Amputation
1.Peripharal vascular disease(any abnormal condition affecting the blood
vessels peripheral to the heart)
2.Diabetes
3.Trauma
4.Infections
5.Tumors
6.Limb deficiencies
 terminologies of Limb deficiencies(congenital):
Amelia- absence of a whole limb
Apodia-absence of a hand or foot
Adactylia-absence of one or more fingers or toes and associated metacarpals or metatarsals
Aphalangia –absence of one or more finger or toes
Phocomelia: "a congenital deformity in which the limbs are extremely shortened so that the feet and
hands arise close to the trunk"
 
 • TYPES

open close
amputation amputation

• Guillotine • revised
• planned
Level of amputation
• Lower Limbs
• Hip disarticulation
• Very short above knee
• Short above knee
• Medium above knee
• Long above knee
• Very long above knee
• Knee disarticulation
• Very short below knee
• Short and below knee.
 LL AMPUTATION
NOMENCLATURE
Current name
Partial foot amputation Chopart amputation
Lisfranc amputation
Ankle disarticulation Syme amputation
Pirogoff amputation
Through ankle disarticulation

Trans-tibial amputation Below-knee amputation

Knee disarticulation Through knee amputation

Trans-femoral amputation Above-knee amputation

Hip disarticulation Through-hip amputation

Trans-pelvic amputation Hemipelvectomy

Hindquarter amputation
Sacroiliac amputation
General principles for amputation surgery

• The greatest skin length possible

should be maintained for muscle
coverage and a tension-free closure.

• Muscle is placed over the cut end of

bones via a ,a long posterior flap
sutured anteriorly, or a well-balanced
myoplasty.
• Nerves are transected under
tension, proximal to the cut
end of bones in a scar- and
tension-free environment.

• The larger arteries and veins

are dissected and separately
ligated. This prevents the
development of
arteriovenous fistulas and
aneurysms.
 Precautions

• Close attention to soft tissue techniques.

• Avoid unnecessary dissection between skin and subcutaneous, fascial &

muscle plane.

• In adult periosteum should not be stripped proximal to the level of

transection .

• In children 0.5cm removal of distal periosteum prevents terminal growth .

 Complications
• Oedema
• Wounds and infection
• Pain
• Muscle weakness and contractures
• Joint instability
• Autonomic dysfunction
• Osseointegration specific complications
Phases of amputee rehabilitation: Modified from
Esquenazi & Meiercited in Esquenazi(2004)
1.Pre-operative
2.Amputation surgery
3.Acute post-surgical
4.Pre-prosthetic
5.Prosthetic prescription
6.Prosthetic training
7.Community integration
8.Vocational rehabilitation and
9.Follow up
 PHASES OF CARE

POSTSURGICAL PREPROSTHETIC
1. Pre operative
• The focus is on the objective assessment looking at ROM and muscle
power. 
• Provide patient with appropriate exercises to aid post-amputation
mobility.
• Breathing exercises to clear lung secretions
• Strengthening exercises
• Mobilisation for hip extension,knee flexion & extension
• Transfer from bed to chair & back
• Wheelchair mobility
• Stabilisation for trunk in sitting & standing
Pre-operative rehabilitation in lower-limb amputation patients and its
effect on post-operative outcomes(Juha M. Hijmans, 2020)

AIM:The aim of this study was to test the hypothesis that given the
positive effects of post-surgical outcomes in many patient populations,
pre-operative rehabilitation will improve post-operative outcomes
METHODS: Review of literature
CONCLUSION:The quantitative study reported a beneficial effect of pre-
rehabilitation, resulting in post-operative mobility (at least indoor
ambulation) in 63% of the included LLA patients.
Amputation surgery
• Amputation surgery and reconstruction is the responsibility of the
surgeon.
Acute post-surgical

• Goals
• Healing residual limb
• Protect remaining limb (if dysvascular)
• Independent in transfers and mobility
• Demonstrate proper positioning
• Begin psychological adjustment
• Understand the process of prosthetic rehabilitation
Acute post-surgical - General systems review
Post surgical dressing
Elastic Wrap
Why is compression bandaging important for ALL
amputees?

