Occupational Therapy & Lower Limb Amputee

Occupational therapy with people
who have had lower limb amputations

Evidence-based guidelines
Occupational therapy with

people who have had lower
limb amputations
College of Occupational Therapists
This publication is an evidence-based resource to support
occupational therapists working with adults with acquired unilateral
or bilateral lower limb amputation. It provides best practice guidance
for those occupational therapists currently working in this specialism,
as well as offering a useful reference document for students and
newly qualified occupational therapists. It can also be used to inform
service users, carers and other professionals working with people
with lower limb amputation about the roles and responsibilities of the
occupational therapist in this clinical area.
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for Download
Available
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ISBN 978-1-905944-25-5
Available
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for Download
Download for
BAOT members
www.COT.org.uk
Tel: 020 7357 6480 Fax: 020 7450 2299
Download for
BAOT members
2010 College of Occupational Therapists Ltd. A registered

charity in England and Wales (No. 275119) and in Scotland
(No. SCO39573) and a company registered in England (No. 1347374)
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Specialist Section
Trauma
and
Orthopaedics
Specialist Section
Trauma
and
Orthopaedics
Front cover photograph Mike Prior

Dr Gill Hicks, MBE FRSA is the founder of not-for-profit organisation
M.A.D for Peace (www.madforpeace.org), and a motivational speaker,
author, curator, and trustee for several cultural organisations. She was
the last living survivor to be rescued from the London 7/7 bombings in
2005. Both her legs were amputated below the knee, and her injuries
were so severe that she was initially not expected to live. During her
rehabilitation after the bombings she was assisted by an occupational
therapist who helped to get her life back. She was honoured with an
MBE for her services to charity in the Queens New Years Honours List
200809 and with an Honorary Doctorate from Metropolitan University,
London for her work in both the worlds of Design and Charity. Her
work as a peacemaker was also acknowledged when in March 2010
she became recipient of the Iman Wa Amal Special Judges Award at the
10th Annual Muslim News Awards for Excellence. The College would
like to thank Gill for her support for this publication and for agreeing to
appear on the cover.
The College would like to thank Mike Prior for the use of his images for
the cover.
About the publisher

The College of Occupational Therapists is a wholly owned
subsidiary of the British Association of Occupational Therapists
(BAOT) and operates as a registered charity. It represents the
profession nationally and internationally, and contributes widely
to policy consultations throughout the UK. The College sets the
professional and educational standards for occupational therapy,
providing leadership, guidance and information relating to research
and development, education, practice
and lifelong learning. In addition,
11 accredited specialist sections support
expert clinical practice.
www.COT.org.uk
1/10

limb amputation
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First published in 2011

by the College of Occupational Therapists
106114 Borough High Street
London SE1 1LB
www.COT.org.uk
Copyright College of Occupational Therapists
Editors: Anita Atwal, Jane McLaughlin, Georgia Spiliotopoulou
Guideline Development Group: Anita Atwal, Sandra Burke, Fiona Carnegie, Karen Cook,
Jane McLaughlin, Joy Rendell, Georgia Spiliotopoulou, Anna Williams, Claire Wilson
All rights reserved, including translation. No part of this publication may be reproduced, stored
in a retrieval system or transmitted, by any form or any means, electronic, mechanical,
photocopying, recording, scanning or otherwise without the prior permission in writing of the
College of Occupational Therapists, unless otherwise agreed or indicated. Copying is not
permitted except for personal and internal use, to the extent permitted by national copyright
law, or under the terms of a licence issued by the relevant national reproduction rights
organisation (such as the Copyright Licensing Agency in the UK). Requests for permission for
other kinds of copying, such as copying for general distribution, for advertising or promotional
purposes, for creating new collective works, or for resale, should be addressed to the
Publications Officer at the above address.
Other enquiries about this document should be addressed to the College of Occupational
Therapists Specialist Section Trauma and Orthopaedics at the above address.
While every effort has been made to ensure accuracy, the College of Occupational Therapists
shall not be liable for any loss or damage either directly or indirectly resulting from the use of
this publication.
ISBN 978-1-905944-25-5
Typeset by Servis Filmsetting Ltd, Stockport, Cheshire
Digitally printed on demand in Great Britain by the Lavenham Press, Suffolk
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Contents
Acknowledgments
Foreword by Professor Rajiv S. Hanspal, FRCP, FRCS
Foreword by Sam Gallop CBE
iv
v
vi
1
1.1
1.2
1.3
1.4
1.5
Rationale
The national population
Background
The development process
Aims of the evidence-based guidelines
Overview of the evidence-based guidelines document
1
1
1
1
2
3
2
2.1
2.2
2.3
2.4
2.5
2.6
Methodology
Evidence-based guidelines question
Literature search
Literature search findings
Critical appraisal of articles
Research priorities
Peer reviewers and stakeholders
4
4
4
5
5
7
7
Summary of evidence-based recommendations
4
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
Evidence-based review and evidence-based recommendations

