CIinicaI guideIines for the pre and post operative

physiotherapy management of aduIts with Iower

Iimb amputation
THE CHARTERED 5OCIETY Of PHY5IOTHERAPY
bRl!l'F /''CCl/!lCN
Cf CF/R!ERE0 lFY'lC!FER/ll'!'
lN /Vlu!EE REF/blLl!/!lCN 200o
8roomhead P, Dawes D, Hahcock A, Uhia P, 8luhdell A, Davies V (2006). Clihical guidelihes !or Ihe pre
ahd posI operaIive physioIherapy mahagemehI o! adulIs wiIh lower limb ampuIaIioh. CharIered
SocieIy o! PhysioIherapy, Lohdoh.
1he ehdorsemehI sIaIemehI is:
1his clihical guidelihe was ehdorsed by Ihe CSP !ollowihg a process o! experI ahd peer review.
1he recommehdaIiohs are based oh Ihe available evidehce ahd experI opihioh idehIi!ed Ihrough
cohsehsus. RecommehdaIiohs are made !or !urIher research ahd users o! Ihe guidelihe should keep
abreasI o! hew evidehce.
IS8N: 978-1-904400-20-2
Clinical guidelines for the pre and post operative
physiotherapy management of adults with lower
limb amputation
Produced by:
Penny 8roomhead
Diana Dawes
Amanda Hancock
Pragna Unia
Anne 8lundell
Vanessa Davies
And members ol lhe 8ACPAP Cuidelines Developmenl Croup
British Association of Chartered Physiotherapists
in Amputee Rehabilitation 2006
Acknowledgments
1hahks are due Io Ihe !ollowihg groups:
The Cuideline Developmenl Croup (Appendix !)
Prolessional Advisers (Appendix !)
Lileralure Appraisers (Appendix !)
Delphi Panel (Appendix !)
Lxlernal Peviewers (Appendix !)
Peer Peviewers (Appendix !)
Charlered Sociely ol Physiolherapy (CSP)
8rilish Associalion ol Charlered Physiolherapisls in Ampulee Pehabililalion (8ACPAP).

Throughoul lhis documenl adulls wilh lower limb ampulalion are relerred lo as
individuals, ampulees or palienls.

CommehIs oh Ihese guidelihes should be sehI Io:
Penny 8roomhead, Cuidelines Co-ordinalor,
8ACPAP
Nollingham Mobilily Cenlre
Nollingham Universily Hospilals
Hucknall Poad
Nollingham NC5 !P8
email. pehhy.broomheadhuh.hhs.uk
Foreword
This is lhe second guideline lhal 8ACPAP has developed, il lollows on and links lo lhe lrsl
documenl Lvidence based clinical guidelines for the physiotherapy management of adults with
lower limb prostheses.
Jhe Clinical guidelines for the pre and post operative physiotherapy management of
adults with lower limb amputation considers whal conslilules besl praclice in lhe physiolherapy
managemenl ol adulls wilh lower limb ampulalion. Agreemenl aboul ellecliveness ol inlervenlions
has been derived lrom consideralion ol research, experl opinion, palienl and prolessional experience.
Pecommendalions in lhe documenl are based on lhe above logelher wilh lhe experl opinion ol lhe
guideline developmenl group.
Peaders are encouraged lo use lhe malerial in lheir praclice laking responsibilily lor idenlilying new
inlormalion as il becomes available. The guidance given here does nol override lhe responsibilily ol
lhe physiolherapisl lo make appropriale decisions lor individual palienls, in consullalion wilh lhe
palienl and/or carer.
The documenl represenls considerable lime, ellorl and commilmenl on lhe parl ol lhe guideline
developmenl group and members ol 8ACPAP and will lorm parl ol lhe evidence base lhal will supporl
physiolherapisls in evalualing and developing lheir praclice in lhis leld.
The guideline developmenl group are lo be congralulaled on lheir ellorls and conlribulion lo
supporling besl praclice in physiolherapy lor lhe managemenl ol adulls wilh lower limb ampulalion.
Davn WheeIer
Head o! Research and CIinicaI E!!ectiveness
Chartered 5ociety o! Physiotherapy
November 2006
2
Contents
ackground and deveIopment o! the guideIines 3
lnlroduclion 3
The need lor evidence based clinical guidelines 4
The developmenl process 6
The lileralure search 7
The appraisal process 8
Cuideline developmenl and consullalion !2
The consensus process !2
The exlernal review !3
Peer review !3
lmplemenlalion and disseminalion !4
Tools lor applicalion !4
Audil !4
Peview !4
Heallh benells, side ellecls and risks !4
8arriers lo implemenlalion and cosl implicalions !5
Recommendations o! the guideIines !6
Seclion ! lhe role ol lhe physiolherapisl wilhin lhe mullidisciplinary leam !7
Seclion 2 knowledge !9
Seclion 3 assessmenl 22
Seclion 4 palienl and carer inlormalion 24
Seclion 5 pre-op managemenl 27
Seclion 6 posl-op managemenl 28
Re!erences 32
Appendicies 35
Appendix ! 8ACPAP guidelines developmenl slruclure and conlribulors 35
Appendix 2 lileralure search slralegy 39
Appendix 3 example ol a crilically appraised lopic (cal) 40
Appendix 4 lable ol papers relerenced in guidelines 4!
Appendix 5 excluded papers 54
Appendix 6 palienl, peer and prolessional advisors' commenls on lhe lramework ol lhe guidelines 55
Appendix 7 prolessional advisors' commenls on drall 2 59
Appendix 8 exlernal, peer and palienl reviewers commenls on drall 3 60
Appendix 9 Delphi queslionnaires 77
Appendix !0 Delphi queslionnaire resulls 82
Appendix !! oulcome measures 84
Appendix !2 audil dala colleclion lorm 87
Appendix !3 delnilion ol a clinical physiolherapy specialisl in ampulee rehabililalion 92
Appendix !4 glossary ol lerms 93
Appendix !5 uselul resources 94
Intrcducticn
The 8rilish Associalion ol Charlered Physiolherapisls in Ampulee Pehabililalion (8ACPAP) is a clinical
inleresl group recognised by lhe Charlered Sociely ol Physiolherapy (CSP). 8ACPAP aims lo promole
besl praclice, lhrough evidence and educalion, in lhe leld ol ampulee and proslhelic rehabililalion
lor lhe benell ol palienls and lhe prolession. ll is commilled lo research and educalion, providing a
nelwork lor lhe disseminalion ol besl praclice in pursuil ol excellence and equily whilsl mainlaining
cosl ellecliveness.
These guidelines have been produced by physiolherapisls who are members ol lhe Charlered Sociely
ol Physiolherapy and who hold Slale Pegislralion wilh lhe Heallh Prolessions Council.
A clinical guideline is nol a mandale lor praclice il can only assisl lhe clinician wilh lhe decision
making process aboul a parlicular inlervenlion. They do nol negale lhe need lor physiolherapisls lo
use lheir clinical reasoning skills or discuss choices wilh palienls. However, where a guideline
recommendalion is based on slrong evidence ol ellecliveness, lhere would need lo be an explicil
reason lor nol implemenling il lor a parlicular palienl, such as olher complicaling condilions or
palienl prelerences and lhis should be documenled !.
This guideline is derived lrom a rigorous search ol lhe lileralure, lorming recommendalions based on
lhe besl available evidence. However, lhe lack ol sullcienl high qualily published evidence meanl lhal
in order lo publish a useable guideline il was necessary lo rely heavily on consensus opinion. This was
gained lhrough a meliculous consensus exercise using physiolherapisls experienced in pre-proslhelic
rehabililalion. The need lo develop so many recommendalions lrom experl opinion highlighls lhe need
lor delailed research in lhis area ol rehabililalion. 8ACPAP has debaled lhe need lor research and has
proposed lhe lollowing lopics as priorilies lor research in lhe leld ol ampulee rehabililalion

A valid lool lo idenlily heallh benells specilc lo people wilh lower limb ampulalion
Heallh gains and benells ol proslhelic prescriplion versus wheelchair use
The impacl ol a specialisl physiolherapisl on lhe mullidisciplinary leam
(lhis has implicalions in olher areas ol rehabililalion)
Pre-operalive physiolherapy managemenl
Larly posl-operalive physiolherapy managemenl.
The guidelines are inlended as a resource lo guide applicalion ol besl praclice. They should be used in
conjunclion wilh lhe CSP Core Slandards 2.
The scope ol lhese guidelines is purposely broad. ll was nol 8ACPAP's inlenlion lo include delails ol
specilc areas ol physiolherapy managemenl as lhese would delracl lrom lhe broader overview lhal
lhese guidelines presenl.
Pecommendalions lor local implemenlalion were developed by lhe Cuidelines Developmenl Croup
(CDC) based on lheir experl knowledge. They are given lo assisl individual physiolherapisls and service
managers lo implemenl lhe recommendalions ol lhe guidelines. ll is recognised lhal local varialions in
service provision will inluence lheir implemenlalion.
These guidelines are inlended lo be uselul lo physiolherapisls working in lhis clinical area as a readily
available source ol inlormalion. They can assisl in clinical decision making, adapling knowledge inlo
praclice and providing recommendalions lo ensure compelence. lor lhe experienced clinician, lhe
guidelines can acl as a relerence lo supporl and guide clinical praclice and service provision. They are
inlended lo be a lramework lor besl praclice lhal all physiolherapisls should aspire lo achieve as parl ol
lheir prolessional responsibililies.
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1
Background and development of the guidelines 1
1he need fcr evidence based cIinicaI guideIines
Denition o! cIinicaI guideIines
'Syslemalically developed slalemenls lo assisl praclilioner and palienl decisions aboul appropriale
heallh care lor specilc circumslances' 3.
The praclice ol evidence based medicine means inlegraling individual clinical experlise wilh lhe besl
available exlernal evidence lrom syslemalic research 4.
ackground to the deveIopment o! cIinicaI guideIines in the UK
ln !997 lhe governmenl While Paper 'The New NHS modern dependable' 5 sel oul a len-year
modernisalion slralegy lor lhe heallh service. ll was lollowed by a consullalion documenl 'A lrsl class
service qualily in lhe NHS' 6 which locused on increasing lhe qualily ol care al local level wilh clear
nalional slandards.
The Nalional lnslilule lor Clinical Lxcellence (NlCL) was eslablished in !999 and has been given a remil
by lhe Deparlmenl ol Heallh lo develop nalional clinical guidelines. lurlher inlormalion aboul NlCL can
be lound al www.nice.org.uk
Since !995 lhe CSP has called lor proposals lrom ils clinical inleresl groups lo develop clinical guidelines.
ln lebruary 2003 lhe CSP endorsed 8ACPAP's lrsl clinical guideline, Lvidence 8ased Clinical Cuidelines
lor lhe Physiolherapy Managemenl ol Adulls wilh Lower Limb Proslheses, available al hllp.//www.csp.
org.uk/elleclive praclice/clinicalguidelines/physiolherapyguidelines.clm#3 7.
Pro!essionaI responsibiIity
The Covernmenl has recognised lhe need lor heallh care prolessionals lo be inlormed ol changes and
improvemenls in lheir clinical praclice and lo remain in louch wilh currenl research lndings lhal allecl
clinical decision-making. Through commilmenl lo conlinuing prolessional developmenl and lilelong
learning, physiolherapisls are required lo be releclive praclilioners and base clinical judgemenls on lhe
mosl appropriale inlormalion available.
ln lhe leld ol ampulee rehabililalion slralegic lhinking is needed lo address lhe long-lerm needs ol lhe
palienl. This involves close leamwork and consullalion belween all members ol lhe mullidisciplinary
leam including lhe palienl and lheir carers.
Resource ImpIications
The prevalence ol ampulalion is small in comparison lo olher chronic impairmenl, allecling 5!,000 ol
lhe UK populalion (approximalely 0.! ol lhe adull populalion) 8. The Nalional Ampulee Slalislical
Dalabase (NASDA8) in lheir reporl 2004/05 recorded 5,2!0 new relerrals lo proslhelic service cenlres
in lhe Uniled Kingdom (hllp.//www.nasdab.co.uk/publicalions.asp). However, as nol all palienls are
relerred lo a proslhelic service cenlre lhis does nol relecl lhe lolal incidence, which is nol published.
Major lower limb ampulalion has a prolound ellecl on qualily ol lile wilh high levels ol morbidily and
morlalily 9-!5.
Mullidisciplinary rehabililalion ol lhis clienl group consumes signilcanl resources in order lo minimise
lhe disabilily caused by lhe loss ol a limb. This includes skilled lherapeulic inpul and provision ol
coslly equipmenl.
The disseminalion ol well-researched clinical guidelines enables palienls and all grades ol clinician lo
base decisions on lhe besl available evidence. They also assisl in lhe delivery ol an ellcienl and cosl
elleclive service.
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Identi!ying the need
The Scollish Physiolherapy Ampulee Pesearch Croup (SPAPC) and lhe Audil Commission demonslraled
wide varialion nalionally in lhe qualily and lype ol service and care ollered by physiolherapisls lo adulls
wilh lower limb ampulalion 8, !6. 8ACPAP has previously idenliled lhe need lor and developed
evidence-based guidelines wilh respecl lo lhe physiolherapy managemenl ol adulls wilh lower limb
proslheses 7. A lurlher need exisls wilh regard lo lhe complex pre and posl-operalive managemenl ol
lhese palienls which lhese guidelines seek lo address.
The cIinicaI question
These guidelines address lhe queslion. "Whal physiolherapy managemenl conslilules besl praclice
lor adulls requiring lower limb ampulalion, lrom lhe pre-ampulalion phase unlil receipl ol lhe lrsl
proslhesis or complelion ol rehabililalion as a non-proslhelic user"?
Aims o! the guideIines
1hese guidelihes have beeh produced Io:
lacililale besl praclice lor lhe physiolherapy managemenl ol ampulees during lhe pre-operalive
and immediale posl-operalive phase ol care
Assisl clinical decision-making based on lhe besl available evidence
lnlorm users and carers
lnlorm service providers in order lo promole qualily and equily
Peduce varialion in lhe physiolherapy managemenl ol adulls undergoing ampulalion
lacililale audil and research
ldenlily areas ol praclice nol supporled by research.
Objectives o! the guideIines
1hese guidelihes have beeh developed Io:
Provide a comprehensive documenl which will inlorm physiolherapisls in lhe pre and
posl-operalive managemenl ol adulls wilh lower limb ampulalion
Pigorously appraise lhe currenl relevanl lileralure
Make recommendalions lor besl praclice based on lhe published evidence and experl
consensus opinion
Disseminale inlormalion
lacililale a lool lor audil and benchmarking.
5cope o! the guideIines
These guidelines address lhe pre and posl-operalive physiolherapy managemenl ol adulls wilh lower
limb ampulalion. They are applicable lo all major levels ol ampulalion, including bilaleral ampulalion,
and all causes and palhologies.
1he levels o! ampuIaIioh covered by Ihe guidelihes are:
Transpelvic
Hip disarliculalion
Trans-lemoral
Knee disarliculalion
Translibial
Ankle disarliculalion (Symes).
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The guidelines commence when lhe decision is laken lo ampulale and conlinue unlil lhe receipl ol
lhe lrsl proslhesis or unlil complelion ol rehabililalion as a non-proslhelic user. The physiolherapy
managemenl ol lhe palienl once a proslhesis is delivered is addressed in Lvidence 8ased Clinical
Cuidelines lor lhe Physiolherapy Managemenl ol Adulls wilh Lower Limb Proslheses 7 .
1he guidelihes are presehIed ih six secIiohs IhaI cover:
The Pole ol lhe Physiolherapisl wilhin lhe Mullidisciplinary Team
Knowledge
Assessmenl
Palienl and Carer lnlormalion
Pre operalive managemenl
Posl-operalive managemenl.

1he guidelihes do hoI cover:
Specilc lypes ol equipmenl such as walking aids, wheelchairs and proslhelic componenlry
Upper limb proslhelic managemenl
Proslhelic care ol lhe ampulee
Care provided by members ol lhe mullidisciplinary leam who are nol physiolherapisls
Children
Digilal and parlial lool ampulalions
Cosl ellecliveness.
1he deveIcpment prccess
GuideIine deveIopment group
A Cuidelihe DevelopmehI Croup (CDC) (Appehdix 1) was !ormed !rom:
Members ol 8ACPAP
Pepresenlalives lrom relevanl prolessional groups
CSP Ollcers
Palienl and Carer represenlalives.
The conlribuling CDC members relecled lhe necessary experience and skills needed lo compile clinical
guidelines. All members had an underslanding ol lhe use ol guidelines in assisling and inlorming clinical
praclice, wilh some members having previous experience in lhe developmenl ol olher guidelines. None
ol lhe CDC declared a conlicl ol inleresl.
8elore and during lhe projecl 8ACPAP look advice lrom lhe Charlered Sociely ol Physiolherapy (CSP)
regarding procedures lor lhe developmenl ol clinical guidelines. The CSP were kepl inlormed al regular
inlervals ol lhe progress ol lhe guidelines.
Pro!essionaI advisers
The CDC approached prolessional bodies and user groups, who were recognised as being slakeholders
and inleresled parlies, lo assisl in lhe developmenl ol lhe guidelines in lhe capacily ol prolessional
advisers (Appendix !). Their commenls and suggeslions inlormed lhe guidelines.
The collaboralive nalure ol lhis projecl relecls lhe mullidisciplinary philosophy ol rehabililalion and
enhances lhe validily ol lhe recommendalions.
funding
The guidelines were developed wilhoul exlernal lunding. The projecl was lunded by lhe CSP
and 8ACPAP.
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1he Iiterature search
Aims o! search
To idenlily lileralure relaling lo lhe pre and posl-operalive managemenl ol adulls wilh lower
limb ampulalion.
1he liIeraIure search was limiIed by:
IncIusion Criteria
ArIicles were ihcluded i! Ihey were:
Published wilhin lhe lasl 25 years (lo provide currency lo lhe recommendalions)
Published in Lnglish (lor praclical reasons)
Pelevanl lo lower limb ampulees
Pelevanl lo adulls, !8 years ol age and over
Pelevanl lo all palhologies/causes ol ampulalion
Pelevanl lo all major levels ol lower limb ampulalion i.e. lranspelvic, hip disarliculalion, lrans-
lemoral, knee disarliculalion, lranslibial and ankle disarliculalion (Symes).
ExcIusion Criteria
ArIicles were excluded i! Ihey were relaIed Io:
Proslhelic care ol lhe ampulee
Surgical managemenl ol lhe ampulee
Upper limb ampulees
Paedialric ampulees
Minor levels ol ampulalion e.g. parlial lool.
The dalabases were searched in March 2004 and lebruary 2006.
Key vords
To make lhe search as sensilive as possible MeSH lerms were used in conjunclion wilh keywords and
lree lexl. These were joined wilh 8oolean operalors (Appendix 2 shows an example and includes lhe lull
research slralegy).
The MeSH lerms used were Ampulalion, Physical Therapy, Lxercise Therapy, and Pehabililalion.
The key words and lree lexl used were Phys*, Therap*, Pehab*, Amp*, Manag*, Care, "Lower limb".
Databases
1he !ollowihg daIabases were searched !or maIerial beIweeh 1978 ahd 2006:
Cochrane Pedro
Pecal (specialisl proslhelic/orlholic dalabase) LmbaseMedline
Cinahl Amed
UnpubIished materiaI
The 8rilish Schools ol Physiolherapy and Occupalional Therapy were conlacled wilh lhe key words and
asked lo lisl relevanl lilles held in lhe libraries, bolh al under and posl graduale levels.
Conlerence proceedings (lnlernalional Sociely ol Proslhelisls and Orlholisls, 8rilish Associalion ol
Proslhelisls and Orlholisls, 8rilish Associalion ol Charlered Physiolherapisls in Ampulee Pehabililalion)
and abslracls relaling lo lhe lopic were hand searched.
No malerial relevanl lo lhe scope ol lhe guidelines was idenliled.
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1he appraisaI prccess
5eIection o! appraisaI tooI.
The Crilical Appraisal Skills programme (CASP) appraisal lool (hllp.//www.phru.nhs.uk/casp/casp.hlm)
as recommended lor use by lhe CSP and NlCL was chosen lor lhis projecl lor ils validily and
clinical applicabilily.
Training in appraisaI skiIIs
The Appraisal group (see appendix !) were lrained in lhe use ol lhe CASP appraisal lool as parl ol lhe
developmenl process ol lhe guidelines.
1he Iraihihg ihcluded:
Use ol appraisal guides lo eslimale bias
Lxlraclion ol numbers lrom papers
Conversion ol numbers inlo 'numbers needed lo lreal'
Produclion ol a declaralive lille aboul lhe arlicle lndings
Lslablishmenl ol level ol evidence.
1he appraisers gaihed khowledge o!:
CASP appraisal lool
Dillerenl slyles ol papers e.g. lherapy, diagnosis, randomised conlrol lrial
Numerical analysis
Levels ol evidence.
5eIection o! articIes !or appraisaI
Arlicles were examined and selecled lor appraisal, based on a review ol lhe abslracl.
Using lhe inclusion and exclusion crileria lhe arlicles were assessed as.
'nol relevanl',
'maybe relevanl',
'possibly relevanl'
'delnilely relevanl'.

based on lhe agreemenl ol al leasl lwo CDC members. Any arlicles in lhe calegory 'nol relevanl'
were rejecled al lhis slage. ll lhere was disagreemenl lhe arlicle was discussed by lhe appraisal group
and a majorily decision laken. All remaining arlicles were relrieved lor appraisal by lhe CASP lrained
physiolherapisls (ligure !, page !0).
Appraising the Iiterature
Two hundred and lhree published papers were relrieved. Arlicles were excluded il al leasl lwo ol lhe
appraisers lell lhe sludy was eilher.
nol relevanl lo lhe guidelines
ol poor sludy design (e.g. described as PCT bul nol randomised, no delned/validaled
oulcome measure)
1
8
conlained poor qualily evidence (e.g. nol sullcienl lollow up, groups were loo
dillerenl, incorrecl slalislics).
or
was purely descriplive.
The appraisal group resolved any disagreemenl over calegorisalion. Thirly-lve papers were agreed as
suilable lor crilical appraisal.
1hese IhirIy-!ve arIicles were classi!ed as:
Therapeulic
Diagnoslic
Prognoslic
Aboul harm or aeliology
Syslemalic review
Lconomical analysis.
No syslemalic reviews were lound.
Seven groups, each consisling ol lwo appraisers, appraised lhe arlicles independenlly. The lwo
appraisers discussed dillerences in opinion and a Crilically Appraised Topic (CAT) was wrillen. ll lhe lwo
did nol agree il was relerred lo lhe wider group lor discussion and a CAT concluded by majorily decision
(page !!)
1
9
Papers retrieved
CA1s sent to two members
of team for hrst draft
of guideIines
"hot reIevant"
iscarded
If disagreement discussed
with team
Search using MeSh terms, free
text and keywords combined with
8ooIean operators
ArticIes assessed as not reIevant/
maybe reIevant/possibIy reIevant/
dehniteIy reIevant
Papers read by two appraisers and
cIassihed as to reIevance
Papers categorised according to
study design
Papers read by two appraisers,
CA1 written and grade of
evidence given
1
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CAT-maker was used lo record lhis process. CAT-maker is a compuler programme designed lo organise
and summarise lhe evidence (Appendix 3).
1he CA1-maker assisIs by:
carrying oul lhe clinical calculalions
sloring appraisals (as well as search slralegies lhal led lo lhem)
generaling lles lhal can be lormalled wilh word processors, slored and prinled lor olher
leam members.
Ol lhe lhirly-lve papers lhal were appraised seven were considered nol suilable lor inclusion inlo lhe
guidelines, lhey were eilher anecdolal papers or nol relevanl lo lhe guidelines. ln addilion, lhe papers
used lo inlorm lhe Lvidence 8ased Clinical Cuidelines lor lhe Physiolherapy Managemenl ol Adulls wilh
Lower Limb Proslheses7 were examined lor lheir relevance lo lhe pre-proslhelic phase. This provided
anolher lhirly papers. ln lolal llly-eighl papers ol supporling evidence inlormed lhe guideline.
Update o! appraisaI
The lileralure search was updaled in lebruary 2006 and !4 arlicles were lound. None were considered
suilable lor inclusion inlo lhe guidelines. The same appraisal prolocol was adhered lo.
CIassication o! articIes
ArIicles were classi!ed accordihg Io Ihe levels o! evidehce recommehded ih Ihe CSP Ih!ormaIioh
Paper ho CLLF07 [1]:
la Lvidence oblained lrom a syslemalic review ol randomised conlrolled lrials
lb Lvidence oblained lrom al leasl one randomised conlrolled lrial
lla Lvidence oblained lrom al leasl one well-designed conlrolled sludy wilhoul randomisalion
llb Lvidence oblained lrom al leasl one olher lype ol well-designed quasi-experimenlal sludy
lll Lvidence oblained lrom well-designed non-experimenlal descriplive sludies, such as
comparalive sludies, correlalion sludies and case sludies
lV Lvidence oblained lrom experl commillee reporls or opinions and/or clinical experience ol
respecled aulhorilies.
Adapled lrom A hierarchy ol evidence, NlCL, 200!.
A lable ol lhe papers used lo develop lhe recommendalions and lheir level ol evidence is presenled in
Appendix 4.
Papers appraised bul nol used are lisled in appendix 5.
1hey were hoI used i! Ihe appraisal Ieam cohsidered Ihem Io be:
irrelevanl lo lhe guideline
ol poor sludy design
or
conlained poor qualily evidence.
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6uideIine deveIcpment and ccnsuItaticn

lollowing appraisal ol lhe lileralure a CDC consensus conlerence was held lo review lhe
lileralure evidence and agree a lramework lor lhe guideline
Seclions were idenliled covering lopics relaling lo lhe clinical queslion. The seclion headings
were decided on by using lhe
CSP Slandards ol physiolherapy praclice lor lhe managemenl ol palienls wilh ampulalions!7
CSP Core Slandards2
Knowledge and experlise ol lhe CDC
Palienls, prolessional advisors and peer reviewers were consulled on lhe proposed lramework
lor lhe guideline (Appendix 6). Their commenls were used lo lurlher delne and clarily lhe
scope and lramework ol lhe documenl. lor example, suggesling addilional delail and lopics
wilhin seclions, splilling seclion 6 inlo subseclions and placing recommendalions on wheel
chairs and discharge planning more approprialely
A lrsl drall was produced using evidence lrom lhe lileralure
The CDC used lheir exlensive clinical experience and knowledge base, lhe CSP Slandards ol
physiolherapy praclice lor lhe managemenl ol palienls wilh ampulalions!7 and lhe CSP Core
Slandards2 lo idenlily areas ol clinical praclice relevanl lo lhe guidelines nol supporled by
evidence lrom lhe lileralure (gaps in lhe evidence)
Caps in lhe evidence were used lo lormulale lhe inilial queslions posed lor consensus opinion
Three rounds ol lhe Delphi process were used lo gain consensus opinion and lhe resulling
recommendalions were incorporaled inlo a second drall
The prolessional advisor's commenls were soughl on lhe second drall and assimilaled
(Appendix 7)
An updaled lileralure search was underlaken bul no addilional evidence was lound lo add lo
lhe guidelines
The lhird drall was circulaled lor peer and exlernal review and amended accordingly
(Appendix 8)
The lnal (lourlh) drall was submilled lo lhe CSP lor endorsemenl.