 Reduce edema
 Controls pain
 Enhances wound healing
 Protects incision during functional activity
 Facilitate preparation for prosthetic placement by shaping
and desensitizing limb
 *1st 4 are required even if pt. not a candidate for
prosthesis
2
 Principles of Ace-wrapping

 Distal pressure should exceed proximal

 Pressure applied on oblique turns only, No wrinkles
 Should be reapplied at least every 4 hours
 Don’t use metal clips—tape down
 No aching, burning or numbness—remove
 Wear 23 hours a day (remove for hygiene only)
 Wash daily, squeeze, don’t wring and air dry (need 2 sets)
 Continue use until pt. has definitive prosthesis & pt. can leave stump
unwrapped overnight and don prosthesis without difficulty in the
morning 6
Pre-prosthetic

Generally 6-8 weeks or longer post-operatively with soft dressings, or 3-

6 weeks with use of an Immediate Post-Operative Prosthesis (IPOP)4.
• Preparatory or training prosthesis may be used to promote residual
limb maturation and for use during gait training.
• Individuals are vulnerable to losses in strength and range of motion
(contractures) during this period
• Early walking aids (EWA) can be used to help decide on a patient’s
suitability for a prosthetic limb.
DOG EAR
Energy expenditure during ambulation with
different levels of lower-limb amputation.
(Alberto Esquenazi, MD*
Robert DiGiacomo 2001)
TRANSTIBIAL EXERCISES
Transtibial exercises:
(A) quad set,
(B) hip extension with knee straight,
(C) straight leg raise,
(D) extension of the residual limb with the knee of
the other leg against the chest,
(E) hip abduction against resistance, and
(F) bridging
TRANSFEMORAL EXERCISES

Transfemoral exercises: (A) gluteal sets, (B) hip abduction

supine, (C) hip abduction
against resistance, (D) hip extension prone, and (E) bridging
STANDING BALANCE Kneeling on a pillow on a chair
EXERCISE ON A provides an opportunity for
COMPLIANT SURFACE some weight-bearing
Prosthetic prescription

• Criteria for fitting of LE prosthesis: Wound must have healed, edema must have
resolved, the stump should be conically shaped and stump maturation should be
achieved.

• Obesity can be a limiting factor because most prosthetic devices are designed
with a maximum load of 330 lbs.

• Patients’ with advanced vascular pathology may be less likely to be able to use a
prosthetic device due to poor skin integrity, delayed healing, and impaired
aerobic capacity/endurance. If they are fit for a prosthesis, appropriate wound
healing may take an extended period of time.
Prosthetic prescription

• The physiotherapist may be needed to assist in the cast appointment,

to ensure a neutral alignment of the pelvis is obtained.

• Physiotherapy provides intervention on mobility guidance, static

balance and weight-bearing.
Medicare Functional Classification Level (MFCL) Descriptions and
Prosthetic Component Recommendations for Each Level
Transfemoral socket designs. Left, Ischial containment. Center,
Quadrilateral. Right, Subischial
Prosthetic training
For patients s/p AKA and BKA using a soft dressing after amputation, a cast for a
temporary socket is often fabricated 6-8 weeks postoperatively.
• Ambulation activities with a LE prosthesis often begin during weeks 10-11 after
amputation.
• The more proximal the amputation, the more energy is demanded from the
cardiovascular and pulmonary systems for prosthetic gait

• The physiotherapist takes a lead role at this stage.

• Beginning with educating the patient about donning and doffing the
prosthesis, skin integrity and weight-bearing areas on their residuum.
• A gait rehabilitation programme can then commence.
Typical Wearing Schedule
for New Amputee
Gait cycle and phases of gait
Normal gait cycle terminology with selected limb
electromyography representation. Human figures in the
different phases of gait with superimposed
primary muscle activity. Muscle shade intensity is roughly
proportional to strength of muscle contraction
Transtibial Gait Deviations Transfemoral Gait Deviations