Functional rehabilitation
Environment
Psychology
Prosthetic use
Assessment tools and outcome measures
Cognition
Work
Leisure and recreation
Appendix 1: Guideline development group

Appendix 2: Search strategies for literature search two
Appendix 3: Excluded papers
Appendix 4: How to assess the evidence (typology)
Appendix 5: Evidence-based review table
Appendix 6: Stakeholders
Appendix 7: Consultation questionnaire
Appendix 8: Glossary of terms
References
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Acknowledgments
With thanks to:
Brunel University, for funding this project under the Knowledge Transfer Scheme
(www.brunel.ac.uk/research/rsdo/collaborative/ktp) and for the time and expert
academic support provided by Dr Anita Atwal and Dr Georgia Spiliotopoulou. It is
recognised that this expertise and financial support have been essential to the
publication of these guidelines.
The College of Occupational Therapists, particularly Julia Roberts, Anna Pettican and
Mandy Sainty for their support, guidance and enthusiasm.
The College of Occupational Therapists Practice Publications Group for reviewing the
document and providing valuable feedback.
The peer reviewers Dr Shelley Crawford and Dr Avril Drummond and the stakeholders
(see Appendix 6).
The preliminary readers for contributing to initially screening identified articles and to
decide their relevance to the guidelines question.
Anne Ewing for her inspiration and motivation to begin the project.
iv
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Occupational therapy with people who have had lower limb amputation
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Foreword
I am delighted to see the publication of these evidence-based guidelines for
occupational therapists in the rehabilitation of people with lower limb loss. The role of
occupational therapists in upper limb rehabilitation and prosthetics is well recognised,
but I feel that their important role in rehabilitation for lower limb loss has often been
underestimated. People too often perceive rehabilitation as simply the provision of a
prosthesis and gait re-education. The patient or client who has lost a lower limb has his
or her whole world changed, physically and emotionally, at home, work and leisure.
Holistic rehabilitation must include addressing all of these aspects. Occupational
therapists often find themselves addressing important needs that are essential to return
the individual to as optimal a participant in the new environment as may be practical.
This document should correct the misconceptions and, I hope, further improve the
standards and support appropriate allocation of resources where necessary.
The fact that the recommendations are evidence-based should give greater validity to
the document, especially to the scientifically oriented. However, in the field of
rehabilitation, lack of evidence should not limit the practice when trying to provide the
most appropriate service to the service user. For them, personal need to fulfil their goals
remains paramount.
Standard methodology for development of guidelines has been used and the process
followed has been described. The report completed a literature search and identified
publications specifically relevant to occupational therapists. It presents its findings and
analysis in a useful structure, including a critique of the articles reviewed, and is thus a
useful summary for the professional. The evidence-based review and recommendations
are presented in eight sections, analysed and supported by relevant references.
Scientific evidence helps guide the decision-making process between the different
possible options in clinical management, but it does not replace common sense, which
may override the decisions in provision of basic care and needs. Occupational therapists
provide an essential component of rehabilitation for people with lower limb loss to
complete a holistic package. This report will help and guide them to continue striving to
provide the best for all their clients. I wish them all success.
Professor Rajiv S. Hanspal, FRCP, FRCS
Consultant in Rehabilitation Medicine, Royal National Orthopaedic Hospital
Past Chair, International Society of Prosthetics and Orthotics (ISPO), UK,
and currently serving on the ISPO Protocol Committee
Past President, British Society of Rehabilitation Medicine
and of the Amputee Medical Rehabilitation Society
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Foreword
Why do I feel privileged to be invited to write this foreword? Because as a double
amputee, with third-degree burns, crush spinal fracture and other injuries, I and my
family have good reasons to be grateful over many years for the caring skills of
occupational therapists in helping to keep me mobile and independent.
There are many adults in the UK with lower limb amputations. Implementation of these
evidence-based guidelines will significantly help all of them, through the work of
occupational therapists as members of multidisciplinary teams, concerned with the
physical, psychological, social, spiritual and environmental needs of each individual.
There is rightly an emphasis on quality of life in which people with lower limb
amputations, family members and carers are enabled to play key roles in identifying the
most important activities of their lives in a spirit of real consultation. Concern with the
prevention of falls will have a practical impact on health, and on keeping people safe in
the community, in their homes and out of hospital. There is also a welcome
understanding of the full importance of body image to the mind and the soul.
Occupational therapists work in many settings, and these are all embraced.
Warm congratulations are due to the team of occupational therapists with their
colleagues in Brunel University for the rigorous and high academic quality of their
research and the clarity of their presentation. They have filled a significant gap in the
literature.
Occupational therapy has a real effect on the rehabilitation and quality of life for
persons with lower limb amputations. These evidence-based guidelines are a further
assurance of that pledge.
I conclude by wishing occupational therapists everywhere continued success and the
resources they need.
Sam Gallop CBE
Advocate Associate, Parliamentary Limb Loss Group
Chair, McIndoes RAF Medical Guinea Pig Club
Chair, emPOWER Charities Consortium
vi
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Rationale
1.1 The national population