1he ccnsensus prccess
The DeIphi technique
Where lhe lileralure did nol provide sullcienl evidence lo develop recommendalions wilhin lhe areas
idenliled consensus opinion was soughl. The Delphi Technique was chosen lo oblain consensus
opinion where lhe lileralure was lacking. This melhod involves a series ol queslions lo 'oblain lhe mosl
reliable consensus ol opinion ol a group ol experls...by a series ol inlensive queslionnaires inlerspersed
wilh conlrolled opinion leedback'!8. Allhough more lime consuming and labour inlensive lhan a
conlerence, lhe Delphi Technique ensures.
all conlribulors have an equal voice
consideralion ol lhe possible oplions lor lrealmenl
conlribulors have lhe opporlunily lo conlribule lo and develop lhe guidelines.
The consensus paneI
The consensus panel consisled enlirely ol physiolherapisls because lhe Delphi queslions were direclly
relaled lo physiolherapy praclice.
All 8ACPAR members (164) were asked Io parIicipaIe i! Ihey !ul!lled Ihe !ollowihg criIeria:
lhey were working as a senior physiolherapisl or clinical specialisl
lhey had worked mainly wilh ampulees (pre- and posl-surgery) lor a minimum ol lwo years
1
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lhey had poslgraduale lraining in lhe leld ol ampulalion rehabililalion.

lilly 8ACPAP members mel lhe eligibilily crileria and agreed lo parlicipale in lhe inilial round
ol queslions.
The DeIphi process
The CDC decided lhal il 75 or more ol lhe respondenls scored more lhan 75 agreemenl wilh a
slalemenl, consensus would be reached. ll consensus was below 75 lhe slalemenl would nol have
lhe agreemenl ol lhe panel and lhe queslion was relned lor a second round, and il necessary a lhird
round. ll no consensus was reached aller all rounds ol queslionnaires lhen no recommendalion would
be wrillen.
A poslal queslionnaire was developed (Appendix 9). An explanalory leller was senl wilh lhe
queslionnaire and copies ol lhe drall evidence based guidelines were supplied.
ResuIts o! the DeIphi process
lilly queslionnaires were senl oul in lhe inilial round. lorly-lhree were relurned, a response rale ol 86.
Lighleen queslions (28) produced agreemenl ol less lhan 75. Thirly-lve queslions (55) had
agreemenl grealer lhan 90 and eleven (!7) had agreemenl belween 75-90 (Appendix 8).
Using lhe commenls made in lhe lrsl round lhe eighleen queslions which did nol have consensus were
redralled lor lhe second round. An addilional !0 queslions were dralled having been generaled lrom
lhe lrsl round commenls. These 28 queslions (Appendix 9) were submilled lo lhe panel.
The response rale lo lhe second round was 78. Crealer lhan 75 agreemenl was gained in 23
queslions and consensus was considered lo have been reached (Appendix !0). Unlorlunalely, no
consensus was gained on 5 queslions. One queslion was dropped lrom lhe guidelines as il was clear
lrom lhe responses lhal consensus would nol be gained. The olher 4 queslions were redralled using lhe
commenls lrom lhe lrsl and second rounds and submilled lo lhe panel (one queslion was splil inlo 2
queslions, making a lolal ol 5 queslions).
The response rale lo lhe lhird round was 82 and grealer lhan 75 agreemenl was gained on all
5 queslions.
1he externaI review
Lxperls in lhe developmenl ol evidence based clinical guidelines were chosen lo relecl dillerenl
backgrounds and perspeclives (Appendix !). Peviewers were asked lo commenl on lhe process ol
developmenl, ils validily and applicabilily, lormal and presenlalion, using lhe Appraisal ol Cuidelines lor
Pesearch and Lvalualion (ACPLL) appraisal inslrumenl as recommended by lhe CSP !.
Their commenls and suggeslions were considered and lhe documenl amended accordingly (Appendix 8).
lor example. The seclion on barriers lo implemenlalion was expanded, lhis was assisled by commenls
lrom lhe peer reviewers.

CommehIs ihcluded:
Jhe 8ACPAR guideline development group (CDC) has produced a well-researched and
thorough guideline for the Pre and Post-Operative Physiotherapy Management of Adults with
Lower Limb Amputation. Jhis guideline rates very well overall with a few minor details that the
CDC may wish to consider
Congratulations on the document
On the whole a very comprehensive document.
Feer review
Twelve physiolherapy slall ol various clinical grades and experience in lhe leld ol ampulee rehabililalion
and lhree palienls and lheir carers were asked lo lesl lhe guidelines (Appendix !). They were asked
lo commenl on lhe applicabilily and presenlalion ol lhe recommendalions and lhe praclicalilies ol
implemenlalion (Appendix 8). Alleralions were made lo lhe presenlalion ol lhe guidelines lollowing
lheir recommendalions.
1
13
lor example. Slalemenls on discharge planning and lransler ol care were added lo seclion !. Several
minor changes lo lhe wording ol lhe documenl were made lo improve lhe ease ol use and readabilily.
Several ol lhe peer reviewers commenled on lhe lack ol published evidence in lhis leld ol rehabililalion.
lor example, 'Nol really surprised al lhe lack on evidence relaling lo physiolherapy. ll's lhe same in
all areas'.
The guidelines also highlighl areas which are currenlly nol well supporled wilh evidence, which may in
lulure become areas lo consider researching.
OIher commehIs ihcluded:

Presentation is well structured, clear and concise throughout.
Jhe evidence presented is perfectly clear and understandable.
Recommendations very nicely set out, easy to access the guidelines and the evidence for each.
Jhey would provide a framework from which we could audit the present system and then
develop towards.
l feel that they are very far reaching and would be an excellent guide (especially to less
experienced clinicians) of the sheer scope of considerations they need to take into account.
A huge amount of work has obviously gone into this - it is very comprehensive and impressive,
especially knowing that it has been put together by volunteers and through good will.
The palienls and carers who reviewed drall lhree underslandably had dillcully wilh lhe medical
lerminology and phraseology used. The largel users ol lhis guideline are physiolherapisls and a
documenl lor palienls and carers use would be wrillen in a very dillerenl lormal.
ImpIementaticn and disseminaticn
The Lvidence 8ased Clinical Cuidelines lor lhe Physiolherapy Managemenl ol Adulls wilh Lower
Limb Proslheses7 published in 2003 were enlhusiaslically laken up inlernalionally, including by lhe
lnlernalional Ped Cross. These guidelines are inlended lo complimenl lhose already published.
ll is recommended lhal lhe CSP Core Slandards (2005) 2 are used alongside lhese guidelines.
As lhese guidelines have been endorsed by lhe CSP a slralegy lor implemenlalion and disseminalion has
been joinlly agreed by lhe CSP and 8ACPAP.
1ccIs fcr appIicaticn
Suggesled oulcome measures are lisled in appendix !!.
Audit
An audil lool is suggesled in Appendix !2.
Reviev
8ACPAP will updale lhese evidence-based guidelines every lhree years.
KeaIth benets, side effects and risks
The recommendalions wilhin lhe guidelines are evidence based and supporl besl praclice, however al
lhe lime ol wriling, no valid lool specilc lo people wilh an ampulalion was available lo measure
heallh benells.
The benells ol lhe approach lo lrealmenl recommended by lhe guideline are idenliled in lhe
inlroduclion and evidence presenled in each seclion.
No side ellecls or risks were idenliled lrom lhe lileralure, prolessional advisers or consensus panel.
1
14
8arriers tc impIementaticn and ccst impIicaticns
ln order lo implemenl lhe recommendalions in lhese guidelines a number ol laclors should be
considered which may inluence lheir implemenlalion.
Allhough implemenlalion ol lhese guidelines may have cosl implicalions a cosl benell analysis
could nol be underlaken. The dala required lo enable an economic evalualion ol ampulee
rehabililalion was nol available al lhe lime ol publicalion bul il is expecled lhal lhe inlroduclion
by lhe NHS ol 'Paymenl by Pesulls' will inlorm lhis economic evalualion in lhe lulure
lmplemenling lhese guidelines may involve lurlher lraining ol slall
lnappropriale skill mix and/or underslallng will limil service developmenl
The co-operalion ol olher members ol lhe Mullidisciplinary Team is required lor lull
implemenlalion ol lhese guidelines
Pesislance lo change ol praclice
Organisalional and operalional praclises/syslems will need lo supporl lhe recommendalions
Abilily lo access a suilable environmenl.
Overcoming barriers lo implemenlalion will require change and change managemenl skills. Pesources,
such as lools and lechniques, lo supporl and lacililale change should be accessed lhrough locally
agreed roules.
1
15

The Cuidelines are divided inlo six seclions lor ease ol use.
1. The roIe o! the physiotherapist vithin the muItidiscipIinary team
2. KnovIedge
3. Assessment
4. Patient and carer in!ormation
5. Pre-operative management
6. Post-operative management.
Lach seclion includes an inlroduclion, a summary ol lhe evidence, lhe relevanl recommendalions and
suggeslions lor local implemenlalion.
Grading GuideIine Recommendations (NICE 2001)
Grade Evidence
A Al leasl one randomised conlrolled lrial as parl ol a body ol lileralure ol overall good
qualily and consislency addressing lhe specilc recommendalion (evidence levels la and lb)
8 Well conducled clinical sludies bul no randomised clinical lrials on lhe lopic ol lhe
recommendalion (evidence levels lla, llb and lll)
C Lxperl commillee reporls or opinions and/or clinical experience ol respecled aulhorilies.
This grading indicales lhal direclly applicable clinical sludies or good qualily are absenl
(evidence lV)
D Pecommended good praclice based on lhe clinical experience ol lhe Cuidelines
Developmenl Croup

Pecommendalions were developed and graded according lo lhe levels ol evidence ol lhe papers
appraised. Aller each ol lhe recommendalions lhe number in brackels relers lo lhe level ol evidence,
lhe leller relers lo lhe grade ol recommendalion. Where a number ol sources ol evidence were used lo
develop a recommendalion lhe grade was based on lhe highesl level ol evidence used.
A lable ol lhe papers used lo develop lhe recommendalions and lheir level ol evidence is presenled in
Appendix 4.
Pecommendalions lor local implemenlalion are given lo assisl individual physiolherapisls and service
managers lo implemenl lhe recommendalions ol lhe guidelines.

Recommendations of the guidelines 2
2
16
Secticn 1 - 1he rcIe cf the physictherapist within the
muItidiscipIinary team
Introduction
A specialisl mullidisciplinary leam (MDT) achieves lhe besl rehabililalion oulcome!9, 20.
To provide an elleclive and ellcienl service lhe leam work logelher lowards goals agreed wilh lhe
palienl. The physiolherapisl plays a key role in coordinaling palienl rehabililalion2!.
The Charlered Sociely ol Physiolherapy (CSP) Core slandards 2 oulline lhe role ol lhe physiolherapisl
wilhin a MDT. These slandards emphasise lhe need lor physiolherapisls lo be aware ol lhe roles ol olher
members ol lhe MDT and lo have clear prolocols and channels ol relerral and communicalion
belween members.
To rehabililale people who have had an ampulalion lhe core mullidisciplinary leam (MDT) may include.
specialisl physiolherapisl, specialisl occupalional lherapisl, surgeon, specialisl nurse and social worker.
Addilional MDT members include. diabelic leam, dielician, general praclilioner, specialisl nurses, housing
and home adaplalion ollcer, orlholisl, podialrisl, counsellor, psychologisl, social services leam, social
worker, pain conlrol leam, wheelchair services, proslhelic services and communily services.
Evidence
The mullidisciplinary leam approach lo rehabililalion lollowing ampulalion is recognised inlernalionally
as lhe rehabililalion mode ol choice, however lhere is lillle published lileralure lo supporl lhis. Campbell
el al22 concluded lrom a case series ol 6! people wilh an ampulalion lhal lhe MDT can reasonably
predicl proslhelic oulcome 85 ol lhe lime in predicled users and 65 ol lhe lime in predicled non
users. Ham el al2! in a case conlrolled sludy suggesled lhal vascular ampulees benell lrom care by a
specialisl MDT resulling in reduced hospilal slay and oul palienl re-allendance.
ln addilion lo Ham el al2!, lwo olher papers supporl lhe role ol lhe physiolherapisl wilhin lhe MDT.
Condie el al23 lound lhal in a cohorl ol Scollish people wilh a lower limb ampulalion lhe lime lrom
surgery lo casling was reduced when lhe palienls received physiolherapy. Klingenslierna24 concluded
lrom 8 case sludies lhal exercise improves lhigh muscle slrenglh in people wilh a lranslibial ampulalion.
ln lhe absence ol olher evidence on lhe role ol lhe physiolherapisl consensus opinion was soughl lo
lurlher inlorm lhis seclion.
Recommendations
1.1 WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes exercise
Iherapy. 8 (III) [24]
1.2 WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes assessmehI
ahd IreaImehI wiIh early walkihg aids. 8 (III) [23]
1.3 1he physioIherapisI cohIribuIes, as parI o! Ihe mulIidisciplihary Ieam, Io Ihe predicIioh
o! prosIheIic use. 8 (III) [22]
1.4 A physioIherapisI specialised ih ampuIee rehabiliIaIioh (Appehdix 13) should be
respohsible !or Ihe mahagemehI o! physioIherapy care. C (IV) [21]
1.5 Wheh iI is possible Io choose Ihe level o! ampuIaIioh Ihe physioIherapisI should be
cohsulIed ih Ihe decisioh makihg process regardihg Ihe mosI !uhcIiohal level o!
ampuIaIioh !or Ihe ihdividual. C (IV) [25]
1.6 1he physioIherapisI should be ihvolved ih producihg proIocols Io be !ollowed by Ihe
MD1. C (IV) [25]
1.7 1here should be ah agreed procedure !or commuhicaIioh beIweeh Ihe physioIherapisI
ahd oIher members o! Ihe MD1. C (IV) [25]
1.8 WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes compressioh
Iherapy. C (IV) [25]
1.9 A physioIherapisI experiehced ih ampuIee rehabiliIaIioh cah, as parI o! Ihe MD1, be
solely respohsible !or Ihe decisioh Io sIarI usihg Ihe Larly Walkihg Aid havihg liased
wiIh oIher members o! Ihe MD1 as hecessary. C (IV) [25]
2
17
1.10 1he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe ih Ihe
mahagemehI o! residual limb wouhd healihg. C (IV) [25]
1.11 1he physioIherapisI, alohg wiIh oIher pro!essiohals should cohIribuIe Io Ihe
mahagemehI o! pressure care. C (IV) [25]
1.12 1he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe Io Ihe
mahagemehI o! wouhd healihg oh Ihe cohIra laIeral limb i! applicable. C (IV) [25]
1.13 1he physioIherapisI, as parI o! Ihe MD1, should cohIribuIe Io Ihe mahagemehI o! paih
as hecessary. C (IV) [25]
1.14 1he physioIherapisI, as parI o! Ihe MD1, should be ihvolved ih makihg Ihe decisioh Io
re!er Ihe paIiehI !or a prosIheIic limb. C (IV) [25]
1.15 1he physioIherapisI should cohIribuIe Io Ihe decisioh oh which MD1 ouIcome measures
are Io be used. C (IV) [25]
1.16 1he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe Io Ihe paIiehI's
psychological ad|usImehI !ollowihg ampuIaIioh. C (IV) [25]
1.17 1he physioIherapisI should be able Io re!er direcIly Io a clihical psychologisI / couhsel
lor i! appropriaIe. C (IV) [25]
LocaI impIementation
The MDT agrees ils approach lo rehabililalion
Poles and responsibililies are agreed wilhin lhe MDT
Palienl and public involvemenl should underpin service delivery and developmenl
Channels ol communicalion and opporlunilies lor educalion and discussion should
be eslablished
Annual largels lor educalion, audil and research should be sel
lnlegraled care palhways should be used
Conlacl delails ol MDT members should be readily available lo lhe palienl and carers
Access lo olher slakeholder agencies should be underslood and agreed lo lacililale discharge
planning and lransler ol care e.g. lnlermediale Care Teams, Social Services elc
A summary ol lhe palienl's lrealmenl and slalus al lransler or discharge should be documenled
in lhe medical noles, wilh delails ol arrangemenls lor lurlher lrealmenl.
2
18
Secticn 2 - kncwIedge
Introduction
ln order lo provide elleclive rehabililalion lhe physiolherapisl needs a good underslanding ol lhe laclors
lhal may inluence lhe oulcome ol rehabililalion 25.
The physiolherapisl also needs lo have an underslanding ol proslhelic prescriplion principles and lhe
proslhelic rehabililalion process lo successlully plan and deliver rehabililalion 25.
Knowledge ol lhe complicalions lhal may arise lollowing ampulalion ol lhe lower limb and how
members ol lhe MDT may deal wilh lhese complicalions is essenlial in order lhal lhe rehabililalion
process may be adapled lo accommodale lhese laclors 26, 27.
Underslanding ol lhe psychological implicalions ol ampulalion is necessary and lhe physiolherapisl
should be aware ol how lhese issues may be deall wilh by lhe physiolherapisl and olher members ol lhe
MDT 28.
The physiolherapisl is responsible lor keeping up lo dale wilh developmenls in ampulee rehabililalion.
This should include awareness ol published guidance and recommendalions (see Appendix !5 lor Uselul
Pesources).
Evidence
Concurrenl condilions will inluence rehabililalion polenlial and lhe physiolherapisl should be aware ol
lhese 25. ln a non-syslemalic overview ol 7! sludies Pernol 20 suggesls lhal concurrenl condilions
along wilh increasing age are prognoslic ol a low level ol lunclion. ln a relrospeclive case series ol 52
dysvascular, hemiplegic palienls Allner 29 lound lhal only neuromuscular slalus had any signilcance
on lhe mobilily ol lhis group ol palienls. Crieve 9, in a case series ol 26 palienls, lound lhal co-
morbidily is associaled wilh lower levels ol lunclion.
ln a !997 pilol sludy ol !0 palienls (7 wilh abnormal resling LCC) wilh peripheral vascular disease,
8ailey el al 30 invesligaled LCC abnormalilies during walking wilh a pneumalic posl-ampulalion
mobilily aid. They lound normal blood pressure elevalion in nine palienls and group mean age-predicled
maximum hearl rale ol less lhan 70, suggesling appropriale exercise levels. However, 5 palienls
reached over 70 ol age-predicled maximum hearl rale. They suggesl lhal physiolherapisls need lo pay
close allenlion lo palienls' cardiac slalus during rehabililalion.
A relrospeclive charl review ol 38 palienls by Czyrny 3! concluded lhal end slage renal disease does
nol reduce lunclional oulcome in palienls wilh ampulalions due lo peripheral vascular disease.
ln a prospeclive case series ol !6 heallhy males Push 32 lound lhal lhere is an increased risk ol
osleopenia in lhe lemur ol lhe ampulaled limb.
ln a prospeclive cohorl ol 2! diabelic palienls wilh unilaleral, lranslibial ampulalions Jayalunga 33
lound lhal lhe use ol orlhoses/appropriale loolwear reduced lhe risk ol damage due lo diabelic
neuropalhy.
lour case series 34-37 have looked inlo lhe relalionship belween ampulalion level and rehabililalion
oulcome. ln 2 ol lhese sludies il was shown lhal palienls wilh a lranslibial ampulalion have a
grealer chance ol succeeding wilh a proslhesis lhan lhose wilh a lrans-lemoral ampulalion 34, 37.
8eekman 35, in a case series ol 55 vascular palienls lound lhal people wilh a lrans-lemoral or knee
disarliculalion ampulalion perlorm al a lunclionally lower level lhan bi-pedal subjecls. ln a relrospeclive
case series ol !8 bilaleral vascular ampulees, Woll 36 concluded lhal 50 ol bilaleral lranslibial
ampulees could be rehabililaled on lwo proslheses.
Ward and Meyers 38 in lheir review lound evidence lhal lhe energy cosl ol ambulalion is grealer wilh
ascending levels ol ampulalion. They also describe lhal wilh daily exercise people wilh an ampulalion
consume signilcanlly less oxygen (i.e. use less energy).
2
19
Use ol lhe early walking aid is well documenled 39, 40. ln a randomised conlrolled lrial ol 80 people
undergoing lower exlremily ampulalion, Pollack 40 lound lhal using a pneumalic proslhesis leads lo
lewer pulmonary, cardiac, urinary lracl and wound complicalions. Lein 39 lound in a cross seclional
survey ol 58 physiolherapisls lhal lhere was a lack ol availabilily ol lhe Vessa Ppam Aid and lhal some
physiolherapisls are using il in a "polenlially dangerous manner" by nol lollowing lhe manulaclurers
inslruclions, lhereby risking wound breakdown.
lour case series, a relrospeclive cohorl and a case conlrol sludy agree lhal exercises play an imporlanl
parl in lhe lunclional rehabililalion programme 24, 30, 4!-43.
Discharge dala lor ampulees in Scolland over a 3 year period 23 shows lhal lhe use ol compression
socks lo conlrol oedema ol lhe residuum can reduce lhe lime lo proslhelic rehabililalion. Lamberl 44
in an audil ol physiolherapisls working in arlilcial limb unils lound lhal compression socks are
widely used.
McCarlney 45 concluded lrom his cross seclional sludy lhal !0 ol palienls had lheir qualily ol lile
allecled by phanlom pain/ sensalion. Smilh 46 lound by use ol a palienl queslionnaire lhal il was
nol uncommon lor ampulees lo experience phanlom limb sensalion/pain. Morlimer 47 suggesls in a
well conducled qualilalive sludy lhal accurale inlormalion on phanlom limb pain / sensalion should be
provided by an individual wilh appropriale knowledge and lraining. A !994 case conlrol sludy by Liaw
48 concluded lhal acupunclure may lemporarily reduce pain.
laclors allecling wound healing include smoking, malnulrilion, previous surgery, gangrene, level ol
ampulalion, anlibiolics, diabeles, surgical lechnique, dressings and drains. No one laclor can be looked
al in isolalion 26.
ln a relrospeclive cohorl ol 254 lower limb ampulees, Meikle 49 lound lhal inlerruplions lo
rehabililalion are common and resull in longer periods ol rehabililalion bul lhe oulcome is nol
adversely allecled.
A sludy by Delahanly 28 ol palienls belore and aller insligaling a psychoeducalional inlervenlion
concludes lhal psychological supporl is benelcial. Hanspal 50, in a relrospeclive case series, lound lhal
oulcome is allecled by cognilive and psychomolor lunclion.
No evidence was available lo supporl lhe need lor an underslanding ol palhology, invesligalions
or surgical lechniques used. lurlher evidence is required regarding long lerm ellecls ol osleopenia,
awareness ol complicalions which may arise, counselling skills and psychology. This evidence was
galhered using lhe Delphi Technique.
Recommendations
2.1 1he use o! early walkihg aids as ah assessmehI ahd IreaImehI Iool is uhdersIood by Ihe
physioIherapisI. A (Ib) [30, 39, 40, 51]
2.2 1he physioIherapisI is aware IhaI level o! ampuIaIioh, pre-exisIihg medical cohdiIiohs
ahd social ehvirohmehI will a!!ecI rehabiliIaIioh. 8 (IIa) [9, 20, 25, 30, 34-36, 52-56]
2.3 1he role o! exercise Iherapy as ah essehIial parI o! Ihe rehabiliIaIioh process is
uhdersIood. 8 (IIb) [24, 30, 38, 41-43, 57, 58]
2.4 1he impacI o! Ihe level o! ampuIaIioh oh rehabiliIaIioh poIehIial is uhdersIood by Ihe
physioIherapisI. 8 (III) [25, 34-38, 56, 59]
2.5 1he physioIherapisI has ah uhdersIahdihg o! Ihe predisposihg !acIors Io success!ul (ahd
uhsuccess!ul) rehabiliIaIioh. 8 (III) [25, 29-31]
2.6 1he various Iechhiques !or cohIrol o! oedema o! Ihe residuum are uhdersIood
by Ihe physioIherapisI. 8 (III) [23, 44]
2.7 1he physioIherapisI is aware IhaI paih (o! Ihe residuum, phahIom or lower back) may
a!!ecI Ihe qualiIy o! li!e o! Ihe ampuIee. 8 (III) [45, 46]
2.8 MeIhods o! paih relie! !or Ihe posI-operaIive IreaImehI o! phahIom paih/sehsaIioh are
uhdersIood by Ihe physioIherapisI. 8 (III) [47, 48]
2.9 1he physioIherapisI has ah awarehess o! Ihe lohg Ierm e!!ecIs o! ampuIaIioh.
8 (III) [32, 38]
2
20
2.10 1he physioIherapisI uhdersIahds Ihe !acIors a!!ecIihg Ihe healihg o! residuum wouhds.
8 (III) [26]
2.11 1he psychosocial issues which may a!!ecI paIiehIs !ollowihg ampuIaIioh ahd Ihe
coghiIive ahd psychomoIor aspecIs a!!ecIihg Ihe rehabiliIaIioh poIehIial o! Ihe
ampuIee are uhdersIood by Ihe physioIherapisI. 8 (III) [28, 50, 55]
2.12 1he risk o! damage Io Ihe remaihihg diabeIic/heuropaIhic !ooI is uhdersIood by Ihe
physioIherapisI. 8 (III) [33]
2.13 1he physioIherapisI should have ah uhdersIahdihg o! complicaIiohs IhaI may arise
!ollowihg ampuIaIioh. C (IV) [25]
2.14 1he physioIherapisI should have ah uhdersIahdihg o! Ihe paIhology leadihg Io
ampuIaIioh. C (IV) [25]
2.15 1he physioIherapisI should have khowledge o! medical ihvesIigaIiohs commohly
uhderIakeh prior Io ampuIaIioh ahd Iheir sighi!cahce. C (IV) [25]
2.16 1he physioIherapisI should have khowledge o! surgical Iechhiques used ih ampuIaIioh.
C (IV) [25]
2.17 1he physioIherapisI should be aware o! oIher guidelihes relevahI Io rehabiliIaIioh
!ollowihg ampuIaIioh. C (IV) [25, 49]
2.18 1he physioIherapisI should have khowledge o! Ihe prihciples o! prosIheIic prescripIioh.
C (IV) [25]
2.19 1he physioIherapisI should be aware o! Ihe possible psychological e!!ecIs which may
occur !ollowihg ampuIaIioh. C (IV) [25]
2.20 1he physioIherapisI should khow wheh iI is appropriaIe Io re!er a paIiehI Io a clihical
psychologisI/couhsellor. C (IV) [25]
2.21 1he physioIherapisI should have basic khowledge o! Ihe prihciples o! couhsellihg.
C (IV) [25]
2.22 1he physioIherapisI should be aware o! Ihe socio-ecohomic impacI o! lower limb
ampuIaIioh. C (IV) [25]
2.23 1he physioIherapisI should be aware o! Ihe sysIems ih place Io re!er !or assessmehI !or
a prosIhesis. C (IV) [25]
2.24 1he physioIherapisI should have basic khowledge o! Ihe provisioh o! wheelchairs ahd
accessories. C (IV) [25]
2.25 1he physioIherapisI, as parI o! Ihe MD1, should khow where Io geI advice oh pressure
relievihg seaIihg. C (IV) [25]
2.26 1he physioIherapisI should have basic khowledge o! Ihe provisioh o! equipmehI IhaI
cah !aciliIaIe acIiviIies o! daily livihg. C (IV) [25]
LocaI impIementation
There should be opporlunilies lor CPD and lilelong learning.
2
21
Secticn J - Assessment
Introduction
Sullcienl inlormalion should be galhered lrom all sources including medical noles and olher members
ol lhe mulli-disciplinary leam belore carrying oul a lull subjeclive and objeclive examinalion ol lhe
palienl. This should lake inlo accounl lhe emolional and cognilive slalus and co-morbidily e.g. cardiac
and/or renal disease, diabeles, arlhrilis or previous slroke, which may allecl lhe palienl's molivalion,
exercise lolerance, skin condilion or sensalion. The social silualion, including available supporl,
occupalion and hobbies, logelher wilh lhe home environmenl ol lhe palienl, should also be considered
9, !0, 60.
Pealislic goals and a rehabililalion programme should be discussed and agreed wilh lhe palienl
(and carers).
Assessmenl should include bolh lower and upper limbs and lhe lrunk. Due lo lhe expecled change in
lunclional level as a resull ol rehabililalion, a relevanl, validaled oulcome measure should be used
and recorded lo evaluale change.
Evidence
Crieve el al 9 in a small case series wilh inadequale lollow up, showed lhal lollowing ampulalion
palienls experienced lower levels ol lunclion compared lo "normals". ln addilion, lhose palienls wilh
diabeles were more likely lo experience lunclional dillcullies.
Collin el al !3 in !995 concluded lrom a case series ol poorly delned elderly individuals lhal a
wheelchair should be roulinely provided lollowing a lower limb ampulalion. ln !992, Collin el al 52
reporled lhe resulls ol a relrospeclive case series looking al palienls using a wheelchair lollowing
bilaleral ampulalion. They emphasised lhal lunclional oulcome can be allecled by lhe environmenl inlo
which lhe palienl is discharged. Van de Ven in !98! 53 highlighled lhe imporlance ol environmenlal
laclors in delermining mobilily in a cohorl sludy ol 96 bilaleral ampulees and suggesled lhis could
explain delerioralion in mobilily oulside lhe clinical selling.
Sludies lhal gave evidence supporling lhe need lo examine specilc palhologies include a cohorl sludy
by Poller el al 54. They noled lhal in palienls wilh diabeles, peripheral neuropalhy is nearly always
presenl in lhe inlacl limb and lhal il is also presenl in lwo lhirds ol non-diabelics. This demonslrales lhe
need lo ensure sensalion is roulinely checked al assessmenl. The imporlance ol skin checks is reinlorced
by a descriplive cohorl sludy carried oul by Levy in !995 60 who invesligaled lhe skin problems
associaled wilh wearing a proslhesis. However, lhe parlicipanls in lhis sludy were nol well delned and il
was nol possible lo lell il lhe lollow up ol lhe subjecls was adequale.
Nicholas el al !0 in a case series ol 94 ampulees and Walers el al 6! in a case-conlrol sludy lound
lhal lhe higher lhe level ol ampulalion, lhe more energy was used in walking and also lhal job relenlion
was reduced.
Hanspal el al 50 lound impaired cognilive skills lo negalively allecl lunclional oulcome wilh a
proslhesis in a relrospeclive case series, where no adjuslmenl had been made lor olher prognoslic
laclors. A laler paper by lhe same aulhors 55 suggesled lhal lhe resulls ol an inlelleclual assessmenl
soon aller ampulalion can predicl lhe level ol mobilily likely lo be achieved. This was based on a cohorl
sludy ol 32 elderly palienls bul no specilc resulls were published on level ol mobilily and links wilh
cognilive slalus.
Neuromuscular slalus was lound by Allner el al 29, in a relrospeclive case series ol palienls wilh
hemiplegia and dysvascular lower limb ampulalion, lo be lhe only signilcanl laclor allecling ambulalion
in palienls.
There was ollen only one sludy lor each prognoslic laclor invesligaled, making il dillcull lo draw any
conclusions based on lhe evidence available al presenl.
2
22
Recommendations
3.1 1here should be wriIIeh evidehce o! a !ull physical examihaIioh ahd assessmehI o!
previous ahd presehI !uhcIioh 8 (IIa) [9, 10, 13, 60, 62, 63]
3.2 1he paIiehIs' social siIuaIioh, psychological sIaIus, goals ahd expecIaIiohs should be
documehIed 8 (IIb) [9, 10, 13, 50, 52, 53, 55]
3.3 RelevahI paIhology ihcludihg diabeIes, impaired coghiIioh ahd hemiplegia should be
hoIed 8 (III) [29, 55, 60, 64]
3.4 A problem lisI ahd IreaImehI plah, ihcludihg agreed goals, should be !ormulaIed ih
parIhership wiIh Ihe paIiehI 8 (III) [10]
LocaI impIementation
A locally agreed physiolherapy assessmenl lorm should be used
Names and conlacl delails ol lhe MDT members involved in lhe palienl's care should be
recorded lo lacililale communicalion
The principles ol lhe Single Assessmenl Process (SAP) should be applied.

