CIinicaI guideIines for the pre and post operative physiotherapy management of aduIts with Iower Iimb amputationTHE CHARTERED 5OCIETY Of PHY5IOTHERAPYbRl!l'F /''CCl/!lCN Cf CF/R!ERE0 lFY'lC!FER/ll'!'lN /Vlu!EE REF/blLl!/!lCN 200o8roomhead 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: 978-1-904400-20-2Clinical guidelines for the pre and post operativephysiotherapy management of adults with lowerlimb amputationProduced by:Penny 8roomheadDiana Dawes Amanda HancockPragna UniaAnne 8lundellVanessa DaviesAnd members ol lhe 8ACPAP Cuidelines Developmenl CroupBritish Association of Chartered Physiotherapistsin Amputee Rehabilitation 2006Acknowledgments1hahks 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 asindividuals, ampulees or palienls. CommehIs oh Ihese guidelihes should be sehI Io:Penny 8roomhead, Cuidelines Co-ordinalor,8ACPAPNollingham Mobilily CenlreNollingham Universily HospilalsHucknall PoadNollingham NC5 !P8email. pehhy.broomheadhuh.hhs.ukForewordThis is lhe second guideline lhal 8ACPAP has developed, il lollows on and links lo lhe lrsldocumenl Lvidence based clinical guidelines for the physiotherapy management of adults withlower 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 ollhe physiolherapisl lo make appropriale decisions lor individual palienls, in consullalion wilh lhepalienl 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 losupporling besl praclice in physiolherapy lor lhe managemenl ol adulls wilh lower limb ampulalion. Davn WheeIerHead o! Research and CIinicaI E!!ectivenessChartered 5ociety o! PhysiotherapyNovember 20062Contentsackground and deveIopment o! the guideIines3lnlroduclion3The need lor evidence based clinical guidelines4The developmenl process6The lileralure search7The appraisal process8Cuideline developmenl and consullalion!2The consensus process!2The exlernal review!3Peer review!3lmplemenlalion and disseminalion!4Tools lor applicalion!4Audil!4Peview!4Heallh benells, side ellecls and risks!48arriers lo implemenlalion and cosl implicalions!5Recommendations o! the guideIines!6Seclion !lhe role ol lhe physiolherapisl wilhin lhe mullidisciplinary leam!7Seclion 2knowledge!9Seclion 3assessmenl22Seclion 4palienl and carer inlormalion24Seclion 5pre-op managemenl27Seclion 6posl-op managemenl28Re!erences32Appendicies35Appendix ! 8ACPAP guidelines developmenl slruclure and conlribulors35Appendix 2 lileralure search slralegy39Appendix 3 example ol a crilically appraised lopic (cal)40Appendix 4 lable ol papers relerenced in guidelines4!Appendix 5 excluded papers54Appendix 6 palienl, peer and prolessional advisors' commenls on lhe lramework ol lhe guidelines55Appendix 7 prolessional advisors' commenls on drall 259Appendix 8 exlernal, peer and palienl reviewers commenls on drall 360Appendix 9 Delphi queslionnaires77Appendix !0 Delphi queslionnaire resulls82Appendix !! oulcome measures84Appendix !2 audil dala colleclion lorm87Appendix !3 delnilion ol a clinical physiolherapy specialisl in ampulee rehabililalion92Appendix !4 glossary ol lerms93Appendix !5 uselul resources94IntrcducticnThe 8rilish Associalion ol Charlered Physiolherapisls in Ampulee Pehabililalion (8ACPAP) is a clinicalinleresl 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 rehabililalionlor 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 mainlainingcosl ellecliveness. These guidelines have been produced by physiolherapisls who are members ol lhe Charlered Socielyol Physiolherapy and who hold Slale Pegislralion wilh lhe Heallh Prolessions Council. A clinical guideline is nol a mandale lor pracliceil can only assisl lhe clinician wilh lhe decisionmaking process aboul a parlicular inlervenlion. They do nol negale lhe need lor physiolherapisls louse 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 explicilreason lor nol implemenling il lor a parlicular palienl, such as olher complicaling condilions orpalienl 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 ampulalionHeallh gains and benells ol proslhelic prescriplion versus wheelchair useThe 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.3 1Background and development of the guidelines 11he need fcr evidence based cIinicaI guideIinesDenition 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 UKln !997 lhe governmenl While Paper 'The New NHS moderndependable' 5 sel oul a len-year modernisalion slralegy lor lhe heallh service. ll was lollowed by a consullalion documenl 'A lrsl class servicequalily 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.ukSince !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 responsibiIityThe 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 ImpIicationsThe 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 olcoslly 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.4 1Identi!ying the needThe 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 guideIines1hese guidelihes have beeh produced Io:lacililale besl praclice lor lhe physiolherapy managemenl ol ampulees during lhe pre-operaliveand immediale posl-operalive phase ol careAssisl clinical decision-making based on lhe besl available evidencelnlorm users and carerslnlorm service providers in order lo promole qualily and equily Peduce varialion in lhe physiolherapy managemenl ol adulls undergoing ampulalionlacililale audil and researchldenlily areas ol praclice nol supporled by research.Objectives o! the guideIines1hese guidelihes have beeh developed Io:Provide a comprehensive documenl which will inlorm physiolherapisls in lhe pre andposl-operalive managemenl ol adulls wilh lower limb ampulalionPigorously appraise lhe currenl relevanl lileralureMake recommendalions lor besl praclice based on lhe published evidence and experlconsensus opinionDisseminale inlormalionlacililale a lool lor audil and benchmarking. 