The United Kingdoms (UK) National Amputee Statistical Database (NASDAB) indicates
that 4957 people with lower limb amputations were referred to the UKs 43 National
Health Service (NHS) prosthetic centres between April 2006 and March 2007. Seventy
per cent of these amputations were due to dysvascular disease, with diabetes
accounting for almost a third of all referrals. Over half of all people referred were aged
over 65 years, with more than a quarter aged 75 years and over. Lower limb
amputations accounted for 92 per cent of all referrals. The most common level of
amputation at referral was the transtibial level (53 per cent) followed by the
transfemoral level at 39 per cent (Information Services Division NHS Scotland 2009).
Although the best information available can be drawn from these figures, it does not
show the whole picture. NASDAB represents only the population at NHS prosthetic
centres and does not include data on a number of people with lower limb amputations
who are referred to other settings, for example primary care trusts, intermediate care
services, social services and private providers. Furthermore, these data have not been
updated since April 2007, when NASDAB ceased to exist due to a lack of funding.
1.2 Background
Occupational therapists have a role to play at all stages of rehabilitation of people with
lower limb amputations. They will be working as part of a multidisciplinary team and
within various settings throughout the persons life pre-amputation, post-amputation,
pre-prosthetic and post-prosthetic phases. The therapists aim is to maintain or restore
the persons functional status with or without the use of a prosthesis or other
equipment. Thus, there is a need to produce guidance to clearly indicate how, why and
when occupational therapy can improve rehabilitation and quality of life for people
with lower limb amputations. Likewise, there is a need to provide an up-to-date,
evidence-based, profession-specific document that details stages of the occupational
therapy rehabilitation process.
1.3 The development process

In December 2006 the College of Occupational Therapists Specialist Section Trauma
and Orthopaedics, Lower Limb Prosthetic Occupational Therapists initiated a project
stemming from a need for occupational therapy guidelines to facilitate best practice.
They were later given a remit by the College to produce evidence-based national
guidelines for occupational therapists working with people with lower limb
amputations. Volunteers from the Lower Limb Prosthetic Occupational Therapists
formed a working group made up of experts in the field and specialists in lower limb
rehabilitation following amputation (see Appendix 1). The group commenced the
project with guidance from the College.
Since the task of producing evidence-based guidelines requires a high level of critical
appraisal and research methods skills, the group sought academic assistance. From
October 2008 the group accessed support from Brunel University, Centre for Professional
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Rationale
Practice Research. As part of this collaboration a 3-day critical appraisal skills workshop
was provided by Dr Anita Atwal and Dr Georgia Spiliotopoulou of Brunel University. Dr
Atwal and Dr Spiliotopoulou continued to provide academic support and guidance
throughout the project under the Knowledge Transfer Scheme. Brunel University is an
active supporter of knowledge transfer and 15,000 was secured to fund the groups
work. Knowledge transfer is a process that facilitates collaboration and active working
between academics and practitioners.
1.4 Aims of the evidence-based guidelines