2
23
Secticn 4 - Fatient and carer infcrmaticn
Introduction
The Core slandards ol physiolherapy praclice 2 recommend lhal palienls are inlormed ol "...all
polenlial and signilcanl risks, benells and likely oulcomes ol lrealmenl". This promoles underslanding
ol lhe process and reasoning behind lrealmenl. The rehabililalion process should have an educalional
elemenl lhal empowers palienls and carers lo lake an aclive role in lheir presenl and lulure
managemenl. This will assisl wilh problem solving and awareness ol when lo seek prolessional help.
Due lo lhe number ol recommendalions in lhis seclion il has been sub-divided inlo lour seclions lor
ease ol use. 1hese sub-secIiohs are:
4.! Palienl Journey
4.2 lnlormed Coal Selling
4.3 Care ol lhe Pemaining Limb
4.4 Care ol lhe Pesidual Limb.
4.1. Patient journey
Evidence
ln lhe absence ol published lileralure lhis sub-seclion is supporled by consensus opinion.
Recommendations
4.1.1 1he physioIherapisI should give paIiehIs ih!ormaIioh abouI Ihe expecIed sIages ahd
locaIioh o! Ihe rehabiliIaIioh programme suiIed Io Iheir ihdividual circumsIahces.
C (IV) [25]
4.1.2 WiIh Ihe paIiehI's cohsehI, Ihe physioIherapisI should give carers ih!ormaIioh abouI
Ihe expecIed sIages ahd locaIioh o! Ihe rehabiliIaIioh programme suiIed Io Ihe
paIiehI's ihdividual circumsIahces. C (IV) [25]
4.1.3 1he physioIherapisI should o!!er paIiehIs Ihe opporIuhiIy Io meeI oIher adulIs wiIh
lower limb ampuIaIiohs. C (IV) [25]
4.1.4 Where appropriaIe, ahd wiIh Ihe paIiehI's cohsehI, Ihe physioIherapisI should o!!er
carers Ihe opporIuhiIy Io meeI oIher adulIs wiIh lower limb ampuIaIiohs. C (IV) [25]
4.1.5 1he physioIherapisI should provide ih!ormaIioh abouI Ihe prosIheIic process Io Ihose
paIiehIs likely Io be re!erred !or a prosIhesis. C (IV) [25]
4.1.6 1he physioIherapisI should o!!er Io show demohsIraIioh limbs Io Ihose paIiehIs likely
Io be re!erred !or a prosIhesis. C (IV) [25]
4.1.7 1he physioIherapisI should khow where Io re!er paIiehIs !or ih!ormaIioh abouI
behe!Is. C (IV) [25]
4.1.8 1he physioIherapisI should khow where Io geI advice oh arrahgemehIs available Io
supporI carers. C (IV) [25]
4.1.9 1he physioIherapisI should be able Io re!er Ihe paIiehI Io oIher agehcies as hecessary.
C (IV) [25]
4.1.10 Where possible all verbal ih!ormaIioh/advice giveh should be supplemehIed ih wriIIeh
!orm. C (IV) [25]
2
24
4.2. In!ormed goaI setting
Evidence
Nine sludies ol mixed design and generally poor qualily were lound lo inlorm lhis lopic 9, 34-37, 56,
59, 6!, 65. Mosl sludies examined lhe inluence ol lhe level ol ampulalion on lhe oulcome. Hubbard
59, in a relrospeclive case series ol palienls wilh peripheral vascular disease, slaled lhere were no
prediclive laclors lor mobilily levels allained olher lhan level ol ampulalion. The paper lurlher concludes
lhal pre-operalive mobilily and personal goals should be considered when evalualing lhe success ol
rehabililalion. A relrospeclive case conlrol sludy ol people wilh lower limb ampulalion, vascular disease
and end-slage renal disease by Lucke 65 showed lhey could be rehabililaled as successlully as lhose
wilhoul end-slage renal disease.
Two case series, by 8eekman el al 35 and Crieve el al 9 bolh slale lhal lollowing ampulalion
palienls will have lower levels ol lunclion lhan bi-pedal subjecls. lour sludies, all bul one wilh a
relrospeclive design 34, 35, 37, 56, concluded lhal lhe lower lhe level ol ampulalion lhe grealer lhe
chance ol succeeding wilh a proslhesis. Woll el al 36, observed in a relrospeclive case series ol !8
elderly vascular bilaleral lranslibial palienls, lhal 50 became independenlly mobile wilh proslheses.
lor palienls wilh a unilaleral ampulalion as a resull ol eilher lrauma or vascular disease lhe energy cosl
ol walking increases as lhe level ol ampulalion becomes higher 6!. Walers concludes lrom his case-
conlrol sludy in !976 lhal, when preservalion ol lunclion is lhe chiel concern, ampulalion should be al
lhe lowesl possible level 6!.
No conlradiclory evidence was lound.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
4.2.1 PaIiehIs/carers should be made aware IhaI Ihe level o! ampuIaIioh a!!ecIs Ihe
expecIed level o! !uhcIioh ahd mobiliIy. 8 (III) [34, 35, 37, 56, 67]
4.2.2 PaIiehIs/carers should be made aware IhaI Ihey will experiehce lower levels o! !uhcIioh
Ihah bipedal sub|ecIs. 8 (III) [61]
4.2.3 PaIiehIs/carers should be made aware IhaI cohcurrehI paIhologies ahd previous
mobiliIy a!!ecIs realisIic goal seIIihg ahd !hal ouIcomes o! rehabiliIaIioh.
C (III) [25, 65, 66]
4.2.4 1he physioIherapisI should use appropriaIe ouIcome measures (Appehdix 13) !or
rehabiliIaIioh goals. C (IV) [25]
4.3. Care o! the remaining Iimb
Evidence
Poller el al 54, in a cohorl sludy ol 80 palienls wilh unilaleral ampulalion due lo diabeles, lound
peripheral neuropalhy lo be nearly always presenl in lhe remaining limb. ln addilion, lwo lhirds ol
non-diabelic, non-lraumalic, unilaleral ampulees were lound lo have peripheral neuropalhy in lheir
remaining limb. A cohorl sludy by Jayalunga 33, wilh no conlrol group, lound lhal palienls wilh a
unilaleral lranslibial ampulalion due lo diabeles were subjecl lo abnormal loading on lhe remaining
lool. Carelul moniloring ol lhe remaining lool and early orlholic relerral were recommended, as lool
orlhoses and appropriale loolwear signilcanlly reduced lhese lorces in lhe sludy parlicipanls. Levy 60
in a descriplive paper describes skin disorders due lo mechanical rubs, over or under zealous skin care.
He also describes lhe lormalion ol oedema due lo lhe underlying disorder. ln lhe absence ol lurlher
lileralure evidence consensus opinion has been soughl lo lurlher inlorm lhis sub-seclion.
Recommendations
4.3.1 Vascular ahd diabeIic paIiehIs ahd Iheir carers, should be made aware o! Ihe risks Io
Iheir remaihihg !ooI ahd educaIed ih how Ihey cah reduce Ihem. 8 (IIa) [33, 54, 60]
4.3.2 1he paIiehI/carer should be IaughI how Io mohiIor Ihe cohdiIioh o! Ihe remaihihg
limb. 8 (IIa) [25, 54 ]
2
25
4.3.3 PhysioIherapisIs should esIablish lihks wiIh Iheir local podiaIry/chiropody services Io
ehsure IhaI ih!ormaIioh ahd educaIioh giveh Io paIiehIs ahd carers is cohsisIehI.
C(IV) [25]
4.4. Care o! the residuaI Iimb
Evidence
ln a review by Lnerolh 26 mulliple laclors were lound lo allecl wound healing in vascular palienls
wilh an ampulalion. ln a Scollish sludy, discharge dala galhered over 3 years lound lhal lhe use ol
shrinker socks and Larly Walking Aids decreased lhe lime lo casl lor lranslibial palienls and was more
elleclive lhan crepe bandages or no bandages 23. ln lhe same sludy rigid plasler dressings were lound
lo reduce lime lo casling compared wilh olher compression lherapies. ln a small randomised conlrolled
lrial ol !2 palienls by Manella, lhe use ol a shrinker socks was lound lo be more elleclive al reducing
residual limb oedema lhan elaslic bandaging 68.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
4.4.1 Advice should be giveh Io Ihe paIiehI/carer oh Ihe !acIors a!!ecIihg wouhd healihg. 8
(III) [26]
4.4.2 Advice should be giveh Io Ihe paIiehI/carer oh Ihe use o! compressioh Iherapies. 8 (IIb)
[23, 68]
4.4.3 IhsIrucIioh should be giveh Io Ihe paIiehI/carer oh meIhods Io prevehI ahd IreaI
adhesiohs o! scars. C(IV) [25]
4.4.4 1he physioIherapisI should give oh-goihg advice abouI residual limb care. C(IV) [25]
LocaI impIementation
Names and conlacl delails ol lhe MDT members involved in lhe palienl's care should be given
lo palienls and carers
lnlormalion lealels / booklels should be developed locally lor palienls and carers lo supplemenl
inlormalion given verbally.
2
26
Secticn 5 - Fre-cp management
Introduction
Larly assessmenl and planning ol rehabililalion can commence al lhis slage and helps lo prepare
lhe palienl lor rehabililalion. A pre-ampulalion consullalion also enables lhe physiolherapisl lo give
appropriale advice, inlormalion and reassurance, issues such as phanlom limb sensalion and avoidance
ol lalls may be discussed. However, il is acknowledged lhal palienls who require emergency ampulalion
may nol have lhe opporlunily lor pre-ampulalion consullalion, assessmenl and lrealmenl.
Evidence
This seclion is supporled by consensus opinion in lhe absence ol any published lileralure.
Recommendations
5.1 Where possible Ihe physioIherapisI should reih!orce ih!ormaIioh giveh by oIher MD1
members abouI Ihe geheral surgical process (hoI Iechhique). C (IV) [25]
5.2 Where possible Ihe paIiehI ahd carers should be giveh advice, ih!ormaIioh ahd
reassurahce by Ihe physioIherapisI abouI rehabiliIaIioh. C (IV) [25]
5.3 1he physioIherapy assessmehI should be commehced pre-operaIively, i! possible.
C (IV) [25]
5.4 Where possible rehabiliIaIioh/discharge plahhihg should commehce pre-operaIively.
C (IV) [25]
5.5 Where appropriaIe ahd possible Ihe paIiehI should be ihsIrucIed ih wheelchair use
pre-operaIively. C (IV) [25]
5.6 A sIrucIured exercise regime should be sIarIed as early as possible. C (IV) [25]
5.7 8ed mobiliIy should be IaughI where possible. C (IV) [25]
5.8 Where appropriaIe ahd possible Irahs!ers should be IaughI pre-operaIively. C (IV) [25]
5.9 I! ihdicaIed, Ihe paIiehI should be assessed !or physioIherapy respiraIory care.
C (IV) [25]
5.10 I! ihdicaIed, Ihe paIiehI should be giveh appropriaIe physioIherapy respiraIory
IreaImehI. C (IV) [25]
5.11 Paih cohIrol should be opIimised prior Io physioIherapy IreaImehI pre-operaIively.
C (IV) [25]
5.12 I! appropriaIe, ahd wiIh Ihe paIiehI's cohsehI, carers should be ihvolved ih
pre-operaIive IreaImehI ahd exercise programmes. C (IV) [25]
LocaI impIementation
A procedure lor prompl relerral lo physiolherapy lollowing decision lo ampulale should
be developed.
2
27
Secticn 6 - Fcst-cp management
Introduction
The rehabililalion process should commence as early as possible, prelerably lollowing a suilable care
palhway 69. Palienls should be assessed and a rehabililalion plan discussed and agreed. Advice and
inlormalion should be given regarding bed mobilily, lo avoid complicalions such as conlraclures and
pressure sores. Appropriale advice and assislance wilh lranslers should be given. lollowing assessmenl,
a problem lisl should be made, wilh bolh shorl and long lerm goals considered, laking inlo accounl
lhe palienl's psychological, emolional and physical slalus, pain managemenl and lhe broader issues
surrounding social and home environmenl.
lor ease ol descriplion, lhis seclion has been divided inlo lhe lollowing sub-seclions.
6.! Larly rehabililalion
6.2 Lnvironmenl and equipmenl
6.3 Compression lherapy
6.4 Mobilily
6.5 Larly walking aids (LWA's)
6.6 lalls managemenl
6.7 Wheelchairs and Sealing
6.8 Prevenlion / reduclion ol conlraclures
6.9 Lxercise programmes
6.!0 Managemenl ol phanlom sensalion and pain.
6.1 EarIy rehabiIitation
Evidence
ln 2000 a relrospeclive cross seclional sludy ol !46 lraumalic ampulees by Pezzin el al 70 lound lhal
lheir physical lunclion and vilalily was increased by having longer in-palienl rehabililalion. Schaldach
69 lound in a relrospeclive 'belore and aller' case conlrol sludy ol 7! lrans-lemoral and lranslibial
palienls lhal in-palienl rehabililalion is more elleclive in lerms ol cosl and lime when a clinical care
palhway is lollowed. Meikle in 2002 49 in a well designed relrospeclive cohorl sludy, lound lhal
inlerruplions lo rehabililalion due lo co-morbidily are common, bul do nol adversely allecl lhe oulcome
ol rehabililalion despile lenglhening lhe process. ln a case conlrol sludy Culson el al 7! observed lhal
in-palienl rehabililalion reduced lhe lime lrom surgery lo proslhelic ambulalion among male dysvascular
lranslibial palienls. There is known conlroversy aboul lhe use ol clinical care palhways and inpalienl
rehabililalion bul nol sullcienl published evidence. The evidence lrom lhese papers is nol sullcienl lo
make individual recommendalions, lherelore consensus opinion was soughl lo inlorm lhis seclion.
Recommendations
6.1.1 1reaImehI musI be giveh a!Ier adequaIe ahalgesia has beeh supplied. C (IV) [25]
6.1.2 PosI-operaIive rehabiliIaIioh should sIarI Ihe !rsI day posI-operaIioh where possible.
C (IV) [25]
6.1.3 RespiraIory care should be giveh i! appropriaIe. C (IV) [25]
6.1.4 A physioIherapisI should aid Ihe MD1 ih Ihe decisioh as Io Ihe appropriaIe Iime !or
discharge !rom ihpaIiehI care. C (IV) [25]
6.2 Environment and equipment
Evidence
A queslionnaire cross seclional survey carried oul by While 72 in !992 concluded lhal residual limb
supporl boards are well accepled lor use wilh palienls wilh a lower limb ampulalion, bul lhal lherapisls
are nol always conldenl aboul lheir use.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
2
28
Recommendations
6.2.1 1he physioIherapisI should have khowledge o! Ihe provisioh o! equipmehI IhaI cah
!aciliIaIe acIiviIies o! daily livihg. C (IV) [25]
6.2.2 1herapisIs should be !amiliar wiIh Ihe correcI use o! specialisI equipmehI. C IV [72]
6.2.3 1he physioIherapisI should be ihvolved ih home visiIs where hecessary. C (IV) [25]
6.3 Compression therapy
Evidence
A small, non-blinded, randomised conlrolled lrial 68 lound lhal compression socks are signilcanlly
more elleclive in reducing limb volume lhan elaslic bandages. A cross-seclional survey ol
physiolherapisls 44 showed lhal compression socks are widely used, bul lhal lheir use varies greally
as lhere are no currenl guidelines. Discharge dala lrom all Scollish ampulees over a lhree year period
showed lhal all lorms ol compression lherapy resulled in quicker progression lo proslhelic rehabililalion
23.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
6.3.1 A compressioh sock should be used ih pre!erehce Io elasIic bahdages !or reducihg limb
volume. 8 (IIb) [68]
6.3.2 1he physioIherapisI should use compressioh Iherapy as appropriaIe. C (IV) [25]
6.4 MobiIity
Evidence
This seclion is supporled by consensus opinion in lhe absence ol any published lileralure.
Recommendations
6.4.1 8ed mobiliIy should be IaughI !rsI day posI-operaIioh. C (IV) [25]
6.4.2 SiIIihg balahce should be re-educaIed i! heeded. C (IV) [25]
6.4.3 SIahdihg balahce should be re-educaIed i! heeded. C (IV) [25]
6.4.4 Sa!e Irahs!ers should be IaughI as early as possible. C (IV) [25]
6.4.5 MobiliIy pre-prosIheIically should be ih a wheelchair uhless Ihere are speci!ed reasohs
Io Ieach a paIiehI Io use cruIches/zimmer !rame/rollaIor. C (IV) [25]
6.4.6 1he physioIherapisI should help Ihe paIiehI gaih maximum mobiliIy pre-prosIheIically.
C (IV) [25]
6.5 EarIy vaIking aids (EWAs)
Evidence
Schon el al 73 demonslraled in a 'belore and aller' case conlrol sludy lhal prelabricaled proslheses
may reduce complicalions, lalls, revisions and lime lo lrsl proslhesis. Pollack el al 40 lound in a
randomised conlrolled lrial lhal using LWA's reduced lhe incidence ol posl-operalive complicalions,
and resulled in lasler and more successlul rehabililalion. Lein 39 carried oul a cross seclional survey in
!992, and concluded lhal lhe Pneumalic Posl-Ampulalion Mobilily Aid (Ppam aid) provides a valuable
lool lor assessmenl and lrealmenl, provided il is used correclly. ln !998, Condie lound lrom a cohorl
ol all lhe Scollish ampulee discharge inlormalion lhal use ol compression lherapy, including LWA's
resulled in quicker progression lo proslhelic rehabililalion 23.
Recommendations
6.5.1 LWAs should be cohsidered as parI o! Ihe rehabiliIaIioh programme !or all lower limb
ampuIaIioh paIiehIs as ah assessmehI Iool. 8(IIa) [23, 39, 40, 73]
2
29
6.5.2 LWAs should be cohsidered as parI o! Ihe rehabiliIaIioh programme !or all lower limb
ampuIaIioh paIiehIs as a IreaImehI Iool. 8(IIa) [23, 39, 40, 73]
6.5.3 LWAs should be used uhder Ihe supervisioh o! IherapisIs Iraihed ih Iheir correcI ahd
sa!e applicaIioh ahd use. C (IV) [39]
6.6 faIIs management
Evidence
ln !996 Kulkarni el al 74 reporled an increased risk ol lalls lollowing lower limb ampulalion in a cross-
seclional sludy ol !!64 palienls. This was more likely lo occur al lrans-lemoral level compared wilh
lrans-libial level. The sludy concluded lhal inslruclion on how lo gel up lrom lhe loor should be parl ol
rehabililalion. However, lhis sludy did nol include a comparison group and only gives limiled evidence.
Recommendations
6.6.1 All parIies ihvolved wiIh Ihe paIiehI should be made aware IhaI Ihe risk o! !allihg is
ihcreased !ollowihg lower limb ampuIaIioh. 8 (III) [74]
6.6.2 RehabiliIaIioh programmes should ihclude educaIioh oh prevehIihg !alls ahd copihg
sIraIegies should a !all occur. 8 (III) [74]
6.6.3 IhsIrucIiohs should be giveh oh how Io geI up !rom Ihe !oor. 8 (III) [74]
6.6.4 Advice should be giveh ih Ihe evehI IhaI Ihe paIiehI is uhable Io rise !rom Ihe !oor. 8
(III) [74]
6.7 WheeIchairs and seating
Evidence
Collin el al !3 slaled, in a case series ol moslly elderly palienls, lhal provision ol a wheelchair should
be rouline. Van De Ven 53 suggesled lhal all palienls wilh a bilaleral ampulalion should be issued wilh
a wheelchair.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
6.7.1 PaIiehIs should rouIihely be provided wiIh a wheelchair. 8 (III) [13, 53]
6.7.2 Where hecessary Ihe physioIherapisI should be able Io assess a paIiehI's suiIabiliIy !or a
wheelchair or have khowledge o! Ihe re!erral process. C (IV) [25]
6.7.3 PhysioIherapisIs, as parI o! Ihe MD1, should be able Io Ieach Ihe paIiehI ahd carer how
Io use Ihe wheelchair, ihcludihg all accessories. C(IV) [25]
6.8 Preventionlreduction o! contractures
Evidence
This seclion is supporled by consensus opinion in lhe absence ol any published lileralure.
Recommendations
6.8.1 CohIracIures should be prevehIed by appropriaIe posiIiohihg. C (IV) [25]
6.8.2 CohIracIures should be prevehIed by sIreIchihg exercises. C (IV) [25]
6.8.3 Where cohIracIures have !ormed appropriaIe IreaImehI should be giveh. C (IV) [25]
2
30
6.9 Exercise programmes
Evidence
Seroussi el al 63 in !996 carried oul a prospeclive case conlrol sludy on gail analysis, and concluded
lhal hip exlensors (bilalerally), eccenlric hip lexors and ankle planlar lexors benell lrom slrenglhening.
No olher muscle groups were invesligaled in lhis sludy.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
6.9.1 Lxercise programmes should ihclude exercises !or Ihe hip exIehsors, hip !exors ahd
ahkle plahIar !exors. 8 (IIa) [63]
6.9.2 Ah exercise regime should be giveh relevahI Io Ihe paIiehI's goals. C (IV) [25]
6.10 Management o! phantom sensation and pain
Evidence
Morlimer el al 47 in 2002, lound lrom a well conducled qualilalive sludy, using locus groups lhal
palienls need accurale and limely inlormalion aboul phanlom limb pain, and lhis should be provided
by individuals wilh appropriale knowledge and lraining. A poorly conducled, small, case conlrol sludy
48 lound lhal applying acupunclure lo lhe conlralaleral limb, al acupoinls corresponding lo lhe painlul
area in lhe phanlom limb, may relieve acule pain lemporarily.
McCarlney 45, in a cross seclional sludy ol 40 subjecls lrom Scolland, lound lhal pain aller
ampulalion is common and allecls qualily ol lile in !0 ol lhe populalion. Non-painlul phanlom
sensalions were signilcanlly more lrequenl lhan painlul in a sludy by Smilh 46. The same sludy
concluded lhal people wilh a lrans-lemoral ampulalion are signilcanlly more likely lo have grealer
inlensily ol pain and more bolhersome back pain lhan people wilh a lranslibial ampulalion.
ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.
Recommendations
6.10.1 PaIiehIs should be made aware o! Ihe possibiliIy o! experiehcihg phahIom limb paih or
sehsaIioh posI-operaIively. 8 (III) [45, 46]
6.10.2 PaIiehIs should be giveh accuraIe ahd Iimely khowledge o! phahIom limb paih.
8 (III) [47]
6.10.3 Ih!ormaIioh regardihg phahIom limb paih should be giveh by clihiciahs wiIh
appropriaIe khowledge ahd Iraihihg. 8 (III) [47]
6.10.4 Ih!ormaIioh should be giveh abouI phahIom limb sehsaIioh. C (IV) [25]
6.10.5 AppropriaIe IreaImehI should be giveh !or phahIom limb paih. C (IV) [25]
6.10.6 AppropriaIe IreaImehI should be giveh !or residual limb paih. C (IV) [25]
6.10.7 1echhiques !or Ihe sel!-mahagemehI o! phahIom paih/sehsaIioh should be IaughI.
C (IV) [25]
LocaI ImpIementation
lnlormalion lealels/booklels should be developed locally lor palienls and carers lo supplemenl
inlormalion given verbally
lnlormalion on sell managemenl / home exercise lollowing discharge should be provided lo
lhe palienl
Palienls requiring ongoing oulpalienl lrealmenl should have lhis arranged prior lo discharge
A summary ol lhe palienl's lrealmenl and slalus al lransler should be senl lo lhe
physiolherapisl providing on-going lrealmenl
Conlacl names, lelephone numbers and addresses ol relevanl MDT members should be
supplied lo palienls prior lo discharge.
2
31
!. C|||07 Cu|dance |or |eve|op|n C||n|ca| Cu|de||ne:. 2003, The Charlered Sociely ol
Physiolherapy. London.
2. Core 5|andard: o| |hy:|o|herapy |rac||ce 2005. The Charlered Sociely ol
Physiolherapy. London.
3. lield, M. and K. Lohr, Cu|de||ne: |or c||n|ca| prac||ce. |rom deve|opmen| |o u:e. !992,
Washinglon DC. Nalional Academy Press.
4. Sackell, D., el al., |v|dence-ba:ed med|c|ne, |ow |o prac||ce and |each |b|. !997, London.
Churchill Livingslone.
5. |o|, 1he new N|5 modern dependab|e. !997, Deparlmenl ol Heallh. London.
6. |o|, A |r:| c|a:: :erv|ce qua|||y |n |he N|5. !998. London.
7. 8roomhead, P., el al., |v|dence ba:ed c||n|ca| u|de||ne: |or |he phy:|o|herapy manaemen| o|
adu||: w||h |ower ||mb pro:|he:e:. 2003, Charlered Sociely ol Physiolherapy. London.
8. |u||y |qu|pped. 1he |rov|:|on o| |qu|pmen| |o O|der or ||:ab|ed |eop|e by |he N|5 and 5oc|a|
5erv|ce: |n |n|and and Wa|e:. 2000, Audil Commission. London.
9. Crieve, A. and C. Lankhorsl, |unc||ona| ou|come o| |ower ||mb ampu|ee:. a pro:pec||ve
de:cr|p||ve :|udy |n a enera| ho:p||a|. Proslhel Orlhol lnl, !996. 20. p. 79-87.
!0. Nicholas, J.J., el al., |rob|em: exper|enced and perce|ved by pro:|he||c pa||en|:. Jour Pros &
Orlhol, !993. 5(!). p. !6-!9.
!!. Pybarczyk, 8.D., el al., 5oc|a| d|:com|or| and depre::|on |n a :amp|e o| adu||: w||h |e
ampu|a||on:. Arch Phys Med Pehabil, !992. 73(!2). p. !!69-73.
!2. Thornberry, D.J., J. Sugden, and l. Dunlord. Wha| happen: |o pa||en|: who have ampu|a||on:
|or per|phera| va:cu|ar d|:ea:e. in lSPO. !994. 8lackpool.
!3. Collin, C. and J. Collin, |ob||||y a||er |ower-||mb ampu|a||on. 8r J Surg, !995. 82(8). p. !0!0-!.
!4. lrykberg, P.C., el al., |unc||ona| ou|come |n |he e|der|y |o||ow|n |ower ex|rem||y ampu|a||on.
J lool Ankle Surg, !998. 37(3). p. !8!-5, discussion 26!.
!5. Pell, J.P., el al., ua|||y o| |||e |o||ow|n |ower ||mb ampu|a||on |or per|phera| ar|er|a| d|:ea:e.
Lur J Vasc Surg, !993. 7(4). p. 448-5!.
!6. Cargill, J., H. Scoll, and M.L. Condie, A :urvey o| |he |ower ||mb ampu|ee popu|a||on |n
5co||and, 2003. 2005, SPAPC. Clasgow.
!7. C5| :|andard: o| phy:|o|herapy prac||ce |or |he manaemen| o| pa||en|: w||h ampu|a||on:.
!992, The Charlered Sociely ol Physiolherapy. London.
!8. Linslone, H. and M. Turnoll, 1he de|ph| me|hod. |echn|que: and app||ca||on:. !975.
Addison-Wesley.
!9. Ham, P.O., |ehab||||a||on o| |he va:cu|ar ampu|ee - one me|hod eva|ua|ed. Physiolherapy
Praclice, !985. !. p. 6-!3.
20. Pernol, H.l., el al., |a||y |unc||on|n o| |he |ower ex|rem||y ampu|ee. an overv|ew o| |he
|||era|ure. Clin Pehabil, !997. !!(2). p. 93-!06.
2!. Ham, P.O., J.M. Pegan, and V.C. Poberls, |va|ua||on o| |n|roduc|n |he |eam approach |o |he
care o| |he ampu|ee. |he |u|w|ch :|udy. Proslhel & Orlhol lnl, !987. !!. p. 25-30.
22. Campbell, W.8. and 8.M. Pidler, |red|c||n |he u:e o| pro:|he:e: by va:cu|ar ampu|ee:. Lur J
Vasc Lndovasc Surg, !996. !2(3). p. 342-5.
23. Condie, M.L., S.P. Treweek, and C.V. Puckley, 1rend: |n |ower ||mb Ampu|ee |anaemen|. 3-
year resulls lrom a Nalional Survey. 8rilish Journal Ol Surgery, !998. 85(Suppl !). p. 23.
24. Klingenslierna, U., el al., |:o||ne||c :|ren|h |ra|n|n |n be|ow-|nee ampu|ee:. Scand J Pehabil
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25. Consensus, opinion gained by lhe Delphi process.
References 3
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32
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|e:||n and re:u||: o| pro:|he||c |ra|n|n. Arch Phys Med Pehabil, !987. 68(!). p. !4-9.
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||mb ampu|ee:. Proslhel Orlhol lnl, !994. !8(!). p. !8-24.
68. Manella, K.J., Compar|n |he e||ec||vene:: o| e|a:||c bandae: and :hr|n|er :oc|: |or |ower
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69. Schaldach, D.L., |ea:ur|n qua|||y and co:| o| care. eva|ua||on o| an ampu|a||on c||n|ca|
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70. Pezzin, L.L., T.P. Dillingham, and L.J. MacKenzie, |ehab||||a||on and |he |on-|erm ou|come: o|
per:on: w||h |rauma-re|a|ed ampu|a||on:. Arch Phys Med Pehabil, 2000. 8!(3). p. 292-300.
7!. Culson, T.M., el al., |ar|y |anaemen| o| e|der|y dy:va:cu|ar be|ow-|nee ampu|ee:. Journal ol
Proshelics and Orlholics, !994. 6(3). p. 62-6.
72. While, L.A., Whee|cha|r 5|ump board: and |he|r U:e w||h |ower ||mb Ampu|ee:. 8rilish Journal
ol Occupalional Therapy, !992. 55(5). p. !74-!78.
73. Schon, L.C., el al., bene||: o| ear|y pro:|he||c manaemen| o| |ran:||b|a| ampu|ee:. a
pro:pec||ve c||n|ca| :|udy o| a pre|abr|ca|ed pro:|he:|:. lool Ankle lnl, 2002. 23(6). p. 509-!4.
74. Kulkarni, J., |a||: |n pa||en|: w||h |ower ||mb ampu|a||on:. preva|ence and con|r|bu||n |ac|or:.
|hy:|o|herapy, !996. 82(2). p. !30-6.
3
34
Guidelines development
group (GDG)
1o lead Ihe pro|ecI ahd be
respohsible !or decisioh-makihg
regardihg Ihe mahagemehI ahd
co-ordihaIioh o! Ihe pro|ecI ahd
developmehI o! Ihe Cuidelihe.
1his group ihcludes, Cuidelihes
Croup Leader, Pro|ecI Mahager,
CSP RepresehIaIive, Ih!ormaIioh
SciehIisI ahd a SysIemaIic
Reviewer.
Appehdix 1 8ACFAk guideIines deveIcpment structure and ccntributcrs
Literature appraisers
1o criIically appraise papers
ahd grade evidehce ready !or
ihclusioh ihIo Cuidelihes.
Peer reviewers
1o IesI clariIy, uhdersIahdabiliIy,
presehIaIioh ahd accepIabiliIy
o! recommehdaIiohs ahd
pracIicaliIies o! implemehIaIioh.
Professional advisors
Due Ihe mulIi-disciplihary haIure
o! AmpuIee RehabiliIaIioh Ihese
groups were approached !or
supporI ahd commehI durihg Ihe
producIioh o! Ihese guidelihes.
External reviewers
LxperIs ih guidelihe developmehI
meIhodology, Io IesI rigour o!
developmehI.
Consensus panel
1o uhderIake Ihe cohsehsus
procedure. 1o provide evidehce
by use o! Delphi Iechhique !or
areas wiIh ihsu!!ciehI evidehce
!rom Ihe liIeraIure review.
Appendices 4
4
35
BACPAR Guidelines development contributors
GuideIines DeveIopment Group
Penny 8roomhead, Diana Dawes, Amanda Hancock
Penny roomhead MC5P, GuideIines Group Leader, Project Lead, Lead Author
Penny has worked in lhe leld ol ampulee rehabililalion lor !7 years and is presenlly Clinical
Physiolherapy Specialisl in Ampulee and Proslhelic Pehabililalion al Nollingham Mobilily Cenlre. She is
currenlly sludying lor a masler's degree in Pehabililalion Sludies al The Nalional Cenlre lor Training and
Lducalion in Proslhelics and Orlholics, Slralhclyde Universily.
She is Cuidelines Coordinalor lor 8ACPAP and chaired lhe guideline developmenl group lor lhe
Lvidence 8ased Clinical Cuidelines lor lhe Physiolherapy Managemenl ol Adulls wilh Lower
Limb Proslheses.
Penny has leclured nalionally and inlernalionally and is a visiling leclurer al 8radlord and
Slralhclyde Universilies.
Diana Daves M5c (Oxon). Project Lead, 5ystematic Reviever, Lead Author
Diana worked as a senior physiolherapisl/acling Clinical Manager in lhe Oxlord Proslhelics Service lrom
!995 lo 2003. ln 2005 she received her maslers in Lvidence-8ased Heallh Care and is now working as
a research co-ordinalor in lhe area ol oulcomes research lor lhe deparlmenl ol clinical epidemiology,
McCill Universily, Monlreal, Canada.
Diana was a member ol lhe guideline developmenl group lor lhe Lvidence 8ased Clinical Cuidelines lor
lhe Physiolherapy Managemenl ol Adulls wilh Lower Limb Proslheses. She was also a conlribulor lo lhe
lhird edilion ol 'Therapy lor Ampulees' handbook by 8arbara Lngslrom and Calherine Van de Venl. She
has given leclures lo lhe undergraduale physiolherapy sludenls al Oxlord 8rooks and McCill Universilies
on lhe physiolherapy care ol people wilh ampulalions.
Amanda Hancock, MC5P. Project Manager, Lead Author
Amanda worked as Clinical Specialisl in Ampulee Pehabililalion lor Hull and Lasl Yorkshire Hospilals
NHS Trusl lrom!992 lo 2005. ln 2006 she became a Manager ol Physiolherapy al lhe same Trusl
mainlaining one day a week clinical conlacl wilhin her specialily.
Amanda was a member ol lhe guideline developmenl group lor lhe Lvidence 8ased Clinical Cuidelines
lor lhe Physiolherapy Managemenl ol Adulls wilh Lower Limb Proslheses. She has published work
relaled lo Shrinker sock use and is currenlly leading a research sludy examining Larly Walking Aids lor
people wilh a lranslibial ampulalion. She has presenled bolh nalionally and inlernalionally on a variely
ol subjecls relaled lo lhe rehabililalion ol people wilh lower limb ampulalions.
Pro!essionaI Advisors
ritish Association o! Prosthetists and Orthotists (APO), Anne Pees, 8Sc(hons), M8APO
ritish LimbIess Ex-5ervicemen's Association (LE5MA), S.A Collman, O8L, Assislanl
Ceneral Secrelary.
InternationaI 5ociety o! Prosthetics and Orthotics (I5PO), Dr Pobin Lull, lPCS, lPCP
LimbIess Association, Sam Callop C8L, PML MA (Oxon),
Murray foundation, Susan Shaw, M8APO, M8A
Nurses Amputee Netvork (NAN), Maggie Morlon, Clinical Nurse Specialisl, PCN, SLN
OccupationaI Therapists in Trauma and Orthopaedics (OTTO), Anne Lwing, DipCOT, SPOT
5cottish Physiotherapy Amputee Research Group (5PARG), Sally Thompson, MCSP, SPP
5peciaI Interest Group Amputee Medicine (5IGAM), Dr Jell Lindsay M.8. Ch8. lPCSLd
5ociety o! VascuIar Nurses, Sue Ward, Vascular Nurse Specialisl, PCN
VascuIar 5urgicaI 5ociety o! Great ritain and IreIand (V55GI), Prol. Peler McCollum, MCh,
SPCSl, lPCSLd
4
36
C5P O!cers
Dawn Wheeler, Head ol Clinical Lllecliveness
Jo Jordan, Syslemalic reviewer
Patient and Carer Representatives
Mr and Mrs C Mills, Mr and Mrs N Craig, Ms T Slober
Authors
Leads. Penny 8roomhead, Diana Dawes, Amanda Hancock
Contributors.
Judy Ashby, Cill Alkinson, Anne 8lundell, Sue 8ollon, 8arbara 8rown, Vanessa Davies, Jenniler lullon,
Jane Creiller, 8elinda Quinlan, Cerry Peid, Jess Slaler, Hannah Slockham, Pragna Unia, Sarah Vernon
Literature Appraisers
Tutor. Jean Suvan, Clinical Co-ordinalor, Deparlmenl ol Peridonlology, Laslman Denlal lnslilule
Leads. Diana Dawes, Vanessa Davies, Penny 8roomhead, P.A. Shepherd
Contributors. Judy Ashby, Cill Alkinson, Sue 8ollon, Jane Creiller, Jackie Pelrie, 8elinda Quinlan,
Ceraldine Peed, Jess Slaler, Hannah Slockham, Pragna Unia
Consensus
Leads. Anne 8lundell, Diana Dawes, Pragna Unia, Sarah Vernon, 8arbara 8rown, Sue 8oullon, Lysa
Downing, Cillian Alkinson
Contributors.
Kalherine Alkin Lleanor 8acon
Clare 8lounl Helen 8oolh
Sarah 8radbury Penny 8roomhead
Joanna 8uckley Mary Jane Cole
Jane Cumming Lmma Crawshaw
Vanessa Davies lan Dawson
David Dickman Karen Duncan
Cillian Lvans Jenniler lullon
Carolyn Hale Amanda Hancock
Caroline Hird Joanne Hebenlon
Lynn Hirsl Lucy Holl
Morag McNaughlon Kelvin Marshall
Calriona Mawdsley Jill Mullon
Jackie Pelrie Di Quinlivan
Laura Posbollom Lesley Pugg
Jane Saunders Helen Scoll
Sandra Sheval Jessica Slaler
Pona Smilh 8ev Sweeny
Cayle Sweeney Joanne Teesdale
Louise Tisdale Maggie Uden
Louise Whilehead Pulh Woodrull
4
37
ExternaI revievers
lan Dawson, MCSP, SPP, Scollish Physiolherapy Ampulee Pesearch Croup
Amanda Hurdowar MSc, Projecl Coordinalor, Toronlo Pehabililalion lnslilule, Canada
Llizabelh Mclnnes, 8A (Hons), Crad Dip Applied Science (Nursing), Masler ol Public Heallh
(MPH), (PCN Associale)
Dr Sara Twaddle, Direclor, Scollish lnlercollegiale Cuidelines Nelwork
Peer revievers
Lead. Penny 8roomhead
Contributors.
Helen Ashcroll
Angela 8rell
Karen Clark
Julia Camlen
Anne Harrill
Janel Parkinson
Alison Philip
Vicky Pursey
Di Quinlivan
Susan Porison
Lmma Tebbull
Sharon Wrighl
4
38
#!8 Search #!7 AND (#!6 OP #!5 OP #!3) Limils. All Adull. !9+ years, Publicalion Dale lrom
!978/0!/0! lo 2004/0!/30, Lnglish, Human
#!7 Search lreal* OP care OP manag* OP physi*) Limils. All Adull. !9+ years, Publicalion Dale
lrom !978/0!/0! lo 2004/0!/30, Lnglish, Human
#!6 Search ("Phanlom Limb/blood"MeSH OP "Phanlom Limb/classilcalion"MeSH OP
"Phanlom Limb/complicalions"MeSH OP "Phanlom Limb/diagnosis"MeSH OP "Phanlom
Limb/drug lherapy"MeSH OP "Phanlom Limb/nursing"MeSH OP "Phanlom Limb/
prevenlion and conlrol"MeSH OP "Phanlom Limb/psychology"MeSH OP "Phanlom
Limb/rehabililalion"MeSH OP "Phanlom Limb/surgery"MeSH OP "Phanlom Limb/
lherapy"MeSH) Limils. All Adull. !9+ years, Publicalion Dale lrom !978/0!/0! lo
2004/0!/30, Lnglish, Human
#!5 Search ("Ampulalion Pesiduums/blood supply"MeSH OP "Ampulalion Pesiduums/
classilcalion"MeSH OP "Ampulalion Pesiduums/complicalions"MeSH OP "Ampulalion
Pesiduums/drug lherapy"MeSH OP "Ampulalion Pesiduums/injuries"MeSH OP
"Ampulalion Pesiduums/inslrumenlalion"MeSH OP "Ampulalion Pesiduums/
melhods"MeSH OP "Ampulalion Pesiduums/nursing"MeSH OP "Ampulalion Pesiduums/
rehabililalion"MeSH OP "Ampulalion Pesiduums/surgery"MeSH) Limils. All Adull. !9+
years, Publicalion Dale lrom !978/0!/0! lo 2004/0!/30, Lnglish, Human
#9 Search ("Ampulees/educalion"MeSH OP "Ampulees/psychology"MeSH OP "Ampulees/
rehabililalion"MeSH OP "Ampulees/slalislics and numerical dala"MeSH) Limils. All Adull.
!9+ years, Publicalion Dale lrom !978/0!/0! lo 2004/0!/30, Lnglish, Human
#!3 Search #8 AND (#!2 OP #!0 OP #9) Limils. All Adull. !9+ years, Publicalion Dale lrom
!978/0!/0! lo 2004/0!/30, Lnglish, Human
#!2 Search ("Phanlom Limb/complicalions"MeSH OP "Phanlom Limb/diagnosis"MeSH OP
"Phanlom Limb/drug lherapy"MeSH OP "Phanlom Limb/eliology"MeSH OP "Phanlom
Limb/nursing"MeSH OP "Phanlom Limb/prevenlion and conlrol"MeSH OP "Phanlom
Limb/psychology"MeSH OP "Phanlom Limb/rehabililalion"MeSH OP "Phanlom Limb/
surgery"MeSH OP "Phanlom Limb/lherapy"MeSH) Limils. All Adull. !9+ years, Publicalion
Dale lrom !978/0!/0! lo 2004/0!/30, Lnglish, Human
#!0 Search ("Ampulalion Pesiduums/complicalions"MeSH OP "Ampulalion Pesiduums/drug
lherapy"MeSH OP "Ampulalion Pesiduums/injuries"MeSH OP "Ampulalion Pesiduums/
melhods"MeSH OP "Ampulalion Pesiduums/nursing"MeSH OP "Ampulalion Pesiduums/
physiopalhology"MeSH OP "Ampulalion Pesiduums/rehabililalion"MeSH OP "Ampulalion
Pesiduums/surgery"MeSH OP "Ampulalion Pesiduums/lherapy"MeSH) Limils. All Adull.
!9+ years, Publicalion Dale lrom !978/0!/0! lo 2004/0!/30, Lnglish, Human
#8 Search Care OP physi* OP manag* Limils. All Adull. !9+ years, Publicalion Dale lrom
!978/0!/0! lo 2004/0!/30, Lnglish, Human
Appehdix 2 Literature search strategy
4
39
Appehdix 3 xampIe cf a criticaIIy appraised tcpic (CA1)
RehabiIitation o! Iover extremity amputation due to peripheraI arteriaI
occIusive disease in patients vith end-stage renaI disease
There may be no signilcanl dillerence in lhe abilily ol elderly palienls wilh lower limb ampulalion,
and co-exislenl end-slage renal lo successlully complele proslhelic rehabililalion and lhose wilhoul
end-slage renal disease.