Uneven Stride Length Asymmetrical Step Lengths

Abrupt Knee Flexion in Loading Response Knee Instability During Loading Response

Absent Knee Flexion in Loading Response External Foot Rotation

Visible “Pistoning” Lateral Trunk Bending

Coronal Knee Instability Excessive Lumbar Lordosis

Lateral Trunk Bending Excessive Heel Rise

Early/Late Heel Rise Swing Phase Whips

Abrupt Sound Side Loading Circumduction

Sound Side Vaulting Vaulting

Excessive Terminal Impact

COMMON GAIT
DEVIATIONS
IN
TRANSTIBIAL
TRANSTIBIAL DESCRIPTION
Absent knee flexion Knee fully extended at heel
strike
Excessive Knee Increased knee flexion at
Flexion
heel strike (or mid stance),
patient feels as though
walking downhill
CAUSES
•Faulty suspension of the prosthesis – too
soft heel cushion or plantar flexor bumpers
•Foot placement too far forward on stepping
•Lack of pre-flexion of the socket
•Discomfort/pain
• Quads weakness
•Faulty suspension of prosthesis
•Prosthetic foot set in too much dorsiflexion
•Stiff heel cushion
•Flexion contracture of the knee
•Foot too posterior in relation to socket
TRANSTIBIAL DESCRIPTION CAUSES

External External rotation of the •heel to hard

Rotation of prosthesis/foot at heel •Loose socket
Foot at Heel strike.
Strike

Knee instability Knee flexion ‘jerky’ in Weak Quadriceps

presentation during heel
strike to foot flat

Valgus/Varus Knee shifts medially or •Foot placement (medial placement causes

Moment laterally during prosthetic lateral thrust and vice versa)
stance phase •Foot alignment on the prosthesis
•Socket loose
TRANSTIBIAL DESCRIPTION CAUSES

Drop Off Heel off occurs too early •Foot too posterior on the prosthesis in
causing early knee flexion relation to the socket
•Excessive dorsiflexion of the foot on the
prosthesis
•Soft heel bumper on the prosthesis

Knee •Delayed heel causing •Foot set too far forward on the prosthesis
Hyperextension hyperextension of the in relation to socket
knee, •Too hard a heel cushion
•walking up hill sensation •Too much plantar flexion on the foot
Whip During swing phase foot •Poor suspension
‘whips’ laterally or •Knee internally or externally rotated
medially
TRANSTIBIAL DESCRIPTION CAUSES

Pistoning Amputee drops into •Lack of prosthetic socks

the socket as the foot •Suspension loose or inadequate
moves into flat foot, •Too large or faulty socket
tibia moves vertically
during alternately
weight bearing and
non-weight bearing
periods of gait
 COMMON GAIT
DEVIATIONS
IN TRANSFEMORAL
TRANSFEMO-RAL DESCRIPTION
Prosthetic Instability The prosthetic knee has a tendency
to buckle on weight bearing
Foot Slap Foot progresses too quickly from
heel strike to foot flat, creating a
slapping noise
CAUSES
•Knee set too far anterior 
•Heel cushion too firm 
•Weak hip extensors 
•Heel of the shoe too high causing the pylon of the
prosthesis to move anteriorly
•Severe hip flexion contracture
•Patient forcing foot contact to gain knee stability 
•Heel cushion too soft 
•Plantar flexion cushion too soft Excessive dorsiflexion
TRANSFEMORAL DESCRIPTION
Abducted Gait Increased base of support during
mobility, prosthetic foot placement
is lateral to the normal foot
placement during the gait cycle
CAUSES
•Prosthesis too long 
•Socket too small 
•Suspension belt may be insufficient-band may be too far
from the ileum 
•Pain in the groin or medial wall of the prosthesis 
•Hip abductor contractures 
•Lateral wall of the prosthesis not supporting the femur
sufficiently 
•Socket of prosthesis abducted in alignment 
•Fear/lack of confidence transferring weight onto
prosthesis 
•Alignment of the lower half of the pylon of the prosthesis
in relation to socket
TRANSFEMORAL DESCRIPTION •CAUSES

Lateral Trunk Bending  Trunk flexes towards prosthesis
during prosthetic stance phase
Anterior Trunk Trunk flexes forwards during
Bending  prosthetic stance phase
•Prosthesis too short 
•Short stump length 
•Weak or contracted hip abductors 
•Foot outset excessively in relation to socket 
•Lack of prosthetic lateral wall support 
•Pain on the lateral distal end of the stump 
•Lack of balance 
•Habit
TRANSFEMORAL DESCRIPTION •CAUSES