The aims of the guidelines are as follows:
To provide an evidence-based resource for occupational therapists working with adults
(aged 18 years and over) with acquired unilateral or bilateral lower limb amputation.
This excludes children and people with congenital limb deficiency, as the groups view
was that the clinical intervention required for these groups would be significantly
different and warrant separate guidelines.
To facilitate best practice for occupational therapists working with people with lower
limb amputation.
To provide a written reference document for use by students and newly qualified
occupational therapists.
To support occupational therapists and service managers in service provision and
planning.
To inform service users and carers.
To inform other professionals working with people with lower limb amputation about
the role and responsibilities of the occupational therapist in this clinical area.
The evidence-based guidelines are applicable to any setting where occupational
therapists are working with adults who have had lower limb amputation. These settings
include:
acute general hospitals (trauma and vascular services);
specialist orthopaedic hospitals or plastic surgery units (reconstructive surgery/bone
tumour);
rehabilitation units (NHS and military);
intermediate and community/social services;
prosthetic and wheelchair services;
vocational rehabilitation services and work environments; and
private practice.
The categories covered were identified by the expert group as being the most pertinent
areas of occupational therapy intervention where evidence existed and include:
functional rehabilitation;
environment;
psychology;
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Rationale
prosthetic use;
assessment tools and outcome measures;
cognition;
work; and
leisure and recreation.
1.5 Overview of the evidence-based guidelines document

This document comprises the initial stage of a project to produce practice guidelines for
occupational therapists working with adults with lower limb amputations.
In this stage, the evidence-based guidelines are presented. Evidence-based markers
were developed by identifying and critiquing the existing literature; recommendations
for practice were made based on this evidence. Each recommendation was based on
one or more research studies, which were critiqued and for which levels of evidence and
quality scores were identified. Further work is now required to agree clinical guidelines
based on a consensus of opinion among specialists in the field of rehabilitation with
people following lower limb amputation. This expert opinion will not necessarily be
based on research evidence but should address many of the gaps that exist in the
evidence.
Please note that the clinician using this document is ultimately responsible for the
interpretation of these evidence-based guidelines in the context of their specific
circumstances and service users. The guidelines are intended to be used alongside the
therapists clinical expertise, with consideration of resources locally available. These
evidence-based guidelines do not cover the requirements of the Health Professions
Councils Standards of conduct, performance and ethics (HPC 2008) or the College of
Occupational Therapists Code of ethics and professional conduct (COT 2010)
knowledge and adherence to which is already assumed.
Note: Throughout this document people with lower limb amputation will be referred to
as service users.
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Methodology
2.1 Evidence-based guidelines question

Is there evidence to support occupational therapy intervention for adults (aged 18 years
and over) with lower limb amputation?
2.2 Literature search