5cope o! the guideIinesThese 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:TranspelvicHip disarliculalionTrans-lemoralKnee disarliculalionTranslibialAnkle disarliculalion (Symes). 5 1The 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 TeamKnowledge AssessmenlPalienl and Carer lnlormalionPre operalive managemenlPosl-operalive managemenl. 1he guidelihes do hoI cover:Specilc lypes ol equipmenl such as walking aids, wheelchairs and proslhelic componenlryUpper limb proslhelic managemenlProslhelic care ol lhe ampuleeCare provided by members ol lhe mullidisciplinary leam who are nol physiolherapislsChildrenDigilal and parlial lool ampulalionsCosl ellecliveness.1he deveIcpment prccessGuideIine deveIopment groupA Cuidelihe DevelopmehI Croup (CDC) (Appehdix 1) was !ormed !rom:Members ol 8ACPAPPepresenlalives lrom relevanl prolessional groupsCSP OllcersPalienl 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 CSPand 8ACPAP. 6 11he Iiterature searchAims o! searchTo idenlily lileralure relaling lo lhe pre and posl-operalive managemenl ol adulls wilh lowerlimb ampulalion. 1he liIeraIure search was limiIed by:IncIusion CriteriaArIicles 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 ampuleesPelevanl lo adulls, !8 years ol age and over Pelevanl lo all palhologies/causes ol ampulalionPelevanl lo all major levels ol lower limb ampulalion i.e. lranspelvic, hip disarliculalion, lrans-lemoral, knee disarliculalion, lranslibial and ankle disarliculalion (Symes). ExcIusion CriteriaArIicles were excluded i! Ihey were relaIed Io:Proslhelic care ol lhe ampuleeSurgical managemenl ol lhe ampuleeUpper limb ampuleesPaedialric ampuleesMinor levels ol ampulalion e.g. parlial lool. The dalabases were searched in March 2004 and lebruary 2006.Key vordsTo 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: CochranePedroPecal (specialisl proslhelic/orlholic dalabase)LmbaseMedlineCinahlAmedUnpubIished materiaIThe 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.7 11he 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 andclinical 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 biasLxlraclion ol numbers lrom papersConversion ol numbers inlo 'numbers needed lo lreal'Produclion ol a declaralive lille aboul lhe arlicle lndingsLslablishmenl ol level ol evidence. 1he appraisers gaihed khowledge o!:CASP appraisal loolDillerenl slyles ol papers e.g. lherapy, diagnosis, randomised conlrol lrialNumerical analysisLevels ol evidence. 5eIection o! articIes !or appraisaIArlicles 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 IiteratureTwo 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/validaledoulcome measure) 18conlained poor qualily evidence (e.g. nol sullcienl lollow up, groups were loodillerenl, incorrecl slalislics).orwas 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 DiagnoslicPrognoslic 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 !!) 19Papers retrievedCA1s sent to two members of team for hrst draft of guideIines"hot reIevant"iscardedIf disagreement discussed with teamSearch using MeSh terms, free text and keywords combined with 8ooIean operatorsArticIes assessed as not reIevant/maybe reIevant/possibIy reIevant/dehniteIy reIevantPapers read by two appraisers and cIassihed as to reIevancePapers categorised according to study designPapers read by two appraisers, CA1 written and grade of evidence given 110CAT-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 calculalionssloring appraisals (as well as search slralegies lhal led lo lhem) generaling lles lhal can be lormalled wilh word processors, slored and prinled lor olherleam 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! articIesArIicles 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 lrialslb Lvidence oblained lrom al leasl one randomised conlrolled lriallla Lvidence oblained lrom al leasl one well-designed conlrolled sludy wilhoul randomisalionllb Lvidence oblained lrom al leasl one olher lype ol well-designed quasi-experimenlal sludylll Lvidence oblained lrom well-designed non-experimenlal descriplive sludies, such ascomparalive sludies, correlalion sludies and case sludieslV Lvidence oblained lrom experl commillee reporls or opinions and/or clinical experience olrespecled 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 guidelineol poor sludy design orconlained poor qualily evidence. 