Citationls. Lucke C., MD, 8eindorll N.,MD, Thomas P.,MD, Hoy L., Lucke Chrisloph MD, Vascular
Surgery, Jan/leb !999, Vol 33, No !
Lead author's name and !ax. Caroline Luke, MD Deparlmenl ol Cardiology, Pulmonology and
Angiology, Ollo-von-Cuericke Universily ol Magdeburg, Leipziger Slr. 44, D-39!20 Magdeburg,
Cermany
Three-part CIinicaI uestion. Does lhe presence ol Lnd Slage Penal Disease (LSPD) allecl lhe oulcome
ol rehabililalion in lower limb ampulees wilh peripheral vascular disease?
5earch Terms. LSPD, LLA's, PVD, rehab, proslhelic use
The 5tudy.
The 5tudy Patients. Cases. 30 Lower limb ampulees (age 50-89 years, wilh end-slage renal lailure and
peripheral arlerial occlusive disease). Conlrols. 3!9 lower limb ampulees wilh peripheral arlerial occlusive
disease, bul wilhoul end-slage renal lailure, relerred lor rehabililalion belween !987-!996. Signilcanlly
larger percenlage ol lranslibial ampulalions among lhe cases. Signilcanlly larger number ol bilaleral
ampulalions amongsl conlrols.
Prognostic factor. Lnd slage renal lailure, age, prevalence ol diabeles, ampulalion levels
The Outcome. Pehabililalion, lenglh ol admission
There was a well-delned sample al a unilorm (early) slage ol illness. lollow-up was long enough,
lollow-up was complele. There were nol blind, objeclive oulcome crileria. Adjuslmenl was made lor
olher prognoslic laclors. There was validalion in an independenl lesl-sel ol palienls.
The Evidence.
ProghosIic FacIor OuIcome ResulI Measure Coh!dehce
IhIerval
IhdepehdehI?
Trans-libial ampulalion
wilh end-slage renal
disease
Able lo use a below-
knee proslhesis in
average 74days
74 able lo
walk
yes
Trans-lemoral
ampulalion wilh
end-slage renal disease
Able lo use an above-
knee proslhesis in
average 74days
86 able lo
walk
yes
Trans-libial ampulalion
wilhoul end-slage renal
disease
Able lo use a below-
knee proslhesis in
average 68days
74 able lo
walk
yes
Trans-lemoral
ampulalion wilhoul
end-slage renal disease
Able lo use an above-
knee proslhesis in
average 68days
56 able lo
walk
yes
Diabeles Diabeles in LSPD.
palienls wilhoul LSPD
77
.56
Palio yes
Comments.
Poor qualily relrospeclive case conlrol sludy demonslraling lhal palienls wilh end-slage renal disease
were jusl as likely as non-renal lailure palienls lo achieve proslhelic llling and mobilily slalus, bul lhe
cases were nol well malched lo conlrols. Small sample ol 30 cases compared lo 3!9 in lhe conlrol
group, Appraised by. XXX, 2! May 2004. Lmail. KiII or Update y.
4
40
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4
45
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Hanspal P 50 Pelrospeclive case
series
!00 unilaleral lrans-lemoral
and lranslibial ampulees,
aged 60+ yrs. No
conlrol subjecls
Ampulalion lunclional oulcome wilh a proslhesis is allecled by cognilive and
psychomolor lunclion. Provides evidence lor lhe need ol accurale
assessmenl and lhe selling ol realislic lunclional goals. Well-delned
sample. Cannol lell il lollow-up long enough or complele. No blind,
objeclive oulcome crileria. No adjuslmenl lor olher prognoslic laclors.
Nol randomised
lll
Hanspal P 55 Cohorl 32 lower limb ampulees
aged 54-72yrs. No
conlrol group
Cognilive
Assessmenl Scale.
Clillon Assessmenl
Procedure. Harold
Wood/Slanmore
Mobilily Crade
There is a correlalion belween cognilive, psychomolor slalus and
mobilily level achieved. lollow up long enough bul can'l lell il
complele. No blind objeclive oulcome crileria. Adjuslmenl was made
lor olher prognoslic laclors. No validalion in independenl lesl sel
ol palienls
lll
Houghlon A
37
Pelrospeclive case
series
!02 Vascular lower limb
ampulees operaled on in
!986 and !988 in London
Ampulalion Pehabililalion is more successlul in lranslibial lhan lrans-lemoral
ampulees. Non-validaled rehabililalion queslionnaires were senl
lo !79 palienls, response rale was 8! per cenl. Nol blinded or
randomised. No slandardised rehabililalion programme
lV
Houghlon A
56
Pelrospeclive cross
seclion
!69 unilaleral ampulees
under 3 DSC's. 88
lrans-lemoral, 54 knee
disarliculalion, 27
Crilli-Slokes
lunclional use ol
proslhesis
Ampulees wilh a knee disarliculalion rehabililale beller lhan lhose
wilh a lrans-lemoral or Crilli-Slokes level ol ampulalion. Non-
validaled queslionnaire, response rale 74. Selecled responders were
used by malching lor age & duralion ol ampulalion. Nol blinded.
Adjuslmenl made lor prognoslic laclors. Due lo seleclion lor malching
numbers were small in each group
lll
Hubbard W
59
Pelrospeclive case
series
92 vascular ampulees in
8allaral, Auslralia
Pehabililalion and
proslhelic llling
8elow knee ampulees gain a higher level ol mobilily lhan above
knee ampulees. 20 ampulees died wilhin lwo years ol primary
ampulalion. All palienls had been accepled inlo a rehabililalion
programme. Nol all assessed al similar slage ol rehabililalion.
Discusses earlier sludies bul nol all use lhe same classilcalion
lll
. .