•Increased Lumbar •Lumbar lordosis is exaggerated •Poor shaping of posterior wall of the prosthesis or pain
Lordosis during prosthetic stance phase on ischial weight bearing, resulting in anterior pelvic
rotation 
•Flexion contracture at the hip 
•Weak hip extensor 
•Habit 
•Poor abdominal muscles 
•Lack of support from the anterior wall of the socket 
•Insufficient socket flexion
Whip (during swing At toe off heel moves laterally •Prosthetic knee alignment 
phase) (lateral whip) or medially (medial •Incorrect donning of the prosthesis i.e. applied internally
whip) rotated or externally rotated weakness around femur 
•Prosthetic too tigh
TRANSFEMORAL DESCRIPTION •CAUSES

Pistoning Socket dropping off when prosthesis •Insufficient suspension 

lifted •Socket too loose[2] or delayed knee flexion during toe off
(‘free knee only’) caused by increased resistance of the
prosthesis 
•Alignment of prosthesis

Excessive Heel Rise Prosthetic heel rises more than •Lack of friction on prosthetic knee 
sound side •Amputee generating more force then required to gain
knee flexion 
•Poor/lack of extension aid

Reduced Heel Rise Prosthetic heel does not rise as •Locked knee 
much as sound side •Lack of hip flexion 
•Too much friction on free knee 
•Extension aid to tight
TRANSFEMORAL DESCRIPTION CAUSES

Circumduction Lateral curvature of swing •Prosthesis too long 

phase of prosthesis •Fixed knee and poor hip hitching 
•Poor suspension causing prosthesis to slip 
•Excessive plantar flexion of the foot 
•Abduction contractures 
•Habit 
•Weak hip flexors 
•Socket too small 
•Insufficient knee flexion

Vaulting Amputee rises onto toe of •Prosthesis too long 

the non prosthetic limb •Habit and Fear of catching toe on the floor 
during prosthetic swing •Insufficient knee flexion (free knee) due to decreased confidence 
phase •Lack of ‘hip hitching’ with a ‘locked/fixed knee’ 
•Poor suspension prosthesis-slips off during swing phase 
•Socket too small 
•Excessive friction on knee flexion of the prosthesis
TRANSTIBIAL DESCRIPTION CAUSES

Terminal Impact Forcible impact as knee goes into Lack of friction of knee flexion 
extension at end of terminal swing
phase, just before heel strike Extension aid too excessive 

Absent extension bumper 

Amputee deliberately snaps knee into extension by

excessive force to ensure extension
Gait Analysis in Lower-Limb Amputation and Prosthetic
Rehabilitation (Alberto Esquenazi)

• gait analysis combined

with sound clinical
judgment play an
important role in
elucidating the factors
involved in pathologic
prosthetic gait and the
selection and effects of
the available
interventions to optimize
it.
Andrysek et al. (2012)
Original article Randomized controlled trial
• Outcome measures
• Postural control using center of pressure (COP)
• –Functional balance using the Community Balance and Mobility
Scale (CB&M)
• –Compliance, safety, feasibility using custom questionnaire

• In-home, video game-based balance training therapies can achieve excellent

compliance in children and adolescents with lower-limb amputation, but long-
term retention remains unclear
 Strengthening

Coordination

Transfer Wheelchair
Training Walking aid
Community integration

• The physiotherapist should ensure that they include

• education for ongoing management,
• strategies for coping and training for resuming functional
activities.
Vocational Rehabilitation
• Involves assessment and training for work activities, and assessment
of further education needs or job modification
• On the basis of residual functional capacity, patients may be able to
return to their previous line of work. In many cases patients’ may
choose a different line of work,dependent on the physical demands of
the job.
• For the successful reintegration of the amputee, return to work
should take place gradually, with time and workload increasing over
several weeks and clinical staff being available for counseling and
consultation
OUTCOME MEASUREMENT TOOLS

o Functional Independence Measure

o Office of Population Censuses and Surveys Scale (OPCS)
o Amputee Activity Score (AAS)
o Get up and Go Test
o 6-minute Walk Test
o Barthel Index
o Medical Outcomes Study 36-Item Short Form Health Survey
o Prosthesis Evaluation Questionnaire (PEQ)
o Locomotor Capabilities Index (LCI)
Follow up

• The consultant and/or prosthetist may ask for physiotherapy input. For
example, if the patient is having a change of prescription, their goals
have changed, their mobility has decreased/increased.