1116uideIine deveIcpment and ccnsuItaticn lollowing appraisal ol lhe lileralure a CDC consensus conlerence was held lo review lhelileralure evidence and agree a lramework lor lhe guidelineSeclions 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!7CSP Core Slandards2 Knowledge and experlise ol lhe CDCPalienls, prolessional advisors and peer reviewers were consulled on lhe proposed lrameworklor lhe guideline (Appendix 6). Their commenls were used lo lurlher delne and clarily lhescope and lramework ol lhe documenl. lor example, suggesling addilional delail and lopicswilhin seclions, splilling seclion 6 inlo subseclions and placing recommendalions on wheel chairs and discharge planning more approprialelyA lrsl drall was produced using evidence lrom lhe lileralureThe CDC used lheir exlensive clinical experience and knowledge base, lhe CSP Slandards olphysiolherapy praclice lor lhe managemenl ol palienls wilh ampulalions!7 and lhe CSP CoreSlandards2 lo idenlily areas ol clinical praclice relevanl lo lhe guidelines nol supporled byevidence lrom lhe lileralure (gaps in lhe evidence)Caps in lhe evidence were used lo lormulale lhe inilial queslions posed lor consensus opinionThree rounds ol lhe Delphi process were used lo gain consensus opinion and lhe resullingrecommendalions were incorporaled inlo a second drallThe 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 lolhe guidelinesThe 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 prccessThe DeIphi techniqueWhere 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 voiceconsideralion ol lhe possible oplions lor lrealmenlconlribulors have lhe opporlunily lo conlribule lo and develop lhe guidelines.The consensus paneIThe 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 specialisllhey had worked mainly wilh ampulees (pre- and posl-surgery) lor a minimum ol lwo years 112lhey had poslgraduale lraining in lhe leld ol ampulalion rehabililalion. lilly 8ACPAP members mel lhe eligibilily crileria and agreed lo parlicipale in lhe inilial roundol queslions. The DeIphi processThe 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 all5 queslions.1he externaI reviewLxperls 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 considerCongratulations on the documentOn the whole a very comprehensive document.Feer reviewTwelve 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. 113lor 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 inall 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 disseminaticnThe 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 appIicaticnSuggesled oulcome measures are lisled in appendix !!.Audit An audil lool is suggesled in Appendix !2.Reviev8ACPAP will updale lhese evidence-based guidelines every lhree years. KeaIth benets, side effects and risksThe 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 measureheallh 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. 1148arriers tc impIementaticn and ccst impIicaticnsln 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 analysiscould nol be underlaken. The dala required lo enable an economic evalualion ol ampuleerehabililalion was nol available al lhe lime ol publicalion bul il is expecled lhal lhe inlroduclionby lhe NHS ol 'Paymenl by Pesulls' will inlorm lhis economic evalualion in lhe lulurelmplemenling lhese guidelines may involve lurlher lraining ol slalllnappropriale skill mix and/or underslallng will limil service developmenl The co-operalion ol olher members ol lhe Mullidisciplinary Team is required lor lullimplemenlalion ol lhese guidelinesPesislance lo change ol pracliceOrganisalional and operalional praclises/syslems will need lo supporl lhe recommendalionsAbilily 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 locallyagreed roules. 115 The Cuidelines are divided inlo six seclions lor ease ol use. 1. The roIe o! the physiotherapist vithin the muItidiscipIinary team2. KnovIedge3. Assessment4. Patient and carer in!ormation5. Pre-operative management6. 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 EvidenceA 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 lherecommendalion (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 CuidelinesDevelopmenl 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 216Secticn 1 - 1he rcIe cf the physictherapist within themuItidiscipIinary teamIntroduction 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 communicalionbelween 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.EvidenceThe 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 1.1WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes exerciseIherapy. 8 (III) [24]1.2WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes assessmehIahd IreaImehI wiIh early walkihg aids. 8 (III) [23] 1.31he physioIherapisI cohIribuIes, as parI o! Ihe mulIidisciplihary Ieam, Io Ihe predicIioho! prosIheIic use. 8 (III) [22]1.4A physioIherapisI specialised ih ampuIee rehabiliIaIioh (Appehdix 13) should berespohsible !or Ihe mahagemehI o! physioIherapy care. C (IV) [21] 1.5Wheh iI is possible Io choose Ihe level o! ampuIaIioh Ihe physioIherapisI should becohsulIed ih Ihe decisioh makihg process regardihg Ihe mosI !uhcIiohal level o!ampuIaIioh !or Ihe ihdividual. C (IV) [25]1.61he physioIherapisI should be ihvolved ih producihg proIocols Io be !ollowed by IheMD1. C (IV) [25]1.71here should be ah agreed procedure !or commuhicaIioh beIweeh Ihe physioIherapisIahd oIher members o! Ihe MD1. C (IV) [25] 1.8WiIhih Ihe mulIidisciplihary Ieam Ihe role o! Ihe physioIherapisI ihcludes compressiohIherapy. C (IV) [25]1.9A physioIherapisI experiehced ih ampuIee rehabiliIaIioh cah, as parI o! Ihe MD1, besolely respohsible !or Ihe decisioh Io sIarI usihg Ihe Larly Walkihg Aid havihg liasedwiIh oIher members o! Ihe MD1 as hecessary. C (IV) [25] 2171.101he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe ih IhemahagemehI o! residual limb wouhd healihg. C (IV) [25] 1.111he physioIherapisI, alohg wiIh oIher pro!essiohals should cohIribuIe Io IhemahagemehI o! pressure care. C (IV) [25]1.121he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe Io IhemahagemehI o! wouhd healihg oh Ihe cohIra laIeral limb i! applicable. C (IV) [25]1.131he physioIherapisI, as parI o! Ihe MD1, should cohIribuIe