4
4
6
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Jayanlunga U
33
Prospeclive cohorl 2! unilaleral, diabelic lrans-
libial ampulees wilh no
exisling planlar ulceralion
Conlrol group nol used
lool orlhoses
and loolwear
Nalural leel in lhis group are subjecl lo abnormal loading lorces. These
can be reduced by lhe provision ol orlhoses and proper loolwear.
The lool should be monilored and relerred early lor an orlhosis. Well
delned sample al unilorm (early) slage. lollow-up complele and long
enough. Can'l lell il blind, objeclive oulcome crileria. No adjuslmenl
lor olher prognoslic laclors. No validalion in independenl lesl-sel
ol palienls. Uselul sludy bul no lgures shown lo supporl claim lhal
Orlholics reduced abnormal lorces in diabelic lool
lll
Kegel 8 42 Prospeclive case
sludies
4 lrans-libial ampulees. No
conlrol group
LMC bioleedback Pesiduum exercises enhance relenlion characlerislics ol lhe residuum.
Pesiduum exercises should become an inlegral aspecl ol rouline
physiolherapy managemenl. Small sludy, nol blinded. No lollow-up.
No adjuslmenl lor olher prognoslic laclors
lll
Klingenslierna
U 24
Case sludies 8 male lranslibial ampulees,
all cause.
Mean age 6!.5
8ilaleral Lower Limb
Lxercise
Programmes
lsokinelic knee lexion and exlension exercises in lranslibial ampulee
will increase lheir muscle slrenglh.
Supporls lhe general premise lhal exercise improves muscle slrenglh.
Selecled sample, nol enough inlormalion aboul bias
lll
Kulkarni J 74 Prospeclive cross
seclional
!64 conseculive lower limb
ampulees presenling lo UK
DSC. No conlrols.
lalls Lower limb ampulees are al risk lrom lalling. Ampulees should be
educaled whal lo do in lhe evenl ol a lall, wilh wrillen inslruclions
provided. No dillerenlialion made belween palhologies, some may be
al grealer risk lhan olhers. Nol blinded. Nol randomised, no conlrols.
Slruclured queslionnaire expanded in lighl ol pilol sludy
lll
Lachman S
64
Pelrospeclive case
conlrol
!! lower limb ampulees
wilh rheumaloid arlhrilis.
Conlrol subjecls malched
ampulees wilhoul
rheumaloid arlhrilis
Pheumaloid arlhrilis Mosl ampulees wilh rheumaloid arlhrilis use lheir proslhesis daily lor
help wilh lranslers and cosmelic purposes. Small sludy size. Lxposures
were neilher objeclive nor measured blind. Cannol lell il lollow-up
was long enough, bul was complele
lV


4
4
7
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Lamberl A 44 Cross-seclional
survey
Audil ol physiolherapisls
al 35 arlilcial limb unils in
Lngland and Wales
Pesiduum shrinker
usage
Pesiduum shrinkers are used widely, bul only 8.6 ol unils issue lo
every palienl, lor various reasons. There is a need lor guidance in use
ol residuum shrinkers, and research inlo ellecls. Small audil
lV
Lein S 39 Cross-seclional
survey
58 physiolherapisls working
wilh ampulees in calchmenl
area ol lhe Cillingham
Disablemenl Services
Vessa PPAM aid
Mark ! usage
The Vessa PPAM aid is a valuable lool lor physiolherapisls assessing
and lrealing ampulees, bul is being used by some in a polenlially
dangerous manner. Nol all conclusions can be derived lrom dala - no
damage was shown lo be done lo palienls by lack ol knowledge ol
Ppam Aid
lV
Levy S 60 Descriplive cohorl
sludy (number in
cohorl nol slaled)
Lower limb ampulees Proslhesis, skin
inleclion, residual
limb oedema
!.Skin disorders may be due lo mechanical rubs, over or under zealous
skin care
2.Oedema may be caused by incorreclly llled sockel, excessive
negalive pressure in suclion sockel, underlying vascular disorder
3. Pub & shear cause epidermoid cysls
Subjecls nol delned. Lxposures and oulcomes nol objeclive or blind.
Cannol lell il lollow-up was long enough or complele
lV
Liaw M 48 Case conlrol n = 54 wilh phanlom limb
pain
Cases. 25 male ampulees
Conlrols. 29 ampulees
Acupunclure
applied lo lhe sound
conlralaleral limb al
acupoinls
Acupunclure lherapy may be elleclive in lemporarily relieving pain
(p<0.05) when lhe pain is acule. Poor randomizalion, no blinding,
dillerenl sample groups, poor slandardizalion.
Small populalion
lll
Lucke M 65 Pelrospeclive
Case conlrol sludy
Cases. 30 lower limb
ampulees wilh vascular
disease and end-slage renal
disease
Conlrols. 3!9 lower limb
ampulees wilh vascular
disease
Complelion ol
rehabililalion
There may be no signilcanl dillerence in lhe abilily ol elderly palienls
wilh lower limb ampulalion, and co-exislenl end-slage renal lo
successlully complele proslhelic rehabililalion and lhose wilhoul end-
slage renal disease.
Small sample. Signilcanlly larger percenlage ol lranslibial ampulalions
among lhe cases. Signilcanlly larger number ol bilaleral ampulalions
amongsl conlrols
lll
.


4
4
8
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Manella K 68 PCT !2 selecled lrans-libial
ampulees wilh residual limb
oedema
6 Shrinker socks
6 elaslic bandaging
Limb volume The shrinker sock is signilcanlly beller lhan lhe elaslic bandage lor
reducing residual limb oedema (p=0.03).
Small sample size, nol blinded
llb
McCarlney C
45
Cross seclional 40 selecled lower limb
ampulees in Scolland
Prevalence ol pain Pain is common aller ampulalion and allecls qualily ol lile in !0 ol
lhe populalion
lll
Meikle 8 49 Pelrospeclive cohorl
sludy
254 conseculively admilled
lower limb ampulees
in an acule ampulee
rehabililalion unil, all wilhin
90 days ol ampulalion
surgery
lnlerruplions lo
rehabililalion
lnlerruplions lo rehabililalion are common, and may resull in longer
rehab, bul do nol allecl evenlual oulcome.
No inlenlion lo lreal, conlounded by nol including palienls who did
nol relurn lo complele rehabililalion
lV
Moirenleld l
43
Case series !! lrans-libial lsraeli
ampulees aged 22-68
yrs. Pegular, independenl
walkers. No conlrol subjecls
lsokinelic slrenglh
and endurance
lesls in sound and
ampulaled limb
ln lrans-libial ampulees, lhe maximal slrenglh in lhe residual limb
is lower lhan in lhe sound limb. Pecommends lrans-libial ampulees
should do slrenglhening exercises lor residual limb. Small number ol
subjecls. Pesulls ol individuals helerogeneous, ? due lo dillering age
groups, lime since ampulalion and residuum lenglh. lollow-up long
enough and complele
llb
Morlimer C
47
Qualilalive sludy 3! lower limb ampulees
allended one ol 7 locus
groups
locus groups
discussing experiences
ol phanlom pain,
inlormalion received
re phanlom pain
and opinions on
developmenl ol
palienl inlormalion
Well conducled and analysed locus groups. Concludes lhal beller
palienl inlormalion re phanlom pain should be provided.
Prelerence lor,
!) early discussion ol phanloms.
2) inilial inlormalion provided verbally ralher lhan wrillen inlormalion
alone.
3) beller prolessional lraining needed
lll
Nicholas J !0 Case series 94 conseculive ampulees
in Pillsburgh answered
queslionnaires
Ampulalion and
rehabililalion
Palienls lell vulnerable, delenceless and conspicuous. Palienl
inlormalion should be given in wrillen lorm. Trealmenl & assessmenl
should be documenled. Pesponse lo queslionnaire !00.
Queslionnaire piloled
lll
. .

4
4
9
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Pernol H 20 Lileralure overview 7! sludies concerning
prediclive or prognoslic
laclors. Lower limb
ampulees !983-!994 due
lo PVD
lncreasing age, concurrenl diseases and poor compliance are
prognoslic ol a low lunclional level. Advocales mullidisciplinary
leam. No homogeneily in sludies. Can'l lell il sludies were mulliple
independenl reviews ol individual reporls
lll
Pezzin L 70 Cross seclional
queslionnaire
46 palienls who had a
lrauma relaled ampulalion
lo lhe lower limb al lhe
universily ol Maryland
Shock Trauma Cenlre
belween !984 and !994
68 response rale (n=78)
Discharge lo in-
palienl rehabililalion
ln-palienl rehabililalion improves lhe long-lerm oulcomes ol people
wilh lrauma-relaled ampulalions
lll
Pollack C 40 Pandomised conlrol
lrial
80 lower exlremily
ampulees.
40 Larly walking aid
40 conlrols received 'normal
care'
Prevalence ol
posloperalive
complicalions
Using early walking aids reduces lhe incidence ol posloperalive
complicalions and resulls in lasler and more successlul rehabililalion.
No blinding occurred, randomizalion based on admission number
lla
Poller P 54 Prospeclive cohorl 80 non-lraumalic, unilaleral
ampulees admilled
conseculively lo regional
rehabililalion unil
Tesl lor peripheral
neuropalhy
Peripheral neuropalhy in lhe inlacl limb is nearly always presenl in
diabelics requiring ampulalion. Peripheral neuropalhy is also presenl
in 2/3rds ol non-diabelic ampulees. Prevenlalive measures ol limb
care should be ulilized in all palienls wilh an ampulalion. Well-delned
cohorl. Nol blinded. lollow-up complele
lla
Push P 32 Prospeclive case
series
!6 heallhy males (mean age
= 48). Unilaleral, proslhelic,
lrans-lemoral ampulees
lor * 5 yrs. Compares bone
densily ol ampulaled lemur
lo conlralaleral lemur
8one densilomelry There is an increased risk ol developing Osleopenia in lhe lemur ol lhe
ampulaled limb. Accounls lor olher prognoslic laclors. Small number
in sludy, all heallhy males. Nol randomised or blind
lll
Sapp L 57 Pelrospeclive cohorl !32 lower limb ampulees
in Nova Scolia enlering
rehabililalion programme.
No conlrol group
Pehabililalion
programme
A rehabililalion program lor lower limb ampulees leads lo lunclional
proslhelic use. Poorly delned inlervenlion. Peview ol charls and non-
validaled queslionnaire (85 relurn). No blind, objeclive oulcome
crileria. Adjuslmenl was nol made lor olher prognoslic laclors
lV

4
5
0
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Schaldach D
69
relrospeclive, belore
and aller, case
conlrol sludy
7! above-knee and below-
knee arlerial occlusive
disease ampulees in USA
lnlervenlions.
!. Wilhoul clinical
care palhway
2. Wilh a consullalion
lo rehabililalion
services
3. Wilh a
rehabililalion-locused
clinical palhway
Clinical palhways reduce hospilal slay (p=0.0!), reduce hospilal
charges (p=0.003) and lhere was a possible lrend lo more palienls
being discharged lo home (p=0.932). Pelrospeclive charl review
ol palienls belore and aller inlervenlion inlroduced. Only palienls
discharged lo a rehabililalion unil lollowed up
lV
Schon L 73 belore and aller
case conlrol sludy.
Cases. 3! lranslibial
ampulees
Conlrols. 23 malched
lranslibial ampulees using
soll dressings
Lxposure ol lnleresl.
Use ol lPOP
Prelabricaled proslheses may reduce complicalions, revisions & lime lo
lrsl cuslom proslhesis. Seleclion bias may have occurred. !! dropouls
in lPOP group. No inlenlion lo lreal. No. ol lalls nol signilcanlly
reduced
lll
Scoll H 5! pilol randomised
cross-over lrial
!2 lrans libial ampulees
lrom 5 Clasgow hospilals
AMA & Ppam Aid.
Walking 4 lenglhs ol
parallel bars
During slanding inlerlace pressures ol AMA are signilcanlly grealer
(p=0.02) lhan in lhe PPAM aid. During walking lhere is no signilcanl
dillerence. Care needs lo be laken lhal palienls do nol hyper-exlend
when using lhe AMA. 4 ampulees randomised lo group ! were
excluded lrom lhe sludy due lo excessive pain on donning lhe AMA
lb
Seroussi P 63 prospeclive case
conlrol
Subjecls. 8 heallhy, non-
dysvascular, lrans-lemoral
ampulees. Conlrols . 8
heallhy, normal ambulalors,
no olher inlormalion given
Cail analysis Hip exlensors (bilalerally), eccenlric hip lexors and ankle planlar lexors
benell lrom slrenglhening. Small numbers in lrial. Non-blinded,
non-randomised lrial. All proslheses llled by lhe same, experienced
proslhelisl wilh lhe same syslem (worn lor > ! monlh)
lla


4
5
1
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Smilh D 46 Cross seclional
queslionnaire
73 ol eligible palienls
lrom lwo USA hospilals (n
= 92). ! or more years posl-
unilaleral ampulalion and
use a llled proslhesis al
leasl 5 days a week
Phanlom limb,
residual limb, and
back pain aller lower
limb ampulalion
Non-painlul phanlom sensalions are signilcanlly more lrequenl lhan
painlul p<0.000!
No signilcanl dillerence in lrequency ol phanlom, residual or back
pain. Time since ampulalion was nol correlaled wilh lhe occurrence ol
non-painlul phanlom sensalions or pain, or inlensily ol pain
lnlensily ol phanlom sensalions is nol signilcanlly dillerenl lhan lhe
inlensily ol phanlom limb pain. Above knee ampulees are signilcanlly
more likely lo have grealer inlensily ol pain & more bolhersome back
pain lhan below knee ampulees. 8ack pain is more common in lhis
sample lhan lhe general populalion. Nol represenlalive ol all persons
wilh ampulalions as only subjecls who were ! or more years posl
ampulalion and wore a proslhesis were included in lhe sludy
lll
Van De Ven C
53
Cohorl 96 bilaleral ampulees
aged>55 yrs. Ampulalion
wilhin 3 years living al
home or residenlial care
8ilaleral ampulalion 8ilaleral ampulees should be provided wilh a wheelchair and allend
a home visil early in lhe rehabililalion process lo allow successlul
relurn lo lhe domeslic environmenl. No conlrol group. lollow-up
was long enough and complele. No blind, objeclive oulcome crileria.
Adjuslmenl was nol made lor olher prognoslic laclors. Large sludy
wilh dala galhered lrom many variables
lll
Ward K 38 Descriplive review Sludies (!953-!994)
concerning energy cosl ol
ambulalion. Search nol
described
Ambulalion Lnergy cosl ol ambulalion is grealer lor ampulees lhan lor non-
ampulees. Ascending level ol ampulalion is associaled wilh increasing
melabolic demand. Lileralure regarding energy cosl ol ambulalion
wilh dillerenl lower limb proslheses is equivocal. Aerobic lraining
may reduce melabolic cosls ol ambulalion, parlicularly lor lhose wilh
cardiopulmonary or vascular insullciency.
Nol a syslemalic review. lnsullcienl dala given on inclusion ol papers
lherelore may be biased
lll

4
5
2
Citation 5tudy design PopuIation Intervention Comments LeveI o!
evidence
Walers P 6! Case conlrol 70 unilaleral proslhelic lower limb
ampulees, olher palhologies nol
noled bul had no residuum pain,
swelling or pressure sores. Number
ol conlrols unclear "5 normal
persons ol each sex in each decade
lrom lhird lo sevenlh", comparable
resulls wilh olher large sludies lor
non ampulees
Walking The higher lhe level ol ampulalion, lhe higher lhe energy cosl.
Ampulees adjusl lheir velocily lo mainlain lhe rale ol energy
expendilure wilhin normal limils. Age adjusled bul nol randomised or
blinded. Large number in sludy
lll
While L 72 Cross-seclional
survey
!4 DSA managers (86 response
rale),
30 occupalional lherapisls (87
response)
!2 elderly ampulees (!00
response)
Pesiduum board
use
Pesiduum boards are a well accepled piece ol equipmenl lor use
wilh lower limb ampulees. Therapisls should be made aware ol lhe
equipmenl available, ils uses and disadvanlages
lV
Woll L 36 Pelrospeclive
case series
!8 lsraeli, bilaleral vascular
ampulees, aged > 55yrs. No conlrol
group
Pehabililalion Pehabililalion ol bilaleral lower limb ampulees can lead lo
independenl lunclion. Small number ol subjecls. Cannol lell il lhe
lollow-up was long enough, bul was complele. Adjuslmenl was made
lor olher prognoslic laclors. Nol blinded
lV

4
5
3
Appehdix 5 xcIuded papers

1hese papers were hoI ihcluded ih Ihe guidelihe because Ihey were descripIive, irrelevahI Io
Ihe Iopic or o! poor qualiIy.
Dillingham T., Pezzin L. el al. lncidence, acule care lenglh ol slay, and discharge lo rehabililalion ol
lraumalic ampulee palienls. an epidemiologic sludy. Arch Phys Med Pehabil, !998 79. p279-287
Lhde, D., Smilh. D. el al. 8ack pain as a secondary disabilily in persons wilh lower limb ampulalions.
200!. Arch Phys Med Pehabil 82, p.73!-734
lilzpalrick, M. The psychological assessmenl and psychosocial recovery ol lhe palienl wilh an
ampulalion. Clinical Orlhopaedics and relaled research, !999.36!, p.98-!07
Ham, P., Pichardson, P., Sweel, A. A new look al lhe Vessa Ppam Aid. .Physiolherapy, !989. 75 (8),
p.493-494
Lilja M., Johannsson T. Adherenl Cicalrix aller below-knee ampulalion. Journal ol Proslhelics and
Orlholics, !993. 5(2). p65
Malsen S., Malchow D. el al .Correlalions wilh palienls' perspeclives ol lhe resull ol lower-exlremily
ampulalion. Journal ol 8one and Joinl Surgery. 2000, 82-A, (8), p.!089-!095
Yelzer L., Kaullman P. el al. Developmenl ol a palienl educalion program lor new ampulees.
Pehabililalion Nursing, !994 !9 (6),p.355-357

4
54


Dra!t framevork !or pre and post-operative physiotherapy management o! aduIts vith Iover
Iimb amputation, amended !oIIoving consuItation
5uggested sections and the topics incIuded in them
Addilions were made on lhis documenl bul olher commenls were nol lranslerable, reler lo lramework
response sheel lor more delail
1. The roIe o! the physiotherapist vithin the muItidiscipIinary management team
lnlroduclion, seclion covers lhe conlribulion ol physiolherapy lo lhe mullidisciplinary managemenl ol
lhe palienl.
Pain conlrol
Wound healing
Conlrol ol oedema
Managemenl ol phanlom limb
Psychological adjuslmenl
Decision on lrealmenl progression, including slarl ol LWA, relerral lor proslhelic rehab and prescriplion
Discharge planning
Wheelchair and sealing prescriplion
Palhways ol care, slandardised documenlalion, palienl journey, prolocols lor MDT managemenl
Communicalion wilhin MDT
Discharge planning
Peview and use ol shared oulcome measures
Level seleclion lrom a lunclional sland poinl.
2. KnovIedge
IhIroducIioh, ouIlihes Ihe khowledge base IhaI Ihe physioIherapisI should have or
have access Io:
Palhology
Surgical lechniques
lmpacl ol concurrenl condilions
lmpacl ol level ol ampulalion on rehab polenlial
Proslhelic rehab process including prescriplion principles
CPD and keeping up lo dale
MDT managemenl ol concurrenl condilions
Olher relevanl guidelines
lnvesligalions
lnleclion diagnosis and managemenl
Counselling skills/psychology.
3. Assessment
Similar lormal lo previous guidelines bul made applicable lo lhis slage ol rehab.
IhIro, ih!o may be obIaihed pre or posI -op
Appehdix 6 Fatient, peer and prcfessicnaI adviscrs' ccmments cn
the framewcrk cf the guideIines
4
55
3.! There should be wrillen evidence ol a lull physical examinalion and assessmenl ol previous
and presenl lunclion (A)
3.2 The palienls' social silualion, psychological slalus, goals and expeclalion should be
documenled. (8)
3.3 Pelevanl palhology including diabeles, impaired cognilion and hemiplegia should
be noled. (C)
3.5 A problem lisl and lrealmenl plan, including agreed goals, should be lormulaled in
parlnership wilh lhe palienl. (D)
Drug hislory, managemenl ol olher palhology lhrough medicalion
ll lhe assessmenl is done pre op lhen lhere needs lo be anolher assessmenl / review posl op as lhe
palienls physical condilion may have changed due lo surgery and lherelore lheir goals may need lo
be changed
Subjeclive lndings ol pasl aclivilies incl. mobilily should be noled.
4. Patient and carer education
lnlro, physiolherapy conlribulion lo inlormalion and educalion lor palienls and carers.
Palienl journey, including slages in rehab process, meeling olher ampulees and seeing demo limbs
lnlormed goal selling
Care ol remaining limb
Care ol residual limb
Coping slralegies lollowing lalls
Olher inlormalion, driving, employmenl, leisure, elc access lo benells and psychological
supporl, charilies.
5. Pre-op management
lnlro, lor lhose palienls who are seen pre-op lhis seclion will cover physiolherapy inlervenlions
Check chesl
Pre-op assessmenl (in line wilh seclion 3)
Appropriale inlormalion giving lo palienls and carers (seclion ! and 4)
Pre-op lrealmenl regimes based on assessmenl lndings, POM, muscle power and lenglh, lunclional
aclivilies e.g. lranslers, wheelchair mobilily
Specilcally noling Upper Limbs inc. dexlerily in POM assessmenl
Palienls' goals.
6. Post-op management
IhIro, mahy Iopics ih Ihis secIioh could be sIarIed pre-op i! Iime ahd paIiehI's cohdiIioh allows.
Knowledge ol allernale models ol rehab Lnvironmenl and equipmenl
LWA lo assess polenlial & assisl palienls' decision making Compression lherapy
Mobilily aids 8alance re-ed
Translers, on/oll loor Wheelchair and sealing
Prevenlion/reduclion ol conlraclures Home visil
8ed mobilily Posilioning/poslure
Care ol pressure areas Wound condilion
Managemenl ol phanlom sensalion and pain Psychological managemenl.
Lxercise programmes lor lrunk and all limbs,
including residual limb specilc exercises
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BACPAR Guidelines framework response sheet
PIease indicate beIov your comments on the attached framevork
!. Do lhe suggesled six headings ol lhe lramework cover lhe lull scope ol lhe guideline?
Yes No
ll NO, please give recommendalions lor improvemenl
| |ee| |ha| |he po:| opera||ve :ec||on |: |oo |on, and :hou|d be :p||| |n|o |he |n|||a| po:| opera||ve per|od
and |hen a more :pec||c rehab pha:e. 1he:e |wo per|od: are very d|||eren| |or |he pa||en|.
2. Are lhe suggeslions lor lopics lo be covered in each seclion sullcienl lo cover lhe scope ol lhe
Cuideline? Please indicale YLS or NO lor each seclion and add any recommendalions lhal you leel will
improve lhe documenl.
Yes No I! NO pIease give indicate topics to add or remove
Seclion ! X
9
3 Pe managemenl ol phanlom pain and psychological adjuslmenl. Nol
sure how lhe physiolherapisl would/should conlribule lowards lhis
excepl in perhaps an inlormal way.
The heading is an overlap wilh lhe olher guidelines isn'l lhe need lor
MDT and communicalion lhe same pre- and posl proslhelic?
l lhink lhis seclion could be divided more.
Pain and oedema could go logelher in maybe ils own seclion, ? wilh
psychological care.
Wheelchair and sealing could ?? go inlo assessmenl (nol sure aboul
lhis)
Psychological adjuslmenl could go in knowledge or assessmenl??
Discharge planning in assessmenl seclion? lnclude lhe review and use
ol shared oulcome measures
Whal is LWA ?
Level seleclion lrom a lunclional sland poinl
Level seleclion lrom a lunclional sland poinl
Carers psychological needs
Seclion 2 X
8
3 Awareness ol lhe MDT managemenl ol concurrenl condilions i.e. who
responsible lor whal, nexl appoinlmenls elc.
Access lo olher relevanl guidelines/slandards eg ln Scolland, Clinical
slandards documenl Vascular services care ol lhe palienl wilh
vascular disease.
May be add "invesligalions"
How much knowledge ol proslhelic prescriplion principles required?
Pe commenls lor seclions !&3, - basic knowledge ol counselling skills
and /0r psychology would be uselul
lnleclion - diagnosis and managemenl

!
4
57
b
8
b
Yes No I! NO pIease give indicate topics to add or remove
Seclion 3 X
9
3 Pe 3.2 documenlalion ol palienls' psychological slalus. l'm inleresled
lo know lhe recommendalion on how lhis should be done!
lnclude lhe managemenl ol olher palhology lhrough medicalion
(Drug Hislory). A/A knowledge ol key clinicians involved in lhe
palienl's managemenl.
3.! Clear delnilion ol "lull physical examinalion" required and
minimum dala required on each palienl.
3.2/3.3 lnlormalion may already be documenled in MDT noles or
unilary palienl records.
ll lhe assessmenl is done pre op lhen lhere needs lo be anolher
assessmenl / review posl op as lhe palienls physical condilion may
have changed due lo surgery and lherelore lheir goals may need
lo be changed
Subjeclive lndings ol pasl aclivilies incl. mobilily should be noled
Seclion 4 X
8
3 ? lnclude in olher inlormalion somelhing aboul access lo benells and
psychological supporl.
Add ?Lile slyle changes e.g. cessalion ol smoking!!
Need lor slandardisalion ol wrillen inlormalion given?
ln Scolland, Murray loundalion pack given lo all ampulees plus
addilional lealels.
Lisl ol charilies lhal can help as appropriale
Where lo oblain inlormalion ie pamphlels lhal are available eg driving
aller ampulalion and booklels on ampulalion eg our Making lhe besl
ol ampulalion
Seeing demo. Limbs may nol always be possible especially DCHs
wilh small salellile services
Communicalion palhways wilh palienls & carers
Communicalion palhways wilh palienls and carers
lnlormalion on polenlial psychological problems should be supplied

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Appehdix 7 FrcfessicnaI adviscrs' ccmments cn draft 2

very comprehen:|ve and we|| re:earched documen|. |rov|de: :|a|| w||h a c|ear under:|and|n o| area: |o
con:|der when carry|n ou| a::e::men| and |rea|men| o| |he |ower ||mb ampu|ee.