These evidence-based guidelines are based on literature from MEDLINE, CINAHL, OT
SEEKER, OTDBASE and the Cochrane Library from 1985 to January 2009. The database
search was undertaken by the two academic advisors of the working group. Two
literature searches were conducted. In literature search one, occupational therapy was
used as the first keyword combined with other keywords, such as lower limb
amputation. OTDBASE and OT SEEKER databases were searched only with the general
keyword lower limb amputation, as this would be the only way to identify all related
papers to occupational therapy and lower limb amputations. No research articles
(qualitative or quantitative) were found that were related directly to occupational
therapy or that answered the proposed question (see 2.1) from an occupational therapy
perspective. Consequently, a second literature search was conducted, in which the
keyword occupational therapy was removed and a more general search was performed
(see Appendix 2).
The second search always used lower limb amputation as a keyword, either on its own
or combined with one of the following keywords: multidisciplinary, activities of daily
living, bathing, self care, domestic, quality of life, rehabilitation, driving,
housing, leisure, transfers, prosthesis, outcome, cognition, falls, elderly/older
people, home visits, work, phantom pain, wheelchair, occupation, social and
skin. The second search had limitations, since articles without direct relevance to
occupational therapy practice were also identified.
The inclusion criteria for the literature search were as follows:
Quantitative, qualitative or mixed-type research.
Research published in English.
Participants had lower limb amputation.
Participants were adults aged 18 years and over.
The exclusion criteria were as follows:
Unpublished literature.
Articles not published in English.
Opinion articles.
Expert opinion or consensus from an expert committee (as these do not arise directly
from scientific investigation).
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Methodology
Once the literature search was completed, the evidence had to be linked directly or
indirectly to occupational therapy practice within the UK. The group of experts in the
field embarked on determining the relevance and importance of the research evidence
to their own practice.
The expert group was asked to consider the following questions:
Is there a direct reference to occupational therapy?
Is there reference to interventions/outcomes or assessments that are of relevance to
occupational therapy?
Is this paper of relevance/importance to occupational therapy practice?
2.3 Literature search findings

A total of 58 papers were identified as being of possible relevance to occupational
therapy. Of these, 29 papers were critically appraised by the group and used in the
evidence-based recommendations. After reading all the other papers, the remaining 29
were finally excluded as they were not relevant to occupational therapy (see Appendix
3). Of the 29 excluded papers, 26 were research papers and 3 were systematic reviews;
these papers have been used within the sections to set the context, but they have not
been used for the evidence-based recommendations. Excluded papers were also used in
the evidence sections to verify ideas and arguments linked to occupational therapy.
Literature reviews were not included in the 58 papers and were excluded from the
critique; however, some literature reviews were used in the background introduction of
each section.
2.4 Critical appraisal of articles

Process
All members of the critical appraisal group received three days of training from the two
academic advisors before appraising the evidence. The training was based on the
McMasters critical appraisal tools for both quantitative (Law et al 1998) and qualitative
(Letts et al 2007) studies. Group members reviewed papers to appraise their quality and
to identify their level of evidence. Each article was distributed according to its design to
a member of the group who was most confident with the relevant research design. The
appraisal of the first couple of papers for each reviewer was triangulated between the
reviewer and the two academic advisors of the group, who were highly experienced in
paper critiquing, until the whole team was confident with the outcome.
Methodology for appraising the evidence

A widely used aid to critical appraisal is the hierarchy of evidence, which involves
ranking a range of studies in order of decreasing internal validity; however, Petticrew
and Roberts (2003) suggested that the concept of a hierarchy of evidence is difficult to
apply in social and public health research. The hierarchy of evidence relates to
quantitative research and, as suggested in The National Service Framework for Longterm Conditions (DH 2005), randomised controlled trials and other quantitative
approaches are not always best to address research questions involving populations
with complex needs and assessment of impact on quality of life rather than cure.
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Methodology
Therefore, in order to produce evidence-based markers for occupational therapy with