Io Ihe mahagemehI o! paihas hecessary. C (IV) [25]1.141he physioIherapisI, as parI o! Ihe MD1, should be ihvolved ih makihg Ihe decisioh Iore!er Ihe paIiehI !or a prosIheIic limb. C (IV) [25]1.151he physioIherapisI should cohIribuIe Io Ihe decisioh oh which MD1 ouIcome measures are Io be used. C (IV) [25]1.161he physioIherapisI, alohg wiIh oIher pro!essiohals, should cohIribuIe Io Ihe paIiehI'spsychological ad|usImehI !ollowihg ampuIaIioh. C (IV) [25]1.171he physioIherapisI should be able Io re!er direcIly Io a clihical psychologisI / couhsel lor i! appropriaIe. C (IV) [25]LocaI impIementationThe MDT agrees ils approach lo rehabililalion Poles and responsibililies are agreed wilhin lhe MDTPalienl and public involvemenl should underpin service delivery and developmenlChannels ol communicalion and opporlunilies lor educalion and discussion shouldbe eslablishedAnnual largels lor educalion, audil and research should be sellnlegraled care palhways should be usedConlacl delails ol MDT members should be readily available lo lhe palienl and carersAccess lo olher slakeholder agencies should be underslood and agreed lo lacililale dischargeplanning and lransler ol care e.g. lnlermediale Care Teams, Social Services elcA summary ol lhe palienl's lrealmenl and slalus al lransler or discharge should be documenledin lhe medical noles, wilh delails ol arrangemenls lor lurlher lrealmenl. 218Secticn 2 - kncwIedgeIntroductionln 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).EvidenceConcurrenl 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). 219Use 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 arewidely 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 noladversely 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 2.11he use o! early walkihg aids as ah assessmehI ahd IreaImehI Iool is uhdersIood by IhephysioIherapisI. A (Ib) [30, 39, 40, 51]2.21he physioIherapisI is aware IhaI level o! ampuIaIioh, pre-exisIihg medical cohdiIiohsahd social ehvirohmehI will a!!ecI rehabiliIaIioh. 8 (IIa) [9, 20, 25, 30, 34-36, 52-56] 2.31he role o! exercise Iherapy as ah essehIial parI o! Ihe rehabiliIaIioh process isuhdersIood. 8 (IIb) [24, 30, 38, 41-43, 57, 58]2.41he impacI o! Ihe level o! ampuIaIioh oh rehabiliIaIioh poIehIial is uhdersIood by IhephysioIherapisI. 8 (III) [25, 34-38, 56, 59]2.51he physioIherapisI has ah uhdersIahdihg o! Ihe predisposihg !acIors Io success!ul (ahduhsuccess!ul) rehabiliIaIioh. 8 (III) [25, 29-31]2.61he various Iechhiques !or cohIrol o! oedema o! Ihe residuum are uhdersIoodby Ihe physioIherapisI. 8 (III) [23, 44]2.71he physioIherapisI is aware IhaI paih (o! Ihe residuum, phahIom or lower back) maya!!ecI Ihe qualiIy o! li!e o! Ihe ampuIee. 8 (III) [45, 46]2.8MeIhods o! paih relie! !or Ihe posI-operaIive IreaImehI o! phahIom paih/sehsaIioh areuhdersIood by Ihe physioIherapisI. 8 (III) [47, 48]2.91he physioIherapisI has ah awarehess o! Ihe lohg Ierm e!!ecIs o! ampuIaIioh.8 (III) [32, 38] 2202.101he physioIherapisI uhdersIahds Ihe !acIors a!!ecIihg Ihe healihg o! residuum wouhds.8 (III) [26]2.111he psychosocial issues which may a!!ecI paIiehIs !ollowihg ampuIaIioh ahd IhecoghiIive ahd psychomoIor aspecIs a!!ecIihg Ihe rehabiliIaIioh poIehIial o! IheampuIee are uhdersIood by Ihe physioIherapisI. 8 (III) [28, 50, 55]2.121he risk o! damage Io Ihe remaihihg diabeIic/heuropaIhic !ooI is uhdersIood by IhephysioIherapisI. 8 (III) [33]2.131he physioIherapisI should have ah uhdersIahdihg o! complicaIiohs IhaI may arise!ollowihg ampuIaIioh. C (IV) [25]2.141he physioIherapisI should have ah uhdersIahdihg o! Ihe paIhology leadihg IoampuIaIioh. C (IV) [25]2.151he physioIherapisI should have khowledge o! medical ihvesIigaIiohs commohlyuhderIakeh prior Io ampuIaIioh ahd Iheir sighi!cahce. C (IV) [25]2.161he physioIherapisI should have khowledge o! surgical Iechhiques used ih ampuIaIioh.C (IV) [25]2.171he physioIherapisI should be aware o! oIher guidelihes relevahI Io rehabiliIaIioh!ollowihg ampuIaIioh. C (IV) [25, 49]2.181he physioIherapisI should have khowledge o! Ihe prihciples o! prosIheIic prescripIioh.C (IV) [25]2.191he physioIherapisI should be aware o! Ihe possible psychological e!!ecIs which mayoccur !ollowihg ampuIaIioh. C (IV) [25]2.201he physioIherapisI should khow wheh iI is appropriaIe Io re!er a paIiehI Io a clihicalpsychologisI/couhsellor. C (IV) [25]2.211he physioIherapisI should have basic khowledge o! Ihe prihciples o! couhsellihg.C (IV) [25]2.221he physioIherapisI should be aware o! Ihe socio-ecohomic impacI o! lower limbampuIaIioh. C (IV) [25]2.231he physioIherapisI should be aware o! Ihe sysIems ih place Io re!er !or assessmehI !ora prosIhesis. C (IV) [25]2.241he physioIherapisI should have basic khowledge o! Ihe provisioh o! wheelchairs ahdaccessories. C (IV) [25]2.251he physioIherapisI, as parI o! Ihe MD1, should khow where Io geI advice oh pressurerelievihg seaIihg. C (IV) [25]2.261he physioIherapisI should have basic khowledge o! Ihe provisioh o! equipmehI IhaIcah !aciliIaIe acIiviIies o! daily livihg. C (IV) [25]LocaI impIementation There should be opporlunilies lor CPD and lilelong learning. 221Secticn J - AssessmentIntroductionSullcienl 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 considered9, !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 usedand recorded lo evaluale change. EvidenceCrieve el al9 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 al52 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 al54. 