• The physiotherapist may be required to re-commence a gait

rehabilitation programme with the patient or advice only may be
required.
Advanced gait trainning
• Stairs, slopes, uneven ground
• On/off floor
• Crowded environments
• Public transport
Contraindications, Precautions, and Considerations for
Treatment
• Early Post-operative Complications
Blood loss requiring transfusion
• Deep vein thrombosis (DVT)
• Pulmonary embolism (PE)
• Cardiac complications including arrhythmia, congestive heart failure (CHF), and
myocardial infarction (MI).
• Systemic complications including pneumonia, renal failure, stroke, and sepsis.
• Complications at the surgical site include hemorrhage or hematoma, wound infection, and
failure to heal requiring additional operative interventions such as split-thickness skin
grafting (STSG), hematoma evacuation, soft tissue debridement, stump revision, and
conversion to AKA after BKA
• Phantom Limb Pain and Sensation

• Immediate post-operative incidence of phantom pain and phantom sensation

has been reported to be 72% and 84%, respectively, while the incidence at 6
months post-operatively changes to 67% and 90%, respectively.

• Both phantom pain and sensation are generally localized to the distal part of
the missing limb.

• Persons with phantom limb pain have worse or lower health-related Quality
of Life (QOL) than persons without phantom pain
Phantom Limb Pain and Sensation
• Phantom limb sensation is the sensation that the limb is still present.

• Phantom pain includes various painful sensations in the body part

that is no longer present
• Based on the person's level of pain,multiple treatments may be combined.
1. Heat application
2. Biofeedback to reduce muscle tension
3. Relaxation techniques
4. Massage of the amputation area
5. Surgery to remove scar tissue entangling a nerve
6. Physical therapy
7. TENS (transcutaneous electrical nerve stimulation) of the stump
8. Neurostimulation techniques such as spinal cord stimulation or deep brain
stimulation
9. Medications, including: pain-relievers, neuroleptics,
anticonvulsants,antidepressants, beta-blockers, and sodium channel blockers.
Phantom limb related phenomena and their rehabilitation
after lower limb amputation(R. CASALE 2009)
• Non-Pharmacologic Options
• Transcutaneous electrical nerve stimulation (TENS) shows moderate
evidence supporting its use. Low-frequency and high-intensity are
thought to be the most effective for PLP. It may also be used to help
relieve RLP.
• Mirror therapy. A small randomized trial of mirror therapy in patients
with lower leg amputation showed a significant benefit of PLP. Another
study was minimally helpful.
• Biofeedback shows limited evidence.
• Acupuncture research is still ongoing.
• Spinal cord stimulation (SCS) is obtained through an implantable
device that stimulates transdural dorsal columns of the spinal cord. It
is often effective therapy for PLP. 
• Apart from TENS and SCS, other neuromodulation approaches such
as peripheral nerve stimulation (PNS) can be helpful for both PLP and
RLP.
• Virtual and Augmented Reality has provided some novel opportunities
to utilize technology as an advanced form of "mirror therapy." 
• A sympathetic block may also help.
• Stump revision
Effectiveness of Mirror Therapy for Phantom Limb Pain: A Systematic
Review and Meta-analysis(2022)