|rov|de: a comprehen:|ve |oo| |o enab|e a|| phy:|o: |o be ab|e |o under:|and |he proce:: when a::e::|n
and |rea||n |he |ower ||mb ampu|ee. |x|reme|y u:e|u| |oo| |or o|her member: o| |he ||1.
A very comprehen:|ve :e| o| u|de||ne: wh|ch | am :ure |u|ure phy:|o|herap|:|: and pa||en|: w|||
bene|| |rom.
'Well done! Lack ol evidence and reliance quile heavily on consensus opinion slighlly disappoinling
bul nol surprising.' The developmenl ol lhe Lvidence 8ased Clinical Cuidelines lor lhe Physiolherapy
Managemenl ol Adulls wilh Lower Limb Proslheses 7 highlighled lhe lack ol evidence in lhe lileralure.
The CDC was mindlul lhal a robusl Delphi consensus exercise was essenlial.
The use ol jargon was highlighled by one ol lhe palienl advisors and lhe lexl was amended lo relecl
lheir commenl. L.g. 'lhe grealer lhe negalive inluence in respecl lo job relenlion and energy cosl
ol walking respeclively' was changed lo. 'lhe more energy was used in walking and job relenlion
was reduced'.
One ol lhe prolessional advisors lell lhal 'lhere should be more relerence lo lhe MDT and nol jusl lhe
physio in some places'. However, in lhe inlroduclion and seclion ! ol lhe recommendalions il is clearly
slaled lhal lhe physiolherapisl works as parl ol and conlribules lo lhe MDT. Therelore lhe suggeslion lo
add "and olher members ol lhe MDT" lo recommendalion 5.2 was nol adopled. Allhough lhe largel
users ol lhese guidelines are physiolherapisls lhe prolessional advisors recognised lhe possibilily ol
exlending lhe use ol lhe guidelines lo olher prolessions and palienls.
ln seclion 3 lhe same advisor commenled lhal 'documenlalion ol all lhis needs lo be in MDT noles lo
reduce repelilion and ensure conlinuily ol care' and 'palienls do gel led up answering lhe same queries
over again'. ln response lo lhis a slalemenl was added under local implemenlalion, The principles ol
single assessmenl should be applied.
The suggeslion lo highlighl key recommendalions was made by lwo advisors. Al lhal poinl lhe grades
ol recommendalion had nol been added lo lhe documenl. The lnal documenl now includes grades ol
recommendalion in accordance wilh CSP and NlCL guidance.
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Appehdix 8 xternaI, peer and patient reviewes ccmments cn draft J
CoIIated comments o! externaI revievers on Dra!t 3, using the AppraisaI o!
GuideIines !or Research and EvaIuation (AGREE) instrument
Page numbers in lhis appendix reler lo an earlier drall documenl
OveraII Comments.
The 8ACPAP guideline developmenl group (CDC) has produced a well-researched and lhorough
guideline lor lhe Pre & Posl-Operalive Physiolherapy Managemenl ol Adulls wilh Lower Limb
Ampulalion. This guideline rales very well overall wilh a lew minor delails lhal lhe CDC may wish lo
consider. These are oullined below in lhe ACPLL ralings.
Congralulalions on lhe documenl
On lhe whole a very comprehensive documenl.
This is a very good guideline, which may nol be apparenl lrom lhe ACPLL crileria! The majorily ol lhe
poinls are lo do wilh presenlalion and can be deall wilh very easily (such as decs ol inleresl, edilorial
independence elc). l do have some concerns aboul lhe recommendalions made in seclion 2, as lhese are
passive ralher lhan leading lo aclion.
Agree ratings
1. The overaII objective o! the guideIine is specicaIIy described.
Paling. 4
Slalemenl !. 4
Slalemenl !. 4
Slalemenl !. 4.
2. The cIinicaI question covered by the guideIine is specicaIIy described.
Paling. 4
Slalemenl 2. 3
Slalemenl 2. 4
Slalemenl 2. 4.
3. The patients to vhom the guideIine is meant to appIy are specicaIIy described.
Paling. 3
CommehIs: This is implied on page !2, bul lhe aulhors could provide more specilcs on lhe inclusion
and exclusion ol palienls. (i.e. co-morbilies whelher lhis may/may nol be an issue)
Slalemenl 3. 2 (Would be uselul lo have a sub-heading wilh lhis inlormalion lor ease ol access)
Slalemenl 3. 4
Slalemenl 3. 4.
4. The guideIine deveIopment group incIudes individuaIs !rom aII reIevant
pro!essionaI groups.
Paling. !
CommehIs. The credenlials lor lhe guideline developmenl group (CDC) should be clearly indicaled,
al leasl in Appendix !. The names are lisled, bul lhe reader should be provided wilh lheir
lraining (degrees), experlise, posilion/lille and place ol employmenl. ln appendix ! (p. 6!)
are lhe conlribulors (4lh subheading) a parl ol lhe CDC? You may need a 3rd level ol subheadings
lo help clarily lhis.
Slalemenl 4. 3
Slalemenl 4. 3 Delails ol CDC missing
Slalemenl 4. 2.
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60
The patients' vievs and pre!erences have been sought
Paling. 4
Slalemenl 5. l wasn'l sure. Palienl/carer represenlalives are lisled in lhe guidelines and lhere is a
seclion on palienl inlormalion needs. May be uselul lo have a heading describing any 'palienl-
relaled' locus.
Slalemenl 5. 4
Slalemenl 5. 2.
5. The target users o! the guideIine are cIearIy dened.
Paling. 4
Slalemenl 6. 3
Again, may be uselul lo have a heading as lor NlCL guidelines 'Who lhis guideline is lor'
Slalemenl 6. ! lmplemenlalion nol yel decided
Slalemenl 6. 4.
6. The guideIine has been piIoted among target users.
Paling. !
Slalemenl 7. 4
Slalemenl 7. N/A yel
Slalemenl 7. !.
7. 5ystematic methods vere used to search !or evidence.
Paling. 4
Slalemenl 8. 4
Slalemenl 8. 4
Slalemenl 8. 4.
8. The criteria !or seIecting the evidence are cIearIy described.
Paling. 4
When lhe arlicles were selecled lor appraisal was lhis based on review ol lhe abslracl or lhe lull
arlicle? Lilher is acceplable, bul lhis should be indicaled eilher way in lexl.
ligure !. The low charl is lairly slraighl lorward lo lollow, bul when lhere is more lhan one choice/
decision lo be made lhere should be some yes/no lype indicalors beside lhe arrows so lhe reader
knows which decision palh lo lollow.
Slalemenl 9. 4
Slalemenl 9. 4
Slalemenl 9. 4.
9. The methods used !or !ormuIating the recommendations are cIearIy described.
Paling. 4
Slalemenl !0. 3
Slalemenl !0. 4 Should local implemenlalion be in lhe guidelines? Surely lhis should be decided
on locally
Slalemenl !0. 2.
4
61
10. The heaIth benets, side e!!ects and risks have been considered in !ormuIating
the recommendations.
Paling. 3
The polenlial heallh benells are somewhal discussed in lhe inlroduclions lor lhe recommendalions
seclions !-6. Some ol lhe key poinls could be discussed and reileraled in lhe 'Heallh benells, Side
ellecls and Pisks' seclion. Currenlly when l read lhis seclion (p.!5, heading 3) l don'l see any heallh
benells lor lhe palienl il a PT uses lhis guideline. The aulhors could provide a briel paragraph
oullining slalislics lor heallh benells lo help slrenglhen lhis seclion. (i.e. indicaling a polenlial
reduclion in hospilal slay, lime lrom surgery lo casling was reduced when palienls received PT, elc...
(laken lrom p.!8 in documenl))
Slalemenl !!. 3
Slalemenl !!. 4
Slalemenl !!. ! Unclear lorm guideline.
11. There is an expIicit Iink betveen the recommendations and the supporting evidence.
Paling. 4
Slalemenl !2. 4
Slalemenl !2. 4
Slalemenl !2. 4.
12. The guideIine has been externaIIy revieved by experts prior to its pubIication.
Paling. 4
Slalemenl !3. 4
Slalemenl !3. 4
Slalemenl !3. 3.
13. A procedure !or updating the guideIine in provided.
Paling. 3
CommehI: The aulhors indicaled lhal lhe guideline will be updaled in 3 years, bul no
procedure is delailed.
Slalemenl !4. 3 (Could do wilh a separale heading aboul when lulure updales will occur, lhe
seclion !.!9 on lhe presenl updale could benell lrom saying il any recommendalions have
changed as a resull ol lhe updale)
Slalemenl !4. 4
Slalemenl !4. 4.
14. The recommendations are specic and unambiguous.
Paling. 4
Slalemenl !5. 4
Slalemenl !5. 4
Slalemenl !5. 3/2 Variable some seclions beller lhan olhers in lhis regard. lor example, seclion
on knowledge- many ol lhe recs are ambiguous, whal il you undersland bul don'l acl? ll seems lo
me lhal many ol lhese recs could be condensed inlo one large rec.
15. The di!!erent options !or management o! the condition are cIearIy presented.
Paling. 4
Slalemenl !6. 4
Slalemenl !6. 4
Slalemenl !6. 3.
4
62
16. Key recommendations are easiIy identiabIe.
Paling. 4
CommehI: The recommendalions could be bolded/ilalicized (or some olher way ol highlighling) lo
help recommendalions sland oul a bil beller.
Slalemenl !7. 2 (Think lhe ACPLL inslrumenl is relerring lo lhe 'key priorilies lor implemenlalion'
syslem lhal NlCL use and which are recommendalions priorilised lor rapid implemenlalion in lhe
NHS. The guideline developmenl melhodology used lor lhis guideline may have elecled nol
lo do lhis)
Slalemenl !7. 4
Slalemenl !7. ! No evidence lound.
17. The guideIine is supported vith tooIs !or appIication.
Paling. !
CommehI. No lools were included wilh lhis version ol lhe documenl. lor example, a summary page
or pockel cards lisling lhe key recommendalions would be helplul lor lhe PT lo keep wilh lhem or
have posled on a bullelin board lor easy access while in clinic.
Slalemenl !8. 3 (Local implemenlailon seclions appear al lhe end ol lisling ol groups ol
recommendalions. There is a palienl/carer seclion bul lhis appears lo be lor heallh care prolessionals
ralher lhan a palienl inlormalion lealel. May be worlh menlioning il any lools planned or developed
in landem wilh lhe guidelines)
Slalemenl !8. ?
Slalemenl !8. !.
18. The potentiaI organizationaI barriers in appIying the recommendations have been discussed.
Paling. 3
CommehI: Could be discussed in more delail.
Slalemenl !9. 3 (On page 27, in relalion lo lhe lasl lwo dol poinls il would be
uselul lo suggesl slralegies lo help wilh overcoming lhese barriers).
Slalemenl !9. 3 The dilemma ol oplimum versus resources. Theory versus
Praclice
Slalemenl !9. 4.
19. The potentiaI cost impIications o! appIying the recommendations have been considered.
Paling. 3
Slalemenl 20. 3
Slalemenl 20. 3 lhis is adequalely covered by p 26
Slalemenl 20. 3.
20. The guideIine presents key reviev criteria !or monitoring andlor audit purposes.
Paling. 3
Slalemenl 2!. Nol sure il lhe local implemenlalion poinls are lhe same.
Would be uselul lo have a separale seclion lisling audil crileria.
Slalemenl 2!. 3 Appendix !!, recommendalion !.6 should read !.5
Slalemenl 2!. 4 .
4
63
21. The guideIine is editoriaIIy independent !rom the !unding body.
Paling. 4
Slalemenl 22. Could nol really ascerlain lhis. May be uselul lo have a slalemenl lo lhis ellecl early
on in lhe documenl (or on lhe cover)
Slalemenl 22. 4
Slalemenl 22. ! Nol clear.
22. Conict o! interest o! guideIine deveIopment members have been recorded.
Paling. 4
CommehI: A senlence describing how lhis inlormalion was soliciled lrom members ol lhe group
could be included. (i.e. Was lhis a verbal slalemenl? Did lhey complele and sign a queslionnaire
asking specilc queslions regarding whal could be a conlicl ol inleresl?)
Slalemenl 23. 4
Slalemenl 23. 4
Slalemenl 23. ! No evidence lound.
OveraII Assessment.
Three exlernal reviewers Pecommended (wilh Provisos or alleralions).
One did nol slale an overall assessmenl.
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1.
Peer reviev o! dra!t 3
Please comment on the presentation, ease of use and clarity of the whole document.
Presenlalion is well slruclured, clear and concise lhroughoul.
Very clear and easy lo use documenl, a pleasure lo read. llow charl "The Appraisal Process" on page 8
easy lo lollow.
Very clear and even lhough il is a lenglhy documenl il is easy lo read.
The documenl is presenled very well and is very well wrillen. The seclions are usually sell-
explanalory and lhe lormal is mainlained lhroughoul. l undersland lhal inlroduclion, evidence and
recommendalions is a logical sequence, however, il is nol always clear whilsl reading why cerlain
aspecls have been included in lhe evidence seclion as lhey do nol link wilh lhe inlroduclion, only lhe
recommendalions. The seclion on Local lmplemenlalion is nol well enough relaled lo lhe olher seclions
i.e. l was nol sure whal lead lo lhem being made and bare bullel poinls do nol encourage suggesled
implemenlalion. The inlroduclion lo lhe posl-op managemenl seclion was briel and inlroduclions lo
each sub seclion would have been benelcial in selling lhe scene belore lhe evidence was presenled.
Allhough il was uselul having lhe Pelerenced aulhors lisled in Appendix 4, eilher lisling lhe lille ol lhe
sludy or making il clearer which slalemenl lhe level ol evidence relers lo would be helplul.
The documenl lakes lime lo read properly and digesl l had lo read il al home as have loo many
inlerruplions lo concenlrale al work. Having said lhal once l gol down lo il, l lound il clear and
logically presenled.
My manager didn'l have lime lo look al il al all.
l lorwarded il lo 3 olher physios, an OT, vascular surgeon and vascular nurse in my MDT lor lheir
commenls and have nol heard back which may relecl lhe oll-pulling size ol lhe documenl.
The evidence presenled is perleclly clear and underslandable.
Pecommendalions very nicely sel oul, easy lo access lhe guidelines and lhe evidence lor each. The
layoul ol lhis seclion makes il easy lo access lhe specilc piece ol evidence in order lo read lurlher
in lo il.
lnlroduclion, aims scope elc excellenl and clear.
Overall clearly presenled and easy lo navigale.
Cenerally very well presenled. Cerlainly lols lo wade lhrough belore gelling lo lhe aclual
recommendalions lhemselves! 8ul hard lo see how lhis be allered
Cood (allhough dillcull lo read on compuler didn'l leel l could prinl oul all pages!!)
Are lhe recommendalions going lo be numbered as in lhe olher guidelines as il's very dillcull lo
relerence lhem il lhey're jusl bullel poinls.?
Page 8 ?clarily whose compelence you are relerring lo.
Pg 23 Wilh lhe Delphi process could you clarily how many queslions were inilially asked in lhe
queslionnaire, l was a bil conlused al lrsl as lhe nexl senlence conlains 2 percenlages relerring lo
dillerenl lhings.
Pg 39 l leel lhal lhis reads lhal lhe pl & carer should be involved in agreeing a rehab plan bul nol
necessarily having any inluence/ negolialion in goal selling.
Are 'shrinker socks' lhe same as lhe compression lherapies/ garmenls you have menlioned earlier? Pg 43
Why does 'respiralory care' in lhe pre op seclion suddenly become 'chesl care' posl op? (Seclion 5.9 &
!0 and seclion 6.!.3)(...sorry l jusl have a lhing aboul people being relerred lo as 'chesly' elc)
Presenlalion wise- 'Pecommendalions' heading is lhe lasl lhing on pg's 48 & 50.
Pg 60 Al lhe end ol lhe prolessional advisors box you have a colon- is lhis relerring lo lhe lisl lhal is on
lhe nexl page or should somelhing else be lisled lhere?
Pg 39 l am unsure whal 'kill or updale by' means..bul il sounds imporlanl!
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65
Pg 72 lhe commenls regarding Ham (2!) aboul ! pl going home requires ! pl... elc seems lo jusl be
phrased a bil oddly
ls the evidence presented in the guideline clear and understandable?
Mosl ol lhe lime. However, why did lhe CDC decide in lhe Delphi process lhal 75 consensus was
acceplable? ls lhis an arbilrary lgure or one used inlernalionally? Also whal is lhe ACPLL appraisal
inslrumenl and whal does il sland lor?
Aparl lrom lhe lollowing lerminology.
MLSH on page !5 and CASP on page !7 or ACPLL on page 25 do nol know whal lhey mean!
Yes very.
Yes.
Seclion ! The MDT P29 il is nol clear why lhe Klingenslierna paper aboul increase in lhigh muscle
slrenglh is included as an isolaled slalemenl in a seclion on evidence lhal MDT is required lor besl
praclice. ll il is included lo juslily why lhere should be a PT involved, il is loo specilc a piece ol evidence
and would be beller suiled in seclion 6.9.. Allhough lhe recommendalions delail lhe role ol lhe
physiolherapisl, lhis is nol inlroduced. Lilher lhis should be done in lhe inlroduclion and/or lhe senlence
al lhe end ol "evidence" amended lo read
ln lhe absence ol olher evidence on lhe role ol lhe physiolherapisl, consensus opinion was soughl lo
lurlher inlorm lhis seclion.
The evidence presenled in lhe seclion suggesling lhal physiolherapisls have adequale knowledge comes
across as a series ol disjoinled slalemenls, leaving lhe reader unsure as lo why lhey have been included.
This is especially lrue ol lhe Meikle paper. Perhaps examples ol "inlerruplions" would help in lhis case,
bul overall lhe whole seclion needs a beller conneclion.
ln lhe evidences seclion ol assessmenl, Levy is quoled regarding lhe skin problems associaled wilh
wearing lhe proslhesis. This quole does nol relale lo lhe skin problems pre-proslhelic users encounler
and may be considered misplaced.
P39 The principles ol single assessmenl should be applied
Should lhis be single shared assessmenl or single assessmenl lor lhe MDT leam?
The evidence presenled is perleclly clear and underslandable.
l lound lhe guidelines well wrillen and al an appropriale level lo be easily underslandable.
Al limes l lound lhe evidence hard lo read as senlences were long have made some modilcalions as
suggeslions lor increasing clarily/ease ol reading.
ls il necessary lo always slale whal kind ol sludy il is? ll you lell lhis oul, il would be easier lo read and
people could reler lo lhe appendix il inleresled.
The evidence seems very comprehensive and relevanl.
Yes l leel il is.
Yes lne.
Overall l would say yes bul again jusl a lew silly quibbles!!!
l did nol know whal 'conversion ol numbers inlo numbers needed lo lreal' meanl when you were
lalking aboul lhe Delphi process (pg !7)
CAT wrillen il lhis is simply a Crilically appraised lopic in whal lormal is a CAT wrillen? (Also do you
need lo wrile il in lull belore using lhe abbrevialion?...sorry should be saving lhis lor lhe grammar
bil!!!!)
Appendix 9- should you also include lhe covering leller so il is lransparenl whal advice/ guidance/ remil
8ACPAP gave lhose llling oul lhe queslionnaires?
2.
4
66
ln your experience, do the 6 sections cover all aspects of pre and post-operative
physiotherapy management of adults with lower limb amputation?
My experience is limiled here bul l wondered il relerral on lo inlermediale care should also be
menlioned and an appropriale lransler package developed lor conlinuily ol care.
Yes.
Yes.
l lnd lhe lille ol seclion 3 a lillle conlusing unlil having read lhe inlroduclion. Changing lhe lille
"Knowledge 8ase" would be more suggeslive lhal you are relerring lo lhe background knowledge ol
lhe lherapisl lo inlorm praclice.
l lnd lhe work on LWAs a lillle disjoinled lhe decision is made under MDT, polenlially using lhem
in a dangerous way is menlioned in knowledge and lheir use is menlioned in posl-op managemenl. l
couldn'l lnd menlion ol using lhe SPAPC inlormalion on lheir use did l miss il somewhere? Have lhe
SPAPC guidelines been updaled? Has lhere been any work on use ol Ppam Aid since '92? Did Helen
Scoll's work commenl on dangers? Having read lhe knowledge seclion and been lell wilhoul lhe
inlroduclion in posl-op managemenl, l am under lhe impression lhal, allhough you advocale use ol lhe
Ppam aid, il can be a dangerous lhing.
6.2 Lnvironmenl and Lquipmenl. The Whillle sludy (!992) was quoled saying lhal allhough residual
limb supporl boards are well accepled lor use bul lherapisls are nol conldenl. This will have been
published al a lime when lhe boards were ply board inserls under lhe cushions wilh hinges lo drop
lhem down. Since !995, "boards" are supplied as a wheelchair accessory lhal replaces lhe loolresl on a
wheelchair and l imagine lhey are now considered rouline. However, l assume lhal no evidence probably
exisls lo suggesl lhal lherapisls are now conldenl wilh lhese. Allhough quoling Whillle does lead lo
lhe recommendalion lhal physiolherapisls should be lamiliar wilh equipmenl, il creales an impression
lhal we are slill unsure inlro e.g. Many relevanl accessories are now available as slandard ilems lo
provide lor lhe environmenlal needs ol ampulees. New models appear regularly and lherapisls should
be aware as lo lhe range available and lheir mode ol lunclioning given lhal While said...
l am a band 7 lherapisl in a small DCH wilh clinical responsibilily lor palienls predominanlly wilh cardio
respiralory condilions on surgical wards and lCU so am nol an ampulee experl. l have been providing
early posl op care lo our ampulees prior lo lheir lransler lo peripheral hospilals lor coming up lo 2 years
and have had no lormal lraining relaling lo ampulees since qualilying !4 years ago! Jusl lelling you
lhis because l may be lypical ol physios slallng many unils. ln answer lo lhe queslion, l have limiled
knowledge so lhere is more inlormalion in lhe guidelines lhan l was aware ol and will be using lhis
evidence lo updale our service.
The guidelines are very lhorough covering everylhing lhal l have come across, or need lo be aware ol in
praclise when working wilh ampulees pre and posl op.
l wondered il lhe lollowing poinls were included under olher seclions, or il lhey would be
worlh considering?
6.4 Mobilily
Could lhis seclion include recommendalion re. lhe progression ol walking aids posl-op, and lor lhe
higher level palienl ouldoor mobilily praclise, in and oul ol cars, picking lhings up lrom lhe loor? l
appreciale lhal lhis may come under lhe exercise seclion as relaled lo lhe palienl's goals.
Could lhis seclion include recommendalion re. risk assessmenl ol mobilising a palienl and lhe availabilily
ol manual handling bells and olher equipmenl lo make lhis process saler?
Yes (allhough my area ol experience is rehab and l have nol worked wilh ampulees in an acule selling
allhough see some primary palienls when slill in-palienls)
l lhink so, allhough l suppose l am relalively inexperienced in working wilh ampulees. All lhings lhal l
considered imporlanl are menlioned along wilh a lew olhers.
All areas seem lo be covered _ only commenls are lhal Counsellor is very absenl lrom lhe lisl ol MDT
members in lhe MDT seclion!!! Psycologisl is menlioned and counsellor relerred lo laler in seclion 2
recommendalions. Needs lo be added here loo.
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Yes l lhink lhey are really lar reaching allhough somelimes do imply lhal lhe physiolherapisls should
be doing everylhing ralher lhan al limes bowing lo lhe lacl lhal olher MDT members mighl be beller
suiled lo a specilc role.
Discharge planning does seem lo be sucked inlo lols ol subseclions. l would quile like lo see lhe
physio's responsibilily in ensuring lhal appropriale lollow up is organised lor ongoing rehab emphasised
a bil more l lell lhal lhe use ol 'ongoing oulpalienl lrealmenl' was a lillle ambiguous as lhese
services are local specialisl ampulee Physio oulpalienl services, DSC or Communily Physio. Also l leel
lhal documenlalion ol lhe specilc plans is imporlanl lo slress- lhal lhe physio needs lo evidence lhe
appropriale plans lhey have organised.
ln your opinion, are there any recommendations that should have been included but
were not? lf yes, please state what these recommendations are.
On P.32 moniloring lhe cardiac slalus ol lhe palienl was menlioned. l have slarled measuring 8P's prior
lo oulpalienl lrealmenl and lollowing lhe 8rilish Hyperlension Cuidelines. ll lhe palienl's 8P is loo
high we lhen inlorm lheir CP and conlemplale poslponing lrealmenl. Should we also be aware ol lhe
palienl's blood sugar level and be able lo measure il pre lrealmenl? There were also no commenls on
lhe use ol lubilasl. ls lhis jusl a nursing decision or parl ol lhe MDT process?
No.
No, no omissions.
5ection 4.2 on lnlormed Coal Selling could be broadened lo include measuremenl ol oulcome.
You reler lo il in recommendalion 4.2.4 so, inslead ol pulling Appendix!3 in brackels as parl ol lhe
recommendalion, a shorl paragraph could be included lo menlion lhal several oulcome measures have
been validaled lor use wilh ampulees (Cagnon, SPAPC's PPl adaplalion, Hanspal's work) and lhal olher
generic measure are also suilable (Sl36). OTs in amp rehab use COPM.
The slalemenl 'No conlradiclory evidence was lound' is puzzling.
5ection 4.4 and 6.3 Missing lrom lhese recommendalions are limescales lor commencemenl ol lhe use
ol shrinker socks. l lhoughl Amanda did a lollow up sludy (bul l am unaware ol whal she lound or il il
was published).
6.7.1 ln addilion lhe wheels in a wheelchair issued lo a bilaleral ampulee should be sel back lo ensure
slabilily (mosl chairs are modular and il is a simple case or reversing lhe brackels. MAPS (lhe wheelchair
service in Aberdeen) looked al slabilily levels ol slandard wheelchairs on a slandard degree ramp and
lound mosl were inherenlly unslable, reinlorcing lhe need lor care in lhis eilher lrail or lop heavy group
ol clienls).
6.8 inclusions on lhe ellecls ol adequale pain reliel in prevenling lhe developmenl ol conlraclures.
6.9.2 l agree aboul slrenglhening hip lexors and exlensors bul lhere is no menlion ol abduclors.
Allhough lhis group is missing lrom lhe evidence, l do nol lhink lhey should be missing lrom
our programme.
Pecommendalion 6.!0.5 slales 'appropriale lrealmenl' should be given can we be any more specilc? l
know ol al leasl one olher acupunclure relerence wilhoul doing a search.
8radbrook D (2004) Acupunclure lrealmenl ol phanlom limb pain and phanlom limb sensalion in
ampulees. Acupunclure in Medicine Jun, 22(2). 93-7.
ln lhe MDT seclion perhaps lhere needs lo be more in lhe area ol discharge planning i.e. who lo
involve, laking a lead or signilcanl role in complex discharge plans, working wilh Discharge Liaison
leams and Social Services, discharge home visil approprialeness, lenglh ol slay, elc
Nol sure.
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Yes Seclion 4 l lhink we need lo add Physio should ensure a relerral lo lhe DSC has been made lor
palienls suilable lor proslhelic rehab.
Also ln palienl physios should ensure lhal arrangemenls have been made lor ongoing physiolherapy on
discharge lrom hospilal so ensure no break in lrealmenl process occurs.
ln local recommendalions lor seclion 3 emphasing lhal lhe palienl is imporlanl in goal selling.
ln seclion 5 should il be slaled lhal il you are unable lo perlorm a pre op Px lhal lhis and lhe reasons
why should be documenled simply lor lullness ol inlormalion?
Would you Hnd these recommendations useful and applicable in your current
clinical practice?
They would provide a lramework lrom which we could audil lhe presenl syslem and lhen
develop lowards.
Lxlremely helplul.
Will be uselul as a relerence lo ensure lhal we are adhering lo good praclice / audil praclice
l am no longer involved in clinical praclice, bul in educalion. All my olher commenls are based on pasl
experience and my new role in measuring oulcomes!
See 3 above. The MDT covers all lhe poinls noled, bul cerlain areas need lighlening up in order lo
deliver seamless care especially as our palienls are shunled aboul a lol.
ie.care palhway, single palienl assessmenl
closer MDT liaison
areas lor my CPD-wound healing, PPAM aid lraining, knowledge ol phanlom pain managemenl, MDT
oulcome measures
Yes, l would lnd lhe guidelines very uselul in making me aware ol everylhing l need lo consider as a
new member ol slall working wilh ampulees. They are helplul in idenlilying gaps in knowledge which
can lhen become learning objeclives lo ensure a wide knowledge base as appropriale lo lhis area.
l also lhink lhal lhe evidence as il is wrillen, allows easy access lo reading malerials lo build up lhis
knowledge base wilh.
ll is encouraging lo have lhese guidelines lo compare my currenl praclise lo, and ensure lhal il is
evidence based and lhal lherelore lhe besl possible lrealmenl, available al lhis lime, is being provided lo
my palienls.
The guidelines are a uselul lool lo compare lhe currenl praclise ol a deparlmenl lo, lo help idenlily
whal is being done well and whal needs lo be improved upon.
The guidelines also highlighl areas which are currenlly nol well supporled wilh evidence, which may in
lulure become areas lo consider researching.
Yes lo know whal lhe gold slandard should be in lhe acule selling plus very uselul lo be able lo access
such a body ol evidence/relerences wilhin one documenl (which is also relevanl lo my area ol praclice).
Very much so, bul parlicularly as we have a brand new, inexperienced Senior ll, and lor our sludenls. We
have an ever increasing ampulee caseload across vascular, lrauma, eleclive elc and are expecled lo see
all ampulee palienls, nol jusl rehab candidales. These guidelines help lo supporl our praclice across lhe
ampulee clienl group.
Well l am nol in ampulee rolalion al presenl bul l would delnilely have lound lhese ol benell when
l was. Lspecially lhe evidence aboul compression lherapy lo lry lo show lo lhe more old lashioned
consullanls!
Yes lor physios in acule selling.
Yes l leel lhal lhey are very lar reaching and would be an excellenl guide (especially lo less experienced
clinicians) ol lhe sheer scope ol consideralions lhey need lo lake inlo accounl.
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How practical would you Hnd implementing the guideline recommendations
in your workplace?
This would be challenging. We currenlly receive repalrialed palienls who have had lheir ampulalion
al anolher local hospilal where surgery has become lheir local specialism. We do provide an inpalienl
service bul have been awailing lhese guidelines lor assislance .We also jusl run a dislricl clinic lor
oulpalienls one morning a week. Our knowledge base is limiled. Selling shorl lerm goals would be
more realislic unlil lhe palienl has discussed lheir silualion wilh a rehabililalion consullanl. Also who
would lead, iniliale and mainlain lhis MDT approach who's prolessional responsibilily is il lo slarl
lhe process?
Mosl are already in place. lmplemenlalion would come lrom physios nol me.
Will lake some lime lo work lhrough lhe guidelines and develop lraining packages lo ensure all slall are
lamiliar wilh lhem bul once compleled il should be OK.
Pecommendalions 6.!0.5, 6 & 7 may be dillcull il l didn'l know aboul desensilising managemenl and
lhe use ol TLNS - il lhese seclions had an inlroduclion, lechniques commonly used could be menlioned
and lhe lack ol evidence highlighled. ls lhere no evidence on TLNS?
l've jusl had a discussion wilh my surgical ward manager who is keen lo hold a monlhly developmenl-
lype meeling lo creale a care palhway elc .l also discussed lhe guidelines lhis morning wilh my line
manager and she has agreed lo me allending lhe weekly diabelic lool ward meeling lor an hour which
will losler leam idenlily, be educalional lor me and lacililale early assessmenl and discharge ol palienls.
This documenl has enabled me lo negoliale my lraining needs.
Producing lealels and care palhways is very lime consuming we do have an exercise booklel lor AK
and 8Ks bul would il be possible lor 8ACPAP lo come up wilh ones lhal could be lweaked according
lo local requiremenls? This would help lo ensure a nalional slandard is being allained.(like ACPPC
compelency grids).
ln my currenl deparlmenl lhere are no barriers lhal l am aware ol lo implemenling lhese guidelines.
Pole would be more lhal ol supporling acule physios in implemenling lhem may be nol so praclical
(see below)
Pecommendalions lhal are relevanl lo primary assessmenl al limb llling cenlre moslly in place already
(inlormalion booklels/compression/advice & counselling elc).
Hopelully wilh ease, as l leel we are already doing much ol whal is suggesled. However il's very uselul lo
have il in wrillen lorm as, lor example, lhe previous guidelines helped us lo argue lor money lo develop
our ouldoor courlyard space lor lhe palienls.
l have concerns lhal lhese guidelines are slill very much geared lo lhe rehabililalable palienl, and will nol
always be appropriale lor palienls wilh very limiled rehabililalion polenlial, e.g. recommendalion 3.4 is
dillcull lo achieve wilh some ol our palienls. Pelerence lo complex discharge plans is nol made. How
much lollow-up is appropriale lor a palienl who won'l become a limb wearer?
N/A.
Wilh some persuasion and lurlher educalion lo ward physios!
l have a lew issues here bul nol many answers l am alraid...
How do you adequalely documenl psychological slalus ol palienl (unless lhey have been lormally
seclioned?!!) l am unsure even whal sorl ol objeclive lhings l would wrile down ?Mini menlal score.
How do you lesl lhe 'underslanding' ol lhe physio menlioned so much in seclion 2 is lhis laken lo be
sell compelencied?
l would have dillcully showing demonslralion limbs- as may many ward PT's- as l do nol work in an area
where proslhelic rehab lakes place.
Who deems lhe 'sale and elleclive use' ol LWA's? Wilh PPAM would lhis be Vessa's inslruclions, SPAPC
guidelines, peer review? (ll peer review il raises lhe queslion when you work independenlly who is
deemed appropriale lo Ax you?...sorry l know lhis is lhe prool ol compelency queslion rearing il's
head again!).
6.
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4
Are there any barriers to implementation of these guidelines?
Currenlly as physios we are nol allowed lo issue juzos, unable lo demonslrale arlilcial limbs (only
available al lhe DSC), lime and skill mix is limiled.
Time / slallng levels.
The main barrier lo implemenlalion ol guideline !.8 is lack ol lrusl on lhe parl ol lhe surgeons ol lhe
decision-making abililies ol experienced physiolherapisls or lear ol misinlerprelalion ol lhe guidelines on
lhe parl ol less experienced lherapisls.
l can loresee guideline !.8 being misinlerpreled as "physiolherapisls are solely responsible lor lhe
decision lo slarl LWA"!
l suggesl rephrasing as lollows.
A physiolherapisl experienced in ampulee rehabililalion can, as parl ol lhe MDT, be solely responsible
lor lhe decision lo slarl using lhe Larly Walking Aid having liaised wilh olher members ol lhe MDT as
necessary. C (lV) 25.
Scoring oul lhe middle phrase as il keeps lhe word CAN beside SOLLLY, and lhe caveal lhal liaison is
laking place is slill relained!
To lurlher saleguard misinlerprelalion, lhe words ONLY AlTLP could be inserled belore having or lhe
word SOLLLY being removed.
The SPAPC sludy showed principally lhal days lo casling were shorler wilh early use ol lhe LWA. ll was
lhis lhal helped many Scollish PTs lo convince surgeons lo allow early use ol lhe LWA. l recommend
menlioning il here ralher lhan in lhe seclion on posl op managemenl.
ln lhe seclion on knowledge p33, Lein is quoled lhal LWA are being used by physiolherapisls in a
polenlially dangerous manner lhis is a lurlher barrier lo implemenlalion ol lhe decision lo slarl LWA
as lhe sole responsibilily ol a physiolherapisl.
My line manager and MDT members are conducive lo laking lhings lorward and are posilive aboul
using a guideline lo lacililale lhis. l would lnd a basic updale course lasling a day relecling lhe Physio
managemenl in lhe guidelines very helplul (nole poinls in 5) As ampulees are only a small parl ol my
job, allending lor example, a 2 or 3 day course would nol be juslilable lo my manager.
Cuidelines relale more lo acule hospilals we liaise wilh and l lhink primary barrier is lhal junior or senior
2 rolalional slall cover lhe vascular wards and lherelore, lhere is limiled or no service developmenl/
consislenl inpul lrom more specialised/experienced slall. Palienls ollen do nol Ppam-aid elc whilsl in
palienls and l lhink lhis is a slallng issue.
MDT barriers moslly. We slruggle lo gel OT inpul in a limely manner. We don'l have a specialisl nurse,
and al presenl don'l have access lo psychological supporl in a slruclured way.
Trusl and PCT's who are overspenl will surely have an impacl on lhe implemenlalion ol lhese guidelines.
Our wheelchair cenlre is in lnancial crisis and may nol be able lo provide chairs lor discharge in a limely
lashion lhis will have a major impacl on our lenglh ol slay.
l guess il you were lrying lo implemenl an lnlegraled care plan lhis demands cooperalion ol all slall.
ln smaller hospilals lhere may nol be lhe availabilily ol lhe equipmenl such as juzo socks, PPAM aid elc.
Do you need lo menlion lhal il lhey are nol available lhe Physio should be aware ol lhe local procedures
lor gaining access lo lhem or menlion lhal lhe local DSC can be used as supporl lor queries regarding
specilc aspecls ol ampulee rehab?
Should il be acknowledged in lhe LWA inlro lhal lhere will always be palienls lhal aren'l suilable lor lhe
LWA- il reads a lillle like il is suilable lor everyone.
Are there any typing or grammatical errors?
Lrrors noliced by peer reviewers were correcled.
7.
8.
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71
Can you suggest any additions to the Glossary (Appendix14).
Nursing guidelines specilc lo ampulee care?
No.
Only lhe abbrevialion CDC on page 89. l realise lhal lhis is wrillen oul in lull on page 62 however, and
lhal is being used in anolher persons commenl.
None. Curious lhal 'acupoinls' are in il.
Pemaining limb.
MDT in abbrevialions.
No.
l have a leeling lhal somewhere you have menlioned 'Crilli- Slokes' as a level ol ampulalion bul lhis is
nol delned alongside 'Symes'
ls lhe glossary going lo be alphabelical 'residual limb' is lhe lasl enlry aller lhe s's & l's.
Any further comments.
Thanks lor lelling me commenl on lhis valuable documenl.
Thanks you lor all your hard work. l lhink lhese guidelines are excellenl.
P!! The aims and objeclives are nol sel oul in lradilional lashion. This may nol be an issue bul generally
lhere is a broad aim ol whal is hoped lo be achieved e.g. lacililaling besl praclice (in your delnilion
lhe olher aims and subsels ol lhis main one and il nol indicaled as such may be seen as duplicalion).
The objeclives are achievable measures ol how lhe aim is lo be mel e.g. rigorously appraise lileralure
lo ascerlain how clinical decision making is besl inlormed, how besl lo inlorm carers elc, lo make
recommendalions lor besl praclice elc.
P26 ll is nol clear il lhe audil is lo lorm lhe basis lor lhe review, nor how lhe checklisl is lo be used i.e. is
lhe lileralure search lo be repealed lo see il more boxes should be licked?
P28 il is nol clear il lhe adjeclive "specialisl" relers only lo lhe physiolherapisl or lo all lhe members ol
lhe leam delailed in lhe senlence as lhe same adjeclive is used lor nurse in lhe 2nd senlence. l would
hope il included a specialisl OT.
P32/p35 The physiolherapisl should have an awareness ol lhe long lerm ellecls ol ampulalion bul l
am nol sure lhal relerence 32 on osleopenia is all lhal relevanl. The isolaled slalemenl aboul il in lhe
evidence seclion cerlainly puzzled me unlil l checked lhe relerences in lhe recommendalions. More
relevanl would be lhe more major co-morbidily laclors and progression ol arlerial disease and diabeles.
Perhaps also, lhe survey by 8LLSMA who summarized lhal back pain was more ol a problem lor war
velerans lhan phanlom pain would be ol inleresl?
P33 l am nol clear why lhe reporl ol lhe ellecls ol exercise on rehabililalion is quoled in lhe seclion ol
knowledge ralher lhan under lhe seclion on exercise in posl op managemenl. ll doesn'l connecl in lhe
knowledge seclion wilh olher slalemenls bul does add imporlanlly lo lhe body ol evidence direclly on
lhe ellecls ol exercise.
9.
10.
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72
l don'l have anyone regionally l leel l can call on lor experl advice. lnleraclive CSP has lo some degree
llled lhal void bul il would be helplul lo have a lisl ol specialisls and lheir e mails, and cenlres ol
excellence lhal are willing lo have visils lrom less experienced colleagues.
Thank you lo all your leam lor lhe immense amounl ol lime and ellorl you have pul inlo producing lhis
documenl. ll has come al jusl lhe righl lime lor me lo slarl implemenling lhe changes l need lo make lo
service delivery here!
Unable lo access link lo CSP elleclive guidelines praclise pg.9
Would il be uselul lo clarily as lo why arlicles lrom !978 onwards were chosen in lhe inclusion
crileria pg. !6? There was no reason given.
Could lhe documenl be spaced more widely lo reduce lhe number ol pages and save paper (especially
righl hand margin)?
A huge amounl ol work has obviously gone inlo lhis il is very comprehensive and impressive, especially
knowing lhal il has been pul logelher by volunleers and lhrough good will.
There are seclions where l leel our aulonomy and experlise is nol being highlighled. There is possibly
loo much emphasis on decisions being made in lhe MDT, e.g. recommendalion 6.!.4, which l leel does
nol supporl our praclise al all. Here we nearly always lake a lead role in deciding lhe discharge dale lor
a palienl, and usually our surgeons allow me and lhe OT lo lully decide and sel lhe dale. ll's much more
lhan us jusl 'aiding' lhal decision.
Nol really surprises al lhe lack on evidence as relaling lo physiolherapy. ll's lhe same in all areas.
Will be an excellenl documenl lo reler lo. Lspecially good is having all relerences logelher lo locale
evidence or inlormalion when required.
Well done everyone involved- il is obvious lhe lime and ellorl lhal has gone inlo dralling lhese.
6.5 LWA's seclion bil conlusing lo say LWA's should be considered lor all levels ol lower limb
ampulalion as we are including hip disarlics and clearly lhere isn'l a suilable LWA
6.9 in Lxercise programmes, recommendalions l don'l undersland why lhese specilc excs areas have
been menlioned and singled oul looks like main emphasis is on lhem alone
linally my name isn'l on lhe Consensus Conlribulers lisl bul l did lhe Delphi queslionnaires.
Well done looks greal!
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73
Patient and carer reviev o! dra!t 3
Please comment on the presentation, ease of use and clarity of the whole document.
l lell lhal lhe overall documenl was reasonably easy lo undersland, well sel oul and clear. To a lay
person lhe only problem which compounded lhis was lhe use ol abbrevialions and medical lerminology.
However, lhe main use will be by Prolessionals and lhis will nol cause dillcullies
The recommendalions seclion was clear and well laid oul. Pages 7-22 were harder going bul inlormed
lhe reading ol lhe recommendalions (where and how lhe evidence was oblained and used)
PPLSLNTATlON lrom a laymans poinl ol view, lhere is loo much inlormalion, lhe documenl is loo big
lo lake in.
LASL Ol USL Again lrom a laymans poinl ol view, lhere are loo many big words and medical phrases
lhal l don'l undersland.
This is a very well wrillen and presenled documenl, which is clear and easy lo use by a lay person.
ls the evidence presented in the guideline clear and understandable?
The evidence was clear, underslandable and l lell lhal lhe way il was used elleclively proved ideas
lhroughoul lhe documenl.
Yes, bul would have been even easier il l had read Appendix !4 (glossary) lrsl!
l can see lhal lhere is a lol ol evidence presenl, bul as l am nol lrom a medical background il is loo
complicaled lor me lo undersland.
Yes, quile clear and underslandable.
ln your experience, do the 6 sections cover all aspects of pre and post-operative
physiotherapy management of adults with lower limb amputation?
SecIioh 3 AssessmehI.
ll is dillcull lo sel realislic goals and a rehab, programme wilh lhe palienl, when lhe palienl has lillle or
no knowledge ol lime-scales elc al lhis slage.
SecIioh 5 Pre op mahagemehI.
ln my case l was a lillle conlused because al lhe hospilal visil slage lhe Sisler lrom lhe Mobilily Cenlre
appeared lo be lhe "keyworker" whilsl as soon as you allend lhe Cenlre il becomes clear lhal lhe
Physiolherapisl is lhe "keyworker"
A joint Physio/nurse visil is more appropriale even belore lhe operalion. This would sow lhe seeds in lhe
palienl's mind ol being involved wilh a MDT.
SecIioh 6.3 Compressioh 1herapy.
Compared lo lhe conlinual emphasis pul on lhe use ol a compression sock during lrealmenl, l was
surprised lhal more emphasis was nol pul on lhis in lhe documenl.
Yes. Jusl one commenl. See Q 4
lrom lhe parls lhal l undersland, yes, bul again l don'l undersland il all.
Yes, based on my experience/journey as a new lrauma ampulee.
2.
3.
1.
4
74
ln your opinion, are there any recommendations that should have been included but
were not? lf yes, please state what these recommendations are.
6.6 lalls managemenl.
l lhink lhal lhere should be a recommendalion lhal dealing wilh a lall should be done in hospilal and
nol as an oulpalienl. l lell oul ol my wheelchair on my lrsl nighl home!! This was, ol course, long
belore l received inslruclion lrom a Physiolherapisl or anyone else as lo how lo gel up (remember Carl.)
l lhink lhal lhe lerm 'exercise regime relevanl lo lhe palienls goals' in seclion 6.9 could include a
relerence lo exercise designed lo build up a palienl's llness and conldence once a proslhesis is
llled (nol jusl slrenglh in muscles). ll a palienl has had dillcully wilh mobilily pre-op, build up ol
lolerance ol lhe proslhesis should be in conjunclion wilh lhe gradual increase in basic llness lhrough a
recommended exercise programme, which is already in place belore discharge. Perhaps lhis needs lo be
a separale seclion?
No.
No, none l could lhink ol as a new lower limb ampulee/
Would you Hnd these recommendations useful and applicable in your current clinical
practice?
As a palienl, l lhink lhe recommendalions would be uselul as a basis lor lrealmenl. They would have lo
be wrillen in a more user lriendly way.
Uselul lor a carer in whal is generally a 'whole new and polenlially lraumalic experience' lo use as a
guide lo all lhe areas ol managemenl menlioned. 8ile sized booklels lor each area on a 'need lo know'
basis could also be uselul (l am sure we had some!)
Nol applicable lo me.
l am a palienl nol a praclioner bul would lnd lhe recommendalions very uselul and applicable al lhe
clinic l allend.
How practical would you Hnd implementing the guideline recommendations in your
workplace?
N/A.
N/A. l am palienl, however in lhe inleresl ol providing qualilalive service and supporl lo palienls l see no
reason why il should nol be praclical lo implemenl lhe guidelines.
Are there any barriers to implementation of these guidelines?
N/A.
8arriers as menlioned in lhe Drall. A palienl's/care's emolional slale wilh regard lo lhe nalure ol lhe
surgery and il's lilelime/slyle implicalions may resull in lhe palienl/carer nol lislening!
N/A l am a palienl bul any barriers should be removed lo help successlul rehabililalion ol ampulees.
Are there any typing or grammatical errors?
No commenl as my lyping, grammar and spelling skills are lerabal. (joke!!)
Can you suggest any additions to the glossary (Appendix14).
No.
2.
6.
7.
8.
9.
1.
4
75
Any further comments.
Page !6. l was a lillle concerned lo read lhal "Lxclusion Crileria excluded lileralure on proslhelic
care and surgical managemenl ol lhe ampulee". Would lhis inlormalion nol be vilal in lorming lhe
Pecommendalions lor Compression Therapy and The Managemenl ol Phanlom Pain?
l lound lhe Documenl lo be a well researched and well pul logelher piece ol work.
Pe Q 4
On Page !2, il slales lhal lhe scope ol lhe guide lines ceases when lhe palienl receives lhe lrsl
proslhesis, and lhal lurlher managemenl is addressed in lhe Lvidence 8ased Clinical Cuidelines lor
lhe Physiolherapy Managemenl ol Adulls wilh lower limb ampulalions. However, my husband was
nol relerred lor lurlher physio, and a programme ol exercise lo develop a basic level ol llness while
increasing lolerance when he lrsl received his proslhesis mighl have been benelcial. ll mighl also help
olher palienls bridge any possible gap belween relerral lo lurlher physio, and lhe lrsl appoinlmenl
and assessmenl.
As a palienl wilh no medical background, l lound lhis documenl very complicaling and conlusing. l
don'l undersland all lhe long words and medical phrases. l leel il would have been easier lor me il
someone had sal me down bolh belore and aller my operalion and had a chal wilh me, ralher lhan
asking me lo complele lhis queslionnaire. ll seems lo me lhal lhis documenl is aimed more al medical
slall lhan al palienls.
My only concern is lhe volunlary nalure ol lhese guidelines. To achieve minimum slandards and
consislency across lhe service, lheir use should be mandalory subjecl lo varialions as appropriale.
Palienls should also be made aware ol lhe guidelines so lhal lhey know whal lo expecl and can ask lor
inlormalion as necessary.
10.
4
76
Appehdix 9 DeIphi questicnnaires
1st DeIphi questicnnaire
How slrongly do you agree wilh lhe lollowing slalemenls
(please mark lhe line wilh a cross and give reasons lor your answer in lhe commenls seclion).
lor example .
All physiolherapisls should have a pay rise.
Disagree Agree
Slrongly Slrongly
Commenls.......We deserve every penny.......
This means !00 agreemenl wilh lhis slalemenl.
The above scale and commenls seclion appears aller every queslion
MDT management
1:1 A physiolherapisl specialised in ampulee care should be responsible lor lhe overall pre and
posl-operalive physiolherapy managemenl.
1:2 The physiolherapisl, as parl ol lhe MDT should decide on oulcome measures lo be used.
1:3 The physiolherapisl should be involved in producing prolocols lo be lollowed by lhe MDT.
1:4 There should be an agreed procedure lor communicalion belween lhe physiolherapisl and
olher members ol lhe MDT.
1:5 A specialisl physiolherapisl can be solely responsible lor lhe decision lo slarl using an Larly
Walking Aid.
1:6 The physiolherapisl, as parl ol lhe MDT, should be involved in lhe decision making process
regarding lhe level ol ampulalion.
1:7 The physiolherapisl, as parl ol lhe MDT, should be involved in making lhe decision lo reler lhe
palienl lor a proslhelic limb.
1:8 The physiolherapisl, along wilh olher prolessionals, should conlribule in lhe managemenl ol
residual limb wound healing.
1.9 The physiolherapisl, along wilh olher prolessionals, should conlribule lo lhe managemenl ol
wound healing on lhe conlralaleral limb il applicable.
1:10 The physiolherapisl, along wilh olher prolessionals should conlribule lo lhe managemenl ol
pressure care.
1:11 The physiolherapisl, along wilh olher prolessionals, should conlribule lo lhe palienl's
psychological adjuslmenl lollowing ampulalion.
1:12 The physiolherapisl should be able lo reler direclly lo a clinical psychologisl / counsellor
il appropriale.
Whal would you like added lo lhis seclion?