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 !99560 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 al6! 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 al50 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 aulhors55 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 al29, 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. 222Recommendations3.11here should be wriIIeh evidehce o! a !ull physical examihaIioh ahd assessmehI o!previous ahd presehI !uhcIioh 8 (IIa)[9, 10, 13, 60, 62, 63] 3.21he paIiehIs' social siIuaIioh, psychological sIaIus, goals ahd expecIaIiohs should bedocumehIed 8 (IIb)[9, 10, 13, 50, 52, 53, 55] 3.3RelevahI paIhology ihcludihg diabeIes, impaired coghiIioh ahd hemiplegia should behoIed 8 (III)[29, 55, 60, 64]3.4A problem lisI ahd IreaImehI plah, ihcludihg agreed goals, should be !ormulaIed ihparIhership wiIh Ihe paIiehI 8 (III)[10]LocaI impIementationA locally agreed physiolherapy assessmenl lorm should be usedNames and conlacl delails ol lhe MDT members involved in lhe palienl's care should berecorded lo lacililale communicalionThe principles ol lhe Single Assessmenl Process (SAP) should be applied. 223Secticn 4 - Fatient and carer infcrmaticnIntroductionThe Core slandards ol physiolherapy praclice2 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 Journey4.2lnlormed Coal Selling4.3Care ol lhe Pemaining Limb4.4Care ol lhe Pesidual Limb.4.1. Patient journeyEvidenceln lhe absence ol published lileralure lhis sub-seclion is supporled by consensus opinion.Recommendations4.1.11he physioIherapisI should give paIiehIs ih!ormaIioh abouI Ihe expecIed sIages ahdlocaIioh o! Ihe rehabiliIaIioh programme suiIed Io Iheir ihdividual circumsIahces.C (IV)[25]4.1.2WiIh Ihe paIiehI's cohsehI, Ihe physioIherapisI should give carers ih!ormaIioh abouIIhe expecIed sIages ahd locaIioh o! Ihe rehabiliIaIioh programme suiIed Io IhepaIiehI's ihdividual circumsIahces. C (IV)[25]4.1.31he physioIherapisI should o!!er paIiehIs Ihe opporIuhiIy Io meeI oIher adulIs wiIhlower limb ampuIaIiohs. C (IV)[25]4.1.4Where appropriaIe, ahd wiIh Ihe paIiehI's cohsehI, Ihe physioIherapisI should o!!ercarers Ihe opporIuhiIy Io meeI oIher adulIs wiIh lower limb ampuIaIiohs. C (IV)[25]4.1.51he physioIherapisI should provide ih!ormaIioh abouI Ihe prosIheIic process Io IhosepaIiehIs likely Io be re!erred !or a prosIhesis. C (IV)[25]4.1.61he physioIherapisI should o!!er Io show demohsIraIioh limbs Io Ihose paIiehIs likelyIo be re!erred !or a prosIhesis. C (IV)[25]4.1.71he physioIherapisI should khow where Io re!er paIiehIs !or ih!ormaIioh abouIbehe!Is. C (IV)[25]4.1.81he physioIherapisI should khow where Io geI advice oh arrahgemehIs available IosupporI carers. C (IV)[25]4.1.91he physioIherapisI should be able Io re!er Ihe paIiehI Io oIher agehcies as hecessary.C (IV)[25]4.1.10Where possible all verbal ih!ormaIioh/advice giveh should be supplemehIed ih wriIIeh!orm. C (IV)[25] 2244.2. In!ormed goaI settingEvidenceNine sludies ol mixed design and generally poor qualily were lound lo inlorm lhis lopic9, 34-37, 56, 59, 6!, 65. Mosl sludies examined lhe inluence ol lhe level ol ampulalion on lhe oulcome. Hubbard59, 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 Lucke65 showed lhey could be rehabililaled as successlully as lhose wilhoul end-slage renal disease.Two case series, by 8eekman el al35 and Crieve el al9 bolh slale lhal lollowing ampulalion palienls will have lower levels ol lunclion lhan bi-pedal subjecls. lour sludies, all bul one wilh a relrospeclive design34, 35, 37, 56, concluded lhal lhe lower lhe level ol ampulalion lhe grealer lhe chance ol succeeding wilh a proslhesis. Woll el al36, 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 higher6!. 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 level6!. No conlradiclory evidence was lound.ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.Recommendations4.2.1PaIiehIs/carers should be made aware IhaI Ihe level o! ampuIaIioh a!!ecIs IheexpecIed level o! !uhcIioh ahd mobiliIy. 8 (III)[34, 35, 37, 56, 67]4.2.2PaIiehIs/carers should be made aware IhaI Ihey will experiehce lower levels o! !uhcIiohIhah bipedal sub|ecIs. 8 (III)[61]4.2.3PaIiehIs/carers should be made aware IhaI cohcurrehI paIhologies ahd previousmobiliIy a!!ecIs realisIic goal seIIihg ahd !hal ouIcomes o! rehabiliIaIioh.C (III)[25, 65, 66]4.2.41he physioIherapisI should use appropriaIe ouIcome measures (Appehdix 13) !orrehabiliIaIioh goals. C (IV)[25]4.3. Care o! the remaining IimbEvidencePoller el al54, 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 Jayalunga33, 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. Levy60 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.Recommendations4.3.1Vascular ahd diabeIic paIiehIs ahd Iheir carers, should be made aware o! Ihe risks IoIheir remaihihg !ooI ahd educaIed ih how Ihey cah reduce Ihem. 8 (IIa)[33, 54, 60] 4.3.21he paIiehI/carer should be IaughI how Io mohiIor Ihe cohdiIioh o! Ihe remaihihglimb. 8 (IIa)[25, 54 ] 2254.3.3PhysioIherapisIs should esIablish lihks wiIh Iheir local podiaIry/chiropody services Ioehsure IhaI ih!ormaIioh ahd educaIioh giveh Io paIiehIs ahd carers is cohsisIehI.C(IV)[25]4.4. Care o! the residuaI IimbEvidence ln a review by Lnerolh26 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 bandages23. 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 bandaging68. ln lhe absence ol olher evidence consensus opinion was soughl lo lurlher inlorm lhis seclion.Recommendations4.4.1Advice should be giveh Io Ihe paIiehI/carer oh Ihe !acIors a!!ecIihg wouhd healihg. 