• Objective :-To evaluate the effectiveness of mirror therapy (MT) for 

phantom limb pain (PLP).
• Study Selection:):-Randomized controlled trials (RCTs) comparing the
pain intensity of MT for PLP were performed. A total of 2094 articles
were found. Among them, 10 were eligible for the final analysis.
• Conclusions :- MT has beneficial effects for patients with PLP in the
short-term, as evidenced by their improved pain scores. There was no
evidence that MT had a long-term effect, but that may be a product of
limited data. For patients with long-term PLP, MT may be an effective
treatment.
Treatment Recommendations for Phantom Limb Pain in
People with Amputations: An Expert Consensus Delphi
Study(2021)
Characteristics of Phantom Limb Pain
Alleviated with Virtual Reality Rehabilitation
• The current findings indicate that VR
rehabilitation may be particularly
effective for PLP associated with
distorted phantom limb movement and
body representations (e.g., clamping,
gnawing), compared with typical
neuropathic sensations (e.g., shooting,
burning, dysesthesia).
• Contractures
• Pain Complications
• Neuroma formation is a natural repair phenomenon that may occur when a
peripheral nerve is transected
• Reflex sympathetic dystrophy, also called complex regional pain syndrome,
includes sensory, autonomic and motor symptoms that may occur in the
affected extremity.
• Bursitis or tendonitis may cause aggravating residual limb pain, characterized
by localized tenderness, mild edema, slight occasional erythema of the
overlying skin, increased skin temperature, and subcutaneous
crepitus.utonomic and motor symptoms that may occur in the affected
extremity.
 VA/DoD CLINICAL PRACTICE GUIDELINE FOR
REHABILITATION OF INDIVIDUALS WITH LOWER
LIMB AMPUTATION

• Department of Veterans Affairs

• Department of Defense
• 2017
 Clinical guidelines for the pre and post
operative
physiotherapy management of adults with
lower limb
amputations
• 2016
(British Association of Chartered Physiotherapists in Amputee Rehabilitation)
• The guidelines are divided into six sections for ease of
reference:

1. The role of the physiotherapist within the MDT

2. Knowledge
3. Assessment
4. Patient and carer information
5. Pre operative management
6. Post operative management
1. The role of the physiotherapist within 1.The physiotherapist contributes, as part of the MDT, to the
the MDT prediction of prosthetic use. B

2.When it is possible to choose the level of amputation the physiotherapist

should be consulted in the decision making process regarding the most
functional level of amputation for the individual. C

3.The physiotherapist, along with other professionals, should contribute in

the management of residual limb wound healing. C

2. Knowledge 1. The use of early walking aids as an assessment and treatment tool is
understood by the physiotherapist. A

2. The role of exercise therapy as an essential part of the rehabilitation

process is understood. B

3.Methods of pain relief for the post-operative treatment of phantom

pain/sensation are understood by the physiotherapist. B

4.The psychosocial issues that may affect patients following amputation and
the cognitive and psychomotor aspects affecting the rehabilitation potential
of the amputee are understood by the physiotherapist. B
3. Assessment 1. There should be written evidence of a full physical
examination and assessment of previous and present function. B

2. The patient’s social situation, psychological status, goals

and expectations should be documented. B

3. Relevant pathology including diabetes, previous arterial

reconstruction, impaired cognition and skin condition should
be noted. B

4. Patient and Carer Information 1. The physiotherapist should give patients information
about the expected stages and location of the rehabilitation
programme suited to their individual circumstances. C

2. Patients/carers should be made aware that concurrent

pathologies and previous mobility affects realistic goal setting
and final outcomes of rehabilitation. C

3. Vascular and diabetic patients and their carers should

be made aware of the risks to their remaining foot and
educated in how they can reduce them. B

4. Advice should be given to the patient/carer on the

factors affecting wound healing. B
5. Pre-op Management 1. Where possible the physiotherapist should reinforce
information given by other MDT members about the general
surgical process (not technique). C

2. The physiotherapy assessment should be commenced preoperatively,

if possible. C

3. Where appropriate and possible the patient should be

instructed in wheelchair use pre-operatively. C

4. A structured exercise regime should be started as early as

possible. C

5. Bed mobility should be taught where possible. C

6. If indicated, the patient should be assessed for

physiotherapy respiratory care. C

7. Pain control should be optimised prior to physiotherapy

treatment pre-operatively. C

8. If appropriate, and with the patient’s consent, carers

should be involved in pre-operative treatment and exercise
programmes. C
6. Post-op Management