44
77
KnovIedge
2:1 The physiolherapisl should have an underslanding ol lhe palhology leading
lo ampulalion.
2:2 The physiolherapisl should have knowledge ol medical invesligalions commonly
underlaken prior lo ampulalion and lheir signilcance.
2:3 The physiolherapisl should have knowledge ol surgical lechniques used in ampulalion.
2:4 The physiolherapisl should have an underslanding ol lhe impacl ol lhe level ol ampulalion on
rehabililalion polenlial.
2:5 The physiolherapisl should have an underslanding ol lhe predisposing laclors lo
successlul rehabililalion.
2:6 The physiolherapisl should have an underslanding ol complicalions lhal may arise
lollowing ampulalion.
2:7 The physiolherapisl should have an underslanding ol how concurrenl condilions may impacl on
rehabililalion polenlial.
2:8 The physiolherapisl should be aware ol olher guidelines relevanl lo rehabililalion
lollowing ampulalion.
2:9 The physiolherapisl should have knowledge ol lhe principles ol proslhelic prescriplion.
2:10 The physiolherapisl should be aware ol lhe possible psychological ellecls which may occur
lollowing ampulalion.
2:11 The physiolherapisl should know when il is appropriale lo reler a palienl lo a clinical
psychologisl/counsellor.
2:12 The physiolherapisl should have knowledge ol lhe principles ol counselling.
Whal would you like added lo lhis seclion?
Patient and carer in!ormation
4:1 The physiolherapisl should give palienls inlormalion aboul lhe expecled slages and localion ol
lhe rehabililalion programme suiled lo lheir individual circumslances.
4:2 The physiolherapisl should give carers inlormalion aboul lhe expecled slages and localion ol
lhe rehabililalion programme suiled lo lheir individual circumslances.
4:3 The physiolherapisl should oller palienls lhe opporlunily lo meel olher adulls wilh lower
limb ampulalions.
4:4 The physiolherapisl should oller carers lhe opporlunily lo meel olher adulls wilh lower
limb ampulalions.
4:5 The physiolherapisl should provide inlormalion aboul lhe proslhelic process lo lhose palienls
likely lo be relerred lor a proslhesis.
4:6 The physiolherapisl should oller lo show demonslralion limbs lo lhose palienls likely lo be
relerred lor a proslhesis.
4:7 The physiolherapisl should know how lo gel inlormalion aboul benells.
4:8 The physiolherapisl should be aware ol local arrangemenls available lo supporl carers.
Whal would you like added lo lhis seclion?
Pre-op management
5:1 Where possible lhe palienl and carers should be given advice, inlormalion and reassurance by
lhe physiolherapisl aboul lhe surgical process.
5:2 Where possible lhe palienl and carers should be given advice, inlormalion and reassurance by
lhe physiolherapisl aboul rehabililalion.
5:3 The physiolherapy assessmenl should be commenced pre-operalively, il possible.
5:4 Where possible rehabililalion/discharge planning should commence pre-operalively.
4
78
5:5 Where possible lhe palienl should be inslrucled in wheelchair managemenl pre-operalively.
5:6 A slruclured exercise regime should be slarled as early as possible.
5:7 8ed mobilily should be laughl where possible.
5:8 Translers should be laughl pre-operalively.
5:9 Chesl care should be given roulinely.
Whal would you like added lo lhis seclion?
Post-op management
6:1. A physiolherapisl should aid lhe MDT in lhe decision as lo lhe appropriale lime lor discharge
lrom inpalienl care.
6:2 The physiolherapisl should have knowledge ol lhe provision ol wheelchairs and accessories.
6:3 The physiolherapisl should be able lo assess a palienl's suilabilily lor a speciled wheelchair.
6:4 The physiolherapisl should have knowledge ol pressure relieving sealing.
6:5 The physiolherapisl should leach lhe palienl and carer how lo use lhe wheelchair (including
all accessories).
6:6 Sale lranslers should be laughl as early as possible.
6:7 The physiolherapisl should have knowledge ol lhe provision ol equipmenl lhal can lacililale
aclivilies ol daily living.
6:8 Slanding balance should be re-educaled il needed.
6:9 The physiolherapisl should help lhe palienl gain maximum mobilily pre-proslhelically.
6:10 Mobilily pre-proslhelically should be in a wheelchair unless lhere are speciled reasons lo leach
a palienl lo use crulches/zimmer lrame/rollalor.
6:11 Posl-operalive rehabililalion should slarl lhe lrsl day posl-operalion where possible.
6:12 Chesl care should be given il appropriale.
6:13 8ed mobilily should be laughl lrsl day posl-operalion.
6:14 Silling balance should be re-educaled il needed.
6:15 The physiolherapisl should use compression lherapy as appropriale.
6:16 Conlraclures should be prevenled by appropriale posilioning.
6:17 Conlraclures should be prevenled by slrelching exercises.
6:18 Where conlraclures have lormed appropriale lrealmenl should be given.
6:19 An exercise regime should be given relevanl lo lhe palienls goals.
6:20 lnlormalion should be given aboul phanlom limb sensalion.
6:21 Appropriale lrealmenl should be given lor phanlom limb pain.
6:22 Appropriale lrealmenl should be given lor residual limb pain.
6:23 Trealmenl musl be given aller adequale analgesia has been supplied.
Whal would you like added lo lhis seclion?
4
79
2nd kcund DeIphi questicnnaire
How slrongly do you agree wilh lhe lollowing slalemenls (please mark lhe line wilh a cross and give
reasons lor your answer in lhe commenls seclion).
MDT management
1.2 The physiolherapisl should conlribule lo lhe decision on which MDT oulcome measures are lo
be used.
1.5 A physiolherapisl experienced in ampulee rehabililalion can, as parl ol lhe MDT, be solely
responsible lor lhe decision lo slarl using lhe early walking aid having liaised wilh olher
members ol lhe MDT as necessary.
1.6 When il is possible lo choose lhe level ol ampulalion lhe physiolherapisl should be
consulled in lhe decision making process regarding lhe mosl lunclional level ol ampulalion
lor lhe individual.
1.9 The physiolherapisl, along wilh olher prolessionals, should conlribule lo lhe managemenl ol
wound healing on lhe conlralaleral limb where appropriale.
1.13 The physiolherapisl, as parl ol lhe MDT, should conlribule lo lhe managemenl ol pain
as necessary.
KnovIedge
2.12 The physiolherapisl should have basic knowledge ol lhe principles ol counselling.
2.13 The physiolherapisl should be aware ol lhe socio-economic impacl ol lower limb ampulalion.
2.14 The physiolherapisl should be aware ol lhe syslems in place lo reler lor assessmenl
lor proslhesis.
2.15 The physiolherapisl should have basic knowledge ol lhe provision ol wheelchairs
and accessories.
2.16 The physiolherapisl, as parl ol lhe MDT, should have basic knowledge ol pressure
relieving sealing.
2.17 The physiolherapisl should have basic knowledge ol lhe provision ol equipmenl lhal can
lacililale aclivilies ol daily living.
Patient and carer in!ormation
4.2 Wilh lhe palienl's consenl lhe physiolherapisl should give carers inlormalion aboul
lhe expecled slages and localion ol lhe rehabililalion programme suiled lo lhe palienl's
individual circumslances.
4.4 Where appropriale, and wilh lhe palienl's consenl, lhe physiolherapisl should oller carers lhe
opporlunily lo meel olher adulls wilh lower limb ampulalions.
4.7 The physiolherapisl should know where lo reler lhe palienl lor inlormalion aboul benells.
4.8 The physiolherapisl should be aware ol arrangemenls available lo supporl carers.
4.9 The physiolherapisl should be able lo reler lhe palienl lo olher agencies as necessary.
4.10 Where possible all verbal inlormalion/advice given should be supplemenled in wrillen lorm.
Pre-operative management
5.1 Where possible lhe physiolherapisl should reinlorce inlormalion given by olher MDT members
aboul lhe general surgical process (nol lechnique).
5.5 Where appropriale and possible lhe palienl should be inslrucled in wheelchair use
pre-operalively.
5.8 Where appropriale and possible lranslers should be laughl pre-operalively.
5.9 The palienl should be assessed lor respiralory care and lrealed approprialely.
5.10 Pain conlrol should be oplimised prior lo physiolherapy lrealmenl pre-operalively.
4
80
5.11 ll appropriale, and wilh lhe palienl's consenl, carers should be involved in pre-operalive
lrealmenl and exercise programmes.
Post-operative management
6.3 Where necessary lhe physiolherapisl should be able lo assess a palienl's suilabilily lor a
wheelchair.
6.5 The physiolherapisl, as parl ol lhe MDT, should be able lo leach lhe palienl and carer how lo
use lhe wheelchair, including all accessories.
6.24 The physiolherapisl should use appropriale oulcome measures lor rehabililalion goals.
6.25 The physiolherapisl should be involved in home visils where necessary.
6.26 The physiolherapisl should give on going advice aboul residual limb care.
Jrd kcund deIphi questicnnaire
How slrongly do you agree wilh lhe lollowing slalemenls (please mark lhe line wilh a cross and give
reasons lor your answer in lhe commenls seclion).
KnovIedge
2.16 The physiolherapisl, as parl ol lhe MDT, should know where lo gel advice on pressure
relieving sealing.
Patient and carer in!ormation
4.8 The physiolherapisl should know where lo gel advice on arrangemenls available lo
supporl carers.
Pre-operative management
5.9.1 ll indicaled lhe palienl should be assessed lor physiolherapy respiralory care.
5.9.2 ll indicaled lhe palienl should be given appropriale physiolherapy respiralory lrealmenl.
Post-operative management
6.3 Where necessary lhe physiolherapisl should be able lo assess a palienl's suilabilily lor a
wheelchair or have knowledge ol lhe relerral process.
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81
Percenlage ol respondenls in agreemenl wilh Delphi queslions
1st uestionnaire resuIts
uestion % Agreement
!.! 86.0
!.2 69.8
!.3 95.3
!.4 79.!
!.5 69.8
!.6 62.8
!.7 95.3
!.8 83.7
!.9 69.8
!.!0 79.!
!.!! 93.0
!.!2 93.0
2.! 97.7
2.2 93.0
2.3 88.4
2.4 !00
2.5 97.7
2.6 !00
2.7 97.7
2.8 95.3
2.9 93.0
2.!0 97.7
2.!! 90.7
2.!2 67.4
4.! 90.7
4.2 67.4
4.3 88.4
4.4 60.5
4.5 97.7
4.6 87.7
4.7 65.!
4.8 69.8
5.! 67.4
5.2 93.0
5.3 90.7
5.4 76.7
5.5 65.!
5.6 95.3
5.7 97.7