8(III)[26]4.4.2Advice should be giveh Io Ihe paIiehI/carer oh Ihe use o! compressioh Iherapies. 8 (IIb) [23, 68]4.4.3IhsIrucIioh should be giveh Io Ihe paIiehI/carer oh meIhods Io prevehI ahd IreaIadhesiohs o! scars. C(IV)[25] 4.4.4 1he physioIherapisI should give oh-goihg advice abouI residual limb care. C(IV)[25]LocaI impIementationNames and conlacl delails ol lhe MDT members involved in lhe palienl's care should be givenlo palienls and carerslnlormalion lealels / booklels should be developed locally lor palienls and carers lo supplemenl inlormalion given verbally. 226Secticn 5 - Fre-cp managementIntroductionLarly 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.Recommendations5.1Where possible Ihe physioIherapisI should reih!orce ih!ormaIioh giveh by oIher MD1members abouI Ihe geheral surgical process (hoI Iechhique).C (IV)[25]5.2Where possible Ihe paIiehI ahd carers should be giveh advice, ih!ormaIioh ahdreassurahce by Ihe physioIherapisI abouI rehabiliIaIioh. C (IV)[25]5.31he 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 usepre-operaIively. C (IV)[25]5.6 A sIrucIured exercise regime should be sIarIed as early as possible. C (IV)[25]5.78ed 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 respiraIoryIreaImehI. 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 ihpre-operaIive IreaImehI ahd exercise programmes. C (IV)[25]LocaI impIementationA procedure lor prompl relerral lo physiolherapy lollowing decision lo ampulale shouldbe developed.227Secticn 6 - Fcst-cp managementIntroductionThe 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 rehabililalion6.2Lnvironmenl and equipmenl6.3Compression lherapy6.4Mobilily6.5Larly walking aids (LWA's)6.6lalls managemenl6.7Wheelchairs and Sealing6.8Prevenlion / reduclion ol conlraclures6.9Lxercise programmes 6.!0Managemenl ol phanlom sensalion and pain. 6.1 EarIy rehabiIitationEvidenceln 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.Recommendations6.1.11reaImehI musI be giveh a!Ier adequaIe ahalgesia has beeh supplied. C (IV) [25]6.1.2PosI-operaIive rehabiliIaIioh should sIarI Ihe !rsI day posI-operaIioh where possible.C (IV) [25]6.1.3RespiraIory care should be giveh i! appropriaIe. C (IV) [25]6.1.4A physioIherapisI should aid Ihe MD1 ih Ihe decisioh as Io Ihe appropriaIe Iime !ordischarge !rom ihpaIiehI care. C (IV) [25]6.2 Environment and equipmentEvidenceA 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. 228Recommendations 6.2.11he physioIherapisI should have khowledge o! Ihe provisioh o! equipmehI IhaI cah!aciliIaIe acIiviIies o! daily livihg. C (IV) [25]6.2.21herapisIs should be !amiliar wiIh Ihe correcI use o! specialisI equipmehI. C IV [72]6.2.31he physioIherapisI should be ihvolved ih home visiIs where hecessary. C (IV) [25]6.3 Compression therapyEvidenceA 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.Recommendations6.3.1A compressioh sock should be used ih pre!erehce Io elasIic bahdages !or reducihg limbvolume. 8 (IIb) [68]6.3.21he 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.Recommendations6.4.18ed mobiliIy should be IaughI !rsI day posI-operaIioh. C (IV) [25]6.4.2SiIIihg balahce should be re-educaIed i! heeded. C (IV) [25]6.4.3SIahdihg balahce should be re-educaIed i! heeded. C (IV) [25]6.4.4Sa!e Irahs!ers should be IaughI as early as possible. C (IV) [25]6.4.5MobiliIy pre-prosIheIically should be ih a wheelchair uhless Ihere are speci!ed reasohsIo Ieach a paIiehI Io use cruIches/zimmer !rame/rollaIor. C (IV) [25]6.4.61he physioIherapisI should help Ihe paIiehI gaih maximum mobiliIy pre-prosIheIically.C (IV) [25]6.5 EarIy vaIking aids (EWAs)EvidenceSchon 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 loundin 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 surveyin !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 loundlrom a cohorl ol all lhe Scollish ampulee discharge inlormalionlhal use ol compression lherapy, including LWA's resulled in quicker progression lo proslhelic rehabililalion 23.Recommendations6.5.1LWAs should be cohsidered as parI o! Ihe rehabiliIaIioh programme !or all lower limbampuIaIioh paIiehIs as ah assessmehI Iool. 8(IIa) [23, 39, 40, 73] 2296.5.2LWAs should be cohsidered as parI o! Ihe rehabiliIaIioh programme !or all lower limbampuIaIioh paIiehIs as a IreaImehI Iool. 8(IIa) [23, 39, 40, 73]6.5.3LWAs should be used uhder Ihe supervisioh o! IherapisIs Iraihed ih Iheir correcI ahdsa!e applicaIioh ahd use. C (IV) [39]6.6 faIIs management Evidenceln !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 6.6.1All parIies ihvolved wiIh Ihe paIiehI should be made aware IhaI Ihe risk o! !allihg isihcreased !ollowihg lower limb ampuIaIioh. 8 (III) [74]6.6.2RehabiliIaIioh programmes should ihclude educaIioh oh prevehIihg !alls ahd copihgsIraIegies should a !all occur. 8 (III) [74] 6.6.3IhsIrucIiohs should be giveh oh how Io geI up !rom Ihe !oor. 8 (III) [74] 6.6.4Advice should be giveh ih Ihe evehI IhaI Ihe paIiehI is uhable Io rise !rom Ihe !oor. 8(III) [74] 6.7 WheeIchairs and seatingEvidence 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.Recommendations6.7.1PaIiehIs should rouIihely be provided wiIh a wheelchair. 