• 6.1 Immediate post-operative care

• 6.2 Environment and equipment
• 6.3 Compression therapy
• 6.4 Mobility
• 6.5 Early walking aids (EWAs)
• 6.6 Falls management
• 6.7 Wheelchairs and seating
• 6.8 Prevention/reduction of contractures
• 6.9 Exercise programmes
• 6.10 Management of phantom sensation and pain
6.1 Immediate post- 6.1.1 Physiotherapy assessment and rehabilitation should
operative care ideally start on the first day post-operatively. C

6.1.2 Pain should be considered and adequately

controlled
prior to every treatment. C
6.1.3 Respiratory care should be given if appropriate. C

6.1.4 A physiotherapist should use their assessments

to inform the MDT regarding interventions and discharge
planning. C
6.2 Environment and 6.2.1 The physiotherapist should have knowledge of the
equipment provision of equipment that can enhance the
rehabilitation
process and facilitate activities of daily living. C

6.2.2 Physiotherapists should be familiar with the correct

use and availability of specialist amputee equipment, e.g.
slings, hoists, residual limb boards. C
6.2.3 The physiotherapist should be involved in home
visits
where necessary. C
6.3 Compression therapy 6.3.1 A compression sock should be used in preference to
elastic bandages for reducing limb volume. D
6.3.2 The physiotherapist should use compression therapy
as
appropriate. D

6.3.3 The timing of compression therapy application

should
be discussed with the MDT at an early stage. C
6.4 Mobility 6.4.1 Ideally, bed mobility should be taught on the first
day
post-operatively. C

6.4.2 Sitting balance should be re-educated if needed. C

6.4.3 Standing balance should be re-educated if needed.

C

6.4.4 Safe transfers should be taught as early as possible.

C

6.4.5 Mobility post-operatively should be in a wheelchair

unless there are specified reasons to teach a patient to
use
crutches/zimmer frame/rollator. C

6.4.6 The physiotherapist should help the patient gain

maximum mobility post-operatively. C
6.5 Early walking aids 6.5.1 EWAs should be considered as part of the
(EWAs) rehabilitation
programme for all lower limb amputation patients as an
assessment tool. B
6.5.2 EWAs should be considered as part of the
rehabilitation
programme for all lower limb amputation patients as a
treatment tool. B
6.5.3 EWAs should be used under the supervision of
therapists
trained in their correct and safe application and use. C
6.6 Falls management 6.6.1 The patient, carers and the MDT should be made
aware that the risk of falling is increased following lower
limb amputation. B

6.6.2 Rehabilitation programmes should include

education
on preventing falls. B
6.6.3 Patients and carers should be given instructions on
how to get up from the floor in the event of the patient
falling. B

6.6.4 Advice should be given in the event that the patient

is
unable to rise from the floor. B
6.7 Wheelchairs and 6.7.1 Patients should routinely be provided with a
seating wheelchair and appropriate accessories to include
residual
limb support (as appropriate) footplates, anti-tips and
appropriate pressure management devices. C
6.7.2 Where necessary the physiotherapist should be able
to assess a patient’s suitability for a wheelchair or have
knowledge of the referral process. C
6.7.3 The physiotherapist as part of the MDT should be
able to teach the patient and carer how to safely use the
wheelchair, including all accessories. C
6.8 Prevention/reduction 6.8.1 Contractures should be prevented by education of
of contractures appropriate positioning. C

6.8.2 Contractures should be prevented by education of

stretching exercises. C
6.8.3 Where contractures have formed appropriate
treatment
should be given. C
6.9 Exercise programmes 6.9.1 Following on from the initial assessment, an exercise
program should be provided to address the problems
identified. This should be reviewed and progressed as
appropriate. C

6.9.2 An exercise regime should be given relevant to the

patient’s goals and reviewed on a regular basis. C
6.10 Management of 6.10.1 As early as possible, patients should be made
phantom sensation and aware
pain they may experience phantom limb sensation or pain
postoperatively.B
6.10.2 Information and treatment regarding phantom
limb sensation and pain should be given by clinicians with
appropriate knowledge and training. B

6.10.3 Techniques for the self-management of phantom

sensation and/or pain should be taught. C

6.10.4 Appropriate information and treatment should be

given for residual limb pain. C
Thank-you