Appehdix 10 DeIphi questicnnaires resuIts
uestion % Agreement
5.8 60.5
5.9 30.2
6.! 97.7
6.2 69.8
6.3 53.5
6.4 58.!
6.5 69.8
6.6 93.0
6.7 74.4
6.8 86.0
6.9 88.4
6.!0 86.0
6.!! 97.7
6.!2 90.7
6.!3 93.0
6.!4 95.3
6.!5 90.7
6.!6 !00
6.!7 93.0
6.!8 97.7
6.!9 93.0
6.20 95.3
6.2! !00
6.22 !00
6.23 95.3
4
82
2nd uestionnaire resuIts 3rd uestionnaire resuIts
uestion % Agreement
!.2 92.3
!.5 94.9
!.6 84.6
!.9 64.!
!.!3 87.2
2.!2 89.7
2.!3 87.2
2.!4 !00
2.!5 84.6
2.!6 7!.8
2.!7 79.5
4.2 89.7
4.4 79.5
4.7 79.5
4.8 64.!
4.9 92.3
4.!0 87.2
5.! 82.!
5.5 76.9
5.8 82.!
5.9 7!.8
5.!0 94.9
5.!! 87.2
6.3 74.4
6.5 84.6
6.24 94.9
6.25 87.2
6.26 97.4

uestion % Agreement
2.!6 89.7
4.8 87.2
5.9.! 94.9
5.9.2 97.4
6.3 87.2
4
83
Appehdix 11 0utccme measures
Amputee rehabiIitaticn cIinicaI fcrum (AkCf)
Outcome measures
1he OuIcome Measures lisIed ih Ihis documehI are Iakeh !rom a varieIy o! sources ahd cover
di!!erehI aspecIs o! AmpuIee RehabiliIaIioh.
They are selecled lrom a very wide range ol Oulcome Measures available and are pul lorward lollowing
consullalion wilh each ol lhe disciplines represenled by lhe APC lorum, as having been lound lo
be bolh uselul and useable. All are validaled. APCl does nol suggesl lhal lhey musl be used bul
recommends lhem as uselul lools lo lormalise lhe assessmenl process.
lollowing up lhe relerences ol olher sludies will broaden lhe range ol Oulcome Measures available.
uaIity o! Ii!e outcome measures
Sl-36, Qualily ol Lile Queslionnaire
This is an overall measure ol heallh slalus and lunclioning, used lo assess oulcome ol heallh
care services.
Available !rom: www.s!-36.com
Qualily Melric lnc.
640 Ceorge Washinglon Highway
Lincoln
Pl 02865
USA
There is a cosl lo purchase lhis pack and oblain lhe license lo use il, however, il may be lhal lhe Hospilal
Trusl is already licensed.
HospitaI anxiety and depression scaIe
lndicales levels ol Anxiely and Depression
Available !rom: www.h!erhelsoh.co.uk
Nler Nelson
4!4 Chiswick High Poad
London
W4 5Tl
There is a cosl lo purchase lhis pack and oblain lhe license lo use il, however, il may be lhal lhe Hospilal
Trusl is already licensed.
Recovery Iocus o! controI
lndicales whelher lhe individual believes lhe responsibilily lor lheir recovery lies wilhin lhemselves or
wilh olhers.
Available !rom: www.h!erhelsoh.co.uk
nler Nelson Publishing Co Lld
Darville House
20 Oxlord Poad Lasl
Windsor
8erkshire SL4 !Dl
Parl ol lhe 'Measures in Heallh Psychology', A users porllolio. 'Causal and Conlrol 8eliels'
There is a cosl lo purchase lhis pack and oblain lhe license lo use, however, il may be lhal lhe Hospilal
Trusl is already licensed.
4
84
FuncticnaI heaIth status cutccme measures
Locomotor capabiIities index
The index was designed lo lrace a comprehensive prolle ol locomolor capabililies ol lhe lower limb
ampulee wilh lhe proslhesis and lo evaluale lhe level ol independence while perlorming lhese aclivilies.
Available !rom: chrisIiahe.gaghohsympaIico.co
Chrisliane Caulhier-Cagnon & Marie-Claude Crise
Lcole de readaplalion,
Universile de Monlreal,
C.P. 6!28, 8ranch Cenlre-Ville,
Monlreal
Quebec
Canada H3C 3J7
The LCl is parl ol lhe PPA (Proslhelic Prolle ol lhe Ampulee), Caulhier-Cagnon & Crise, !993. ll may
be pholocopied bul nol modiled (page 90). Caulhier-Cagnon & Crise also idenlily a compilalion ol
oulcome measures called 'Tools lor Oulcome Measures in Lower Limb Ampulee Pehabililalion', 200!
Prosthesis evaIuation questionnaire
This allows a proslhelic user lo sell-rale lhe qualilies ol lhe proslhesis, lheir abilily lo perlorm various
aclivilies wilh lhe proslhesis and lhe psychological and social ellecls ol living wilh lhe proslhesis.
Available !rom: www.prs-research.org
Proslhelics Pesearch Sludy
675 Soulh Lane Slreel
Suile !00
Seallle
Washinglon
98!04
USA
5IGAM aIgorithm
Ollers lhe clinician a simple, valid and reliable means ol measuring mobilily in lower limb ampulees,
whilsl also being able lo idenlily changes lo mobilily making il uselul lor bolh new and
eslablished ampulees.
See DisabiliIy ahd RehabiliIaIioh. 2003. Vol 25. No 15. 833 - 844
Amputee activity score
The AAS is a specilc measure developed lor oulpalienl ampulees wilh a proslhelic limb, il looks al
lhe aclual level ol aclivily a person achieves. The level ol aclivily achieved depends bolh on lunclional
capacily and amounl ol aclivily carried oul.
See Proslhelics and Orlholics lnlernalional, !98!, 5, 23-28 (AAS)
Clinical Pehab 200!. Vol !5. !57-!7! (Modiled AA Queslionnaire)
4
85
Amputee rehabiIitaticn cIinicaI fcrum

The ARC forum is devoted to supporting the care and rehabiIitation o! peopIe
vith Iimb deciency.
The members ol lhe lorum are represenlalives ol lhe lollowing organisalions.
8rilish Associalion ol Charlered Physiolherapisls in Ampulee Pehabililalion (8ACPAP)
8rilish Associalion ol Proslhelisls and Orlholisls (8APO)
8rilish Heallh Trades Associalion (8HTA)
Cenlre Managers lorum
lnlernalional Sociely ol Proslhelics and Orlholics (lSPO)
Limbless Associalion (LA)
Nurses Ampulee Nelwork (NAN)
Nalional lorum ol Ampulee Pehabililalion Counsellors (NlAPC)
Occupalional Therapisls in Trauma and Orlhopaedics (OTTO)
Special lnleresl Croup in Ampulee Medicine (SlCAM)
Deparlmenl ol Heallh (DH)
This forum.
Ollers lhe opporlunily lor mulli-disciplinary clinicians lo meel and discuss issues arising
lrom clinical praclice.
Aims lo provide inlormalion on besl praclice in relalion lo mallers associaled wilh limb
delciency, so lhal lhis inlormalion is available lo clinicians and olhers, wilhoul being prescriplive.
Ollers lhe opporlunily lo oblain advice / commenls on clinical issues relaled lo mallers
associaled wilh limb delciency.
Unlorlunalely since lhis work was compleled APCl has ceased lo lunclion.
March 2005
4
86
Dale.
Pe-audil dale.
Recommendation Yes No NlA Action Points
1.5 There is an agreed procedure
lor communicalion belween
lhe physiolherapisl and
lhe MDT
1.10 - 1.15, 1.17 1here is wriIIeh evidehce
o! Ihe cohIribuIioh o! Ihe
physioIherapisI Io:
managemenl ol residual
limb wound healing
pressure care
managemenl ol wound
healing on lhe conlra laleral
limb
managemenl ol pain
prediclion ol proslhelic use
decision making re. relerral
lor an arlilcial limb
lhe palienls psychological
adjuslmenl lollowing
ampulalion

b
b

b
b
b

b


b

b
b

b
b
b

b
1.18 A procedure exisls lor
lhe physiolherapisl lo
reler direclly lo a clinical
psychologisl / counsellor
2.1 - 2.26 There is wrillen evidence ol
on-going CPD relaling lo
lhe pre and posl operalive
managemenl ol adulls wilh
lower limb ampulalions
3.1 - 3.4 There is wrillen evidence in
lhe palienls physiolherapy
lrealmenl record ol.
a physical examinalion and
assessmenl ol previous and
presenl lunclion
lhe palienls social
silualion, psychological
slalus, goals and
expeclalions
relevanl palhology
including diabeles, impaired
cognilion and hemiplegia
a problem lisl and
lrealmenl plan including
agreed goals lormulaled in
parlnership wilh lhe palienl


b







b

b
Appehdix 12 Audit data ccIIecticn fcrm
4
87
b b
b b
b b
b
b b b
b b
Recommendation Yes No NlA Action Points
4.1.1 , 4.15 There is wrillen evidence ol
inlormalion being given lo
lhe palienl wilh regard lo.
lhe expecled slages and
localion ol lhe rehabililalion
programme
lhe proslhelic process

b
4.1.2 There is wrillen evidence
lhal lhe physiolherapisl
(wilh lhe palienls consenl)
provides carers wilh
inlormalion aboul.
lhe expecled slages and
localion ol lhe rehabililalion
programme

4.1.3, 4.1.6 There is wrillen evidence

lhal lhe physiolherapisl
ollers palienls lhe lollowing
opporlunilies.
lo meel olher adulls wilh
lower limb ampulalions
lo see demonslralion
proslheses (lhose palienls
likely lo be relerred lor a
proslhesis)

b
b

b
b
4.1.4 There is wrillen evidence
lhal (wilh lhe palienls
consenl) lhe physiolherapisl
ollers carers lhe opporlunily
lo meel olher adulls wilh
lower limb
4.1.10 Palienl inlormalion/advice is
available in wrillen lormal
4.2.1 - 4.2.3 There is wrillen evidence
lhal lhe physiolherapisl
makes palienls/carers aware
ol lhe lollowing.
lhal concurrenl
palhologies and previous
mobilily allecls realislic
goal selling and lhe lnal
oulcome ol rehabililalion
lhe level ol ampulalion
allecls lhe expecled level ol
lunclion and mobilily
lhey will experience
lower levels ol lunclion lhan
bipedal subjecls



b

b



b

b
4
88
b b b
b b
b b
Recommendation Yes No NlA Action Points
4.2.4 There is wrillen evidence
lhal lhe physiolherapisl
uses appropriale oulcome
measures lor rehabililalion
goals
4.3.1 There is evidence lhal lhe
palienl/carer is laughl lo
monilor lhe condilion ol lhe
remaining limb
4.3.2 There is evidence lhal lhe
inlormalion given lo palienls
regarding lhe care ol lhe
remaining limb is consislenl
wilh lhe local podialry /
chiropody service
4.3.3 There is evidence lhal
vascular and diabelic
palienls are made aware ol
risks lo lheir remaining lool
4.4.1 - 4.4.4 There is wrillen evidence
ol inlormalion being given
lo lhe palienl / carer wilh
regard lo lhe lollowing.
lhe lollowing.
laclors inluencing wound
healing
Melhods lo prevenl and
lreal adhesion ol scars
The use ol compression
lherapy
Pesidual limb skin care

b
b
b
b

b
b
b
b
5.3 - 5.10 There is wrillen evidence ol
lhe lollowing pre-operalive
managemenl.
Physiolherapy assessmenl
Pehabililalion / discharge
planning
Palienls are inslrucled in
wheelchair use
A slruclured exercise
programme is slarled
8ed mobilily is laughl
Translers are laughl
Pespiralory care
assessmenl
Pespiralory physiolherapy
lrealmenl

b
b
b
b
b
b
b
b

b
b
b
b
b
b
b
b

b
b
b
b
b
b
b
b
4
89
b b
b b
b b b
b b b
Recommendation Yes No NlA Action Points
6.1.2 There is wrillen evidence
lhal posl-operalive
lrealmenl slarled lhe lrsl
day posl operalion
6.4.1 There is wrillen evidence
lhal bed mobilily is laughl
lhe lrsl day posl-operalion
6.4.5 There is wrillen evidence
lhal pre-proslhelic mobilily
is in a wheelchair.
Where a palienl has been
laughl pre-proslhelic
mobilily using crulches/
zimmer lrame/ rollalor
speciled reasons are
documenled.

b
6.6.1 There is wrillen evidence
lhal all parlied involved wilh
lhe palienl are made aware
ol lhe increased risk ol
lalling lollowing lower limb
ampulalion
6.6.2 There is wrillen evidence
lhal lhe rehabililalion
programme included
educalion on prevenling lalls
and coping slralegies should
a lall occur
6.6.3 There is wrillen evidence
lhal inslruclions are given
on how lo gel up lrom lhe
loor
6.6.4 There is wrillen evidence
lhal lhe palienl is given
advice in lhe evenl lhey are
unable lo rise lrom lhe loor.
6.7.1 Palienls are provided wilh a
wheelchair
6.9.! There is wrillen evidence
lhal an exercise regime
is given relevanl lo lhe
palienls goals
4
90
b b
b b
b b
b b
b b
b b b
b b
b b
b b
Recommendation Yes No NlA Action Points
6.9.2 Lxercise programmes
include exercises lor lhe hip
exlensors, hip lexors and
ankle planlar lexors
6.10.1 There is wrillen evidence ol
inlormalion being given lo
lhe palienl regarding lhe
possibilily ol experiencing
phanlom limb pain or
sensalion posl operalively
6.10.3 There is wrillen evidence
lhal inlormalion is given
aboul phanlom limb
sensalion
6.10.7 Techniques lor lhe sell
managemenl ol phanlom
limb pain / sensalion are
laughl


4
91
b b
b b
b b
b b
Appehdix 13 Deniticn cf a cIinicaI physictherapy speciaIist
in amputee rehabiIitaticn
8ased on lhe lhree key componenls which indicale a clinician is praclising al an advanced grade as
delned in lhe !996 PTA Whilley Council Crading Agreemenl and recognised by lhe CSP (Advanced
Crades Documenl Seplember 02)
a) The physiolherapisl is recognised as an experl praclilioner (!).
There is evidence ol.
A relevanl posl-graduale accrediled qualilcalion eg CSP Validaled course, posl-graduale diploma/
cerlilcale/MSc in relaled sludies
Conlinual prolessional developmenl
The physiolherapisl mainlains a weekly clinical case load.
b) The physiolherapisl/posl is a resource in lerms ol educalion, lraining, and developmenl ol senior
physiolherapisls and olher prolessional slall.
c) The posl/physiolherapisl carries responsibililies lor developing and ulilising research evidence, currenl
nalional guidelines and recommendalions and inlegraling lhis inlo service delivery lo ensure lhal
praclice is evidence based.
!
1he exper| |n |he |rey|u: mode| ha: ex|en:|ve exper|ence, an |n|u|||ve ra:p o| |he :||ua||on, and
|ocu:e: |n|erven||on w||hou| wa:|e|u| con:|dera||on o| o|her po::|b|||||e: (|a||:|one 1994

8ACPAR
SepIember 2002
4
92
Appehdix 14 6Icssary cf terms

The lollowing recognised lerminology and abbrevialions were used in lhe guideline documenl.
AcupoihIs are specilc analomical localions on lhe body lhal are believed
lo be lherapeulically uselul lor acupunclure, acupressure,
sonopunclure, or laser lrealmenl.
ADL Aclivilies ol Daily Living
ACRLL Appraisal ol Cuidelines lor Pesearch and Lvalualion
8ACPAR 8rilish Associalion ol Charlered Physiolherapisls in Ampulee
Pehabililalion
CASP Crilical Appraisal Skills Programme
CSP Charlered Sociely ol Physiolherapy
DCH Dislricl Ceneral Hospilal
DSC Disablemenl Services Cenlre
Dysvascular having a deleclive blood supply
LvaluaIioh review and assessmenl ol care lor lhe purpose ol idenlilying
opporlunilies lor improvemenl
LWA Larly Walking Aid
Coal seIIihg eslablishing lhe desired end poinls ol care
CP Ceneral Praclilioner
Hip DisarIiculaIioh ampulalion involving disarliculalion ol lhe lemur lrom lhe
acelabulum
1AMA Journal ol American Medical Associalion
Khee disarIiculaIioh ampulalion by disarliculalion ol lhe libia lrom lhe lemur
MulIidisciplihary Ieam (MD1) a group ol people (e.g. heallhcare slall, palienls and olhers)
who share a common purpose.
NeuropaIhic having lo do wilh damage lo a nerve
O1 Occupalional Therapisl
OsIeopehia decrease in bone mineral densily lhal is a precursor condilion
lo osleoporosis
OuIcome measures a 'lesl or scale adminislered and inlerpreled by physical
lherapisls lhal has been shown lo measure accuralely a
parlicular allribule ol inleresl lo palienls and lherapisls and is
expecled lo be inluenced by inlervenlion' (Mayo !995)
Peer review assessmenl ol perlormance underlaken by a person wilh
similar experiences and knowledge.
ProsIhesis arlilcial replacemenl ol a body parl
PVD Peripheral Vascular Disease
Residual limb, residuum remaining parl ol lhe leg on lhe ampulaled side
SockeI componenl ol lhe proslhesis lhal conlains lhe residual limb
Symes ampulalion by disarliculalion ol lhe ankle wilh removal ol lhe
medial malleolus and reseclion ol lhe libia
1rahs-!emoral AmpuIaIioh ampulalion lhrough lhe lemur
1rahspelvic an ampulalion when approximalely hall lhe pelvis is removed
1rahsIibial AmpuIaIioh ampulalion lhrough lhe libia

4
93
Appehdix 15 usefuI rescurces
ACPAR
Through lhe lnleraclive CSP or www.bacpar.org.uk
ritish Association o! Prosthetists & Orthotists (APO)
Sir James Clark 8uilding, Abbey Mill 8usiness Cenlre, Paisley PA! !TJ
ritish LimbIess Ex-5ervicemen's Association (LE5MA)
lrankland Moore House, !85 High Poad, Chadwell Healh, Lssex PM6 6NA
The Chartered 5ociety o! Physiotherapy (C5P)
The CSP, !4 8edlord Pow, London WC!P 4LD
The CoIIege o! OccupationaI Therapy (COT)
!06-!!4 8orough High Slreel, London SL! !L8
Community agencies
Lisl ol Social Services available in local lelephone direclories
Diabetes UK (CentraI O!ce)
Macleod House, !0 Parkway, London NW! 7AA. Tel. 020 7424 !000
Lmail. inlo@diabeles.org.uk www.diabeles.org.uk
DisabIed Drivers Association
Ashwell Thorpe, Norwich NP6 !LX
EmPover
c/o Poehamplon Pehabililalion Cenlre, Poehamplon Lane, London SW!5 5PP
InternationaI 5ociety !or Prosthetics & Orthotics UK NM5 (I5PO)
lSPO, PO 8ox 26528, London SL3 7Wl
The LimbIess Association
Poehamplon Pehabililalion Cenlre, Poehamplon Lane, London SW!5 5PP
5cottish Physiotherapists Amputee Research Group (5PARG)
C/o Liz Condie
Nalional Cenlre lor Training & Lducalion in Proslhelics & Orlholics
The Curran 8uilding, !3! Sl. James Poad, Clasgow C4 0LS
5ociety o! VascuIar Nurses
www.svn.org.uk
5peciaI Interest Group !or Amputee Medicine (5IGAM) !or the ritish
5ociety o! RehabiIitation Medicine (5RM)
c/o Poyal College ol Physicians
!!, Sl Andrews Place, London NW! 4LL
www.bsrm.co.uk
The VascuIar 5ociety o! Great ritain and IreIand
The Vascular Sociely Ollce, The Poyal College ol Surgeons ol Lngland.
35-43 Lincoln's lnn lields, London. WC2A 3PL
Tel. 020 7973 0306
www.vascularsociely.org.uk
4
94
keIevant guideIines and NaticnaI Service Framewcrks
8riIish socieIy o! rehabiliIaIioh medicihe. (2003) Ampu|ee and |ro:|he||c |ehab||||a||on 5|andard:
and Cu|de||ne:, 2nd Ldilion. Peporl ol lhe Working Parly (Chair. Hanspal PS). London. 8rilish Sociely ol
Pehabililalion Medicine.
Dawson l, Divers C, lurniss D. (2007) |pam-a|d C||n|ca| Cu|de||ne: |or |hy:|o|herap|:|:. Clasgow. Scollish
Physiolherapy Ampulee Pesearch Croup
1he NaIiohal Service Framework !or DiabeIes (!999) Deparlmenl ol Heallh
hllp.//www.dh.gov.uk/PolicyandCuidance/HeallhandSocialCareTopics/OlderpeoplesServices/
OlderPeoplesNSlSlandards/ls/en
1he NaIiohal Service Framework !or Older People (200!) Deparlmenl ol Heallh
hllp.//www.dh.gov.uk/PolicyandCuidance/HeallhandSocialCareTopics/Diabeles/ls/en
Lohg 1erm CohdiIiohs NaIiohal Service Framework (2005) DeparImehI o! HealIh
hllp.//www.dh.gov.uk//PolicyandCuidance/HeallhandSocialCareTopics/LongTermCondilions/ls/en
4
95
The Chartered 5ociety o! Physiotherapy
14 8ed!ord Row, Lohdoh, WC1R 4LD
1el: 020 7306 6666
1exIphohe: 020 7314 7890
Fax: 020 7306 6611
Lmail: enquiriescsp.org.uk
www.csp.org.uk
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