8 (III) [13, 53] 6.7.2Where hecessary Ihe physioIherapisI should be able Io assess a paIiehI's suiIabiliIy !or awheelchair or have khowledge o! Ihe re!erral process. C (IV) [25]6.7.3PhysioIherapisIs, as parI o! Ihe MD1, should be able Io Ieach Ihe paIiehI ahd carer howIo use Ihe wheelchair, ihcludihg all accessories. C(IV) [25]6.8 Preventionlreduction o! contracturesEvidenceThis seclion is supporled by consensus opinion in lhe absence ol any published lileralure.Recommendations6.8.1CohIracIures should be prevehIed by appropriaIe posiIiohihg. C (IV) [25]6.8.2CohIracIures should be prevehIed by sIreIchihg exercises. C (IV) [25] 6.8.3Where cohIracIures have !ormed appropriaIe IreaImehI should be giveh. C (IV) [25] 2306.9 Exercise programmesEvidenceSeroussi 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.Recommendations6.9.1Lxercise programmes should ihclude exercises !or Ihe hip exIehsors, hip !exors ahdahkle plahIar !exors. 8 (IIa) [63]6.9.2Ah 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.Recommendations6.10.1PaIiehIs should be made aware o! Ihe possibiliIy o! experiehcihg phahIom limb paih orsehsaIioh posI-operaIively. 8 (III) [45, 46]6.10.2PaIiehIs should be giveh accuraIe ahd Iimely khowledge o! phahIom limb paih.8 (III) [47]6.10.3Ih!ormaIioh regardihg phahIom limb paih should be giveh by clihiciahs wiIhappropriaIe khowledge ahd Iraihihg. 8 (III) [47] 6.10.4Ih!ormaIioh should be giveh abouI phahIom limb sehsaIioh. C (IV) [25]6.10.5AppropriaIe IreaImehI should be giveh !or phahIom limb paih. C (IV) [25]6.10.6AppropriaIe IreaImehI should be giveh !or residual limb paih. C (IV) [25]6.10.71echhiques !or Ihe sel!-mahagemehI o! phahIom paih/sehsaIioh should be IaughI.C (IV) [25] LocaI ImpIementationlnlormalion lealels/booklels should be developed locally lor palienls and carers lo supplemenlinlormalion given verballylnlormalion on sell managemenl / home exercise lollowing discharge should be provided lolhe palienlPalienls requiring ongoing oulpalienl lrealmenl should have lhis arranged prior lo dischargeA summary ol lhe palienl's lrealmenl and slalus al lransler should be senl lo lhephysiolherapisl providing on-going lrealmenlConlacl names, lelephone numbers and addresses ol relevanl MDT members should be supplied lo palienls prior lo discharge. 231!.C|||07 Cu|dance |or |eve|op|n C||n|ca| Cu|de||ne:. 2003, The Charlered Sociely olPhysiolherapy. London.2.Core 5|andard: o| |hy:|o|herapy |rac||ce 2005. The Charlered Sociely olPhysiolherapy. 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 moderndependab|e. !997, Deparlmenl ol Heallh. London.6.|o|, A |r:| c|a:: :erv|cequa|||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 |eampu|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. PhysiolherapyPraclice, !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 |hecare 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 JVasc 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 PehabilMed, !990. 22(!). p. 39-43.25.Consensus, opinion gained by lhe Delphi process.References 333226.Lnerolh, M., |ac|or: a||ec||n wound hea||n a||er major ampu|a||on |or va:cu|ar d|:ea:e. arev|ew. Proslhel Orlhol lnl, !999. 23(3). p. !95-208.27.llelcher, D.D., el al., |ehab||||a||on o| |he er|a|r|c va:cu|ar ampu|ee pa||en|. a popu|a||on- ba:ed :|udy. Arch Phys Med Pehabil, 200!. 82(6). p. 776-9.28.Delehanly, P.D. and L. Trachsel, |||ec|: o| 5hor|-1erm Croup 1rea|men| on |ehab||||a||onOu|come o| Adu||: w||h Ampu|a||on:. lnlernalional Journal ol Pehabililalion and Heallh, !995.!(2). p. 6!-73.29.Allner, P.C., P. Pockley, and K. Kirby, |em|p|e|a and |ower ex|rem||y ampu|a||on. doub|ed|:ab||||y. Arch Phys Med Pehabil, !987. 68(6). p. 378-9.30.8ailey, M. and C. MacWhannell, C||n|ca| mon||or|n o| |y:va:cu|ar |ower ||mb Ampu|ee:dur|n |n|||a| Ca|| 1ra|n|n. Physiolherapy, !997. V83 N6. p. 278-283.3!.Czyrny, J.J. and A. Merrill, |ehab||||a||on o| ampu|ee: w||h end-:|ae rena| d|:ea:e. |unc||ona|ou|come and co:|. Am J Phys Med Pehabil, !994. 73(5). p. 353-7.32.Push, P.J., el al., O:|eopen|a |n pa||en|: w||h above |nee ampu|a||on. Arch Phys Med Pehabil,!994. 75(!). p. !!2-5.33.Jayanlunga, U., 8. Panagamuwa, and J. Lindsay. Wha| |: our ro|e |n pro|ec||n ood |ee| o|un||a|era| d|abe||c ampu|ee:? |n |5|O. !999. Soulh Normanlon.34.Chrislensen, 8., el al., 1he e||ec| o| pro:|he||c rehab||||a||on |n |ower ||mb ampu|ee:. ProslhelOrlhol lnl, !995. !9(!). p. 46-52.35.8eekman, C.L. and L.A. Axle||, Proslhelic use in elderly palienls wilh dysvascular above-kneeand lhrough-knee ampulalions. Phys Ther, !987. 67(!0). p. !5!0-6.36.Woll, L., el al., |ro:|he||c rehab||||a||on o| e|der|y b||a|era| ampu|ee:. lnl J Pehabil Pes, !989.!2(3). p. 27!-8.37.Houghlon, A.D., el al., 5ucce:: ra|e: |or rehab||||a||on o| va:cu|ar ampu|ee:. |mp||ca||on: |orpreopera||ve a::e::men| and ampu|a||on |eve|. 8r J Surg, !992. 79(8). p. 753-5.38.Ward, K.H. and M.C. |eyer:, |xerc|:e per|ormance o| |ower-ex|rem||y ampu|ee:. Sporls Med,!995. 20(4). p. 207-!4.39.Lein, S., |ow are |hy:|o|herap|:|: U:|n |he ve::a |neuma||c |o:|-ampu|a||on |omb||||y A|d?Physiolherapy, !992. 78(5). p. 3!8-322.40.Pollack, C.V., Jr. and M.D. Kerslein, |reven||on o| po:|-opera||ve comp||ca||on: |n |he |ower- ex|rem||y ampu|ee. J Cardiovasc Surg (Torino), !985. 26(3). p. 287-90.4!.Chin, T., el al., |||ec| o| endurance |ra|n|n proram ba:ed on anaerob|c |hre:ho|d (A1 |or|ower ||mb ampu|ee:. J Pehabil Pes Dev, 200!. 38(!). p. 7-!!.42.Kegel, 8., el al., |||ec|: o| |:ome|r|c mu:c|e |ra|n|n on re:|dua| ||mb vo|ume, :|ren|h, and a||o| be|ow-|nee ampu|ee:. Phys Ther, !98!. 6!(!0). p. !4!9-26.43.Moirenleld, l., el al., |:o||ne||c :|ren|h and endurance o| |he |nee ex|en:or: and |exor: |n|ran:-||b|a| ampu|ee:. Proslhel Orlhol lnl, 2000. 24(3). p. 22!-5.44.Lamberl, A. and J. Johnson, 5|ump :hr|n|er:. A :urvey O| |he|r U:e. Physiolherapy, !995.8!(4). p. 234-6.45.McCarlney, C.J.L., el al., |a|n and ||:ab||||y |o||ow|n |ower ||mb ampu|a||on - a qua|||a||ve andquan|||a||ve :|udy. The Pain Clinic., !999. !!(4). p. 293-300.46.Smilh, D.C., el al., |han|om ||mb, re:|dua| ||mb, and bac| pa|n a||er |ower ex|rem||yampu|a||on:. Clin Orlhop, !999(36!). p. 29-38.47.Morlimer, C.M., el al., |a||en| |n|orma||on on phan|om ||mb pa|n. a |ocu: roup :|udy o|pa||en| exper|ence:, percep||on: and op|n|on:. Heallh Lduc Pes, 2002. !7(3). p. 29!-304.48.Liaw, M.Y., A.M. Wong, and P. Cheng, 1herapeu||c 1r|a| o| Acupunc|ure |n |han|om ||mb |a|no| Ampu|ee:. Amer|can Iourna| o| Acupunc|ure, !994. 22(3). p. 205-!3.49.Meikle, 8., M. Devlin, and S. Carlnkel, ln|errup||on: |o ampu|ee rehab||||a||on. Arch Phys MedPehabil, 2002. 83(9). p. !222-8.50.Hanspal, P.S. and K. lisher, A::e::men| o| con|||ve and p:ychomo|or |unc||on andrehab||||a||on o| e|der|y peop|e w||h pro:|he:e:. 8MJ, !99!. 302(20). p. 940. 3335!.Scoll, H., el al., An eva|ua||on o| |he Ampu|ee |ob||||y A|d (A|A ear|y wa|||n a|d. ProslhelOrlhol lnl, 2000. 24(!). p. 39-46.52.Collin, C., D. Wade, and C. Cochrane, |unc||ona| ou|come o| |ower ||mb ampu|ee: w||hper|phera| va:cu|ar d|:ea:e. Clin Pehabil., !992. 6(!). p. !3-2!.53.Van De Ven, C.M., An |nve:||a||on |n|o |he manaemen| o| b||a|era| |e ampu|ee:. 8r Med J,!98!. 283(!2 Sepl). p. 707-!0.54.Poller, P.J., el al., |nc|dence o| per|phera| neuropa|hy |n |he con|ra|a|era| ||mb o| per:on: w||hun||a|era| ampu|a||on due |o d|abe|e:. J Pehabil Pes Dev, !998. 35(3). p. 335-9.55.Hanspal, P.S. and K. lisher, |red|c||on o| ach|eved mob||||y |n pro:|he||c rehab||||a||on o| |hee|der|y u:|n con|||ve and p:ychomo|or a::e::men|. lnl J Pehabil Pes, !997. 20(3). p. 3!5-8.56.Houghlon, A., el al., |ehab||||a||on a||er |ower ||mb ampu|a||on. a compara||ve :|udy o| above- |nee, |hrouh-|nee and Cr||||-5|o|e: ampu|a||on:. 8r J Surg, !989. 76(6). p. 622-4.57.Sapp, L. and C.L. Lillle, |unc||ona| ou|come: |n a |ower ||mb ampu|ee popu|a||on. ProslhelOrlhol lnl, !995. !9. p. 92-96.58.Chin, T., el al., |hy:|ca| ||ne:: o| |ower ||mb ampu|ee:. Am J Phys Med Pehabil, 2002. 8!(5).p. 32!-5.59.Hubbard, W., |ehab||||a||on ou|come: |or e|der|y |ower ||mb ampu|ee:. Ausl J Physiolher, !989.35(4). p. 2!9-24.60.Levy, S.W., Ampu|ee:. :||n prob|em: and pro:|he:e:. Culis, !995. 55(5). p. 297-30!.6!.Walers, P.L., el al., |nery co:| o| wa|||n o| ampu|ee:. |he |n|uence o| |eve| o| ampu|a||on.J 8one Joinl Surg Am, !976. 58(!). p. 42-6.62.Dingwell, J.8., 8.L. Davis, and D.M. lrazier, U:e o| an |n:|rumen|ed |readm||| |or rea|-||me a||:ymme|ry eva|ua||on and |eedbac| |n norma| and |ran:-||b|a| ampu|ee :ubjec|:. Proslhel Orlhollnl, !996. 20(2). p. !0!-!0.63.Seroussi, P.L., el al., |echan|ca| wor| adap|a||on: o| above-|nee ampu|ee ambu|a||on. ArchPhys Med Pehabil, !996. 77(!!). p. !209-!4.64.Lachman, S.M., 1he mob||||y ou|come |or ampu|ee: w||h rheuma|o|d ar|hr|||: |: poor. 8rilishJournal ol Pheumalology, !993. 32(!2). p. !083-!088.65.Lucke, C., el al., |ehab||||a||on o| |ower |x|rem||y Ampu|a||on |ue |o |er|phera| Ar|er|a|Occ|u:|ve ||:ea:e |n |a||en|: w||h |nd-5|ae |ena| |a||ure. VascularSurgery, !999. 33(!).p. 33-40.66.Cruls, H.L., el al., |ower ex|rem||y ampu|ee: w||h per|phera| va:cu|ar d|:ea:e. raded exerc|:e|e:||n and re:u||: o| pro:|he||c |ra|n|n. Arch Phys Med Pehabil, !987. 68(!). p. !4-9.67.De lreles, A., A.M. 8oonslra, and L.D. Vos, |unc||ona| ou|come o| rehab||||a|ed b||a|era| |ower||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 |owerex|rem||y ampu|ee:. Phys Ther, !98!. 6!(3). p. 334-7.69.Schaldach, D.L., |ea:ur|n qua|||y and co:| o| care. eva|ua||on o| an ampu|a||on c||n|ca|pa|hway. J Vasc Nurs, !997. !5(!). p. !3-20.70.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 olProshelics 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 Journalol 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:. apro: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. 334Guidelines 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 ccntributcrsLiterature appraisers1o criIically appraise papers ahd grade evidehce ready !or ihclusioh ihIo Cuidelihes.Peer reviewers1o IesI clariIy, uhdersIahdabiliIy, presehIaIioh ahd accepIabiliIy o! recommehdaIiohs ahd pracIicaliIies o! implemehIaIioh.Professional advisorsDue Ihe mulIi-disciplihary haIure o! AmpuIee RehabiliIaIioh Ihese groups were approached !or supporI ahd commehI durihg Ihe producIioh o! Ihese guidelihes.External reviewersLxperIs ih guidelihe developmehI meIhodology, Io IesI rigour o! developmehI.Consensus panel1o uhderIake Ihe cohsehsus procedure. 1o provide evidehce by use o! Delphi Iechhique !or areas wiIh ihsu!!ciehI evidehce !rom Ihe liIeraIure review.Appendices 4 435BACPAR Guidelines development contributors GuideIines DeveIopment GroupPenny 8roomhead, Diana Dawes, Amanda Hancock Penny roomhead MC5P, GuideIines Group Leader, Project Lead, Lead AuthorPenny 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 LowerLimb Proslheses.Penny has leclured nalionally and inlernalionally and is a visiling leclurer al 8radlord andSlralhclyde Universilies.Diana Daves M5c (Oxon). Project Lead, 5ystematic Reviever, Lead AuthorDiana 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 AuthorAmanda 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 wo