people with lower limb amputation, a typology was used. This was based on a mixed
methodology involving:
designation of levels of evidence (adapted from the National Health and Medical
Research Council (NHMRC) of Australia 1999 (see Appendix 4, Table 1));
markers related to the quality of the evidence (based on the typology used for the NSF
for Long-term Conditions (DH 2005, p 88; see Appendix 4, Table 2)).
Furthermore, the research designs were categorised into primary and secondary
research, and then split into quantitative, qualitative or mixed types of research
(adapted from the NSF for Long-term Conditions (Department of Health 2005, p 88; see
Appendix 4, Table 3)).
The designation of levels of evidence table was used as a guide to summarise study
designs according to their generally perceived capacity for causing bias. This was
adapted from A guide to the development, implementation and evaluation of clinical
practice guidelines (NHMRC 1999). The initial designation of levels of evidence included
levels I to IV. However, the group added a level V of evidence, since the original
designation did not include a level for surveys, correlation studies, reliability and validity
studies, outcome measures development, case studies and focus groups. Level V was
used for these designs as many were identified during the literature search that were of
relevance to occupational therapy. From the papers used for evidence-based
recommendations, 26 papers were at level V, 1 at level IV, 1 at level III-3 and 1 at III-2.
The quality assessment resulted in the assignment of a score from 0 to 10 for each paper
(0 being very poor, 10 being excellent). This score related to the papers quality of
research design, methodological strengths and weaknesses, integrity of conclusions, and
the potential for generalisation of results. The papers used for the evidence-based
recommendations scored as follows:
High quality (7/10 or greater) = 5
Medium quality (score 46/10) = 19
Poor quality (score 3/10 or less) = 5
In order for the group to make an informed decision on the quality of the paper,
further guidance was provided using the McMasters guiding questions on quantitative
and qualitative research.
After completion of the evidence appraisal, the findings were cross-checked with the
two academic advisors and compiled in an evidence-based table. This included
information on the studys authors, year and location, design, participants, interventions
and outcome measures used, results, limitations, relevance to occupational therapy,
level of evidence and quality score (see Appendix 5).
Evidence-based recommendations
At a further stage, the group and academic advisors met to look at the appraised
research evidence. This stage involved the whole group discussing the evidence and
reaching agreement in order to produce relevant evidence-based recommendations for
occupational therapy practice. The group worked together to identify pertinent points
from the literature and easily agreed on the statements generated. The evidence-based
recommendations were categorised into the following sections: functional rehabilitation,
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Methodology
environment, psychology, prosthetic use, assessment tools and outcome measures,

cognition, work, and leisure and recreation.
Due to a lack of further research evidence, a number of specific aspects of occupational
therapy management of people with lower limb amputations have not been included in
this document. However, further work based on a consensus of expert opinion among
professionals would help to address these areas.
2.5 Research priorities

Large gaps exist in this document as the research found was often of a low evidence
level, or did not directly discuss the application of occupational therapy. The research
found did not always demonstrate areas of occupational therapy clinical practice
deemed important by the group. Current practice amongst the group can be
categorised under the broad headings of pre-amputation, post-amputation/nonprosthetic rehabilitation, pre-prosthetic preparation and prosthetic rehabilitation.
However, much of the evidence found did not explore the occupational therapists role
in these areas. The guideline development group decided it was not appropriate to
identify and underpin research priorities on the basis of the findings of the evidence
review; however research priorities highlighted as important to the group include: the
value of occupational therapy in environmental assessment and discharge planning; the
provision of wheelchairs; and integration of the prosthesis into activities of daily living.
This list is by no means exhaustive.
2.6 Peer reviewers and stakeholders

The evidence-based guidelines document was sent in draft format to peer reviewers and
stakeholders (see Appendix 6). The peer reviewers were professionals working in related
fields of occupational therapy and with experience of research and guidelines. The
stakeholders were charities, user organisations or groups of other professional bodies
involved with people with lower limb amputations. They were invited to comment on
the quality and ease of use of the evidence-based guidelines. They gave their comments
on a consultation questionnaire, which originated from the College of Occupational
Therapists (see Appendix 7). The peer reviewers and stakeholders feedback and
suggested amendments were integrated into the final document.
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3
Section
Evidence
level/quality
score
Evidence-based recommendation for occupational

therapy with people who have had lower limb
amputation
Functional
rehabilitation
V/3
1. Occupational therapists need to adhere to key

milestones with respect to bed mobility and upper
and lower body dressing (Ham et al 1994)
V/4
2. It is recommended that stump boards are provided

for people with transtibial amputations (White
1992)
III-2/5
3. Indoor electric wheelchairs should be provided for

personal independence for patients with
rheumatoid arthritis (Lachman 1993)
V/4, V/6, III3/4, V/8, V/6,

IV/3
4. Occupational therapists need to identify falls risk

factors and provide appropriate individual
interventions in collaboration with the
multidisciplinary team (Kulkarni et al 1996, Miller et
al 2001, Gooday and Hunter 2004, Miller and
Deathe 2004, Pauley et al 2006, Dyer et al 2008)
V/7
5. Frequency of occupational therapy sessions along

with the service users physical independence,
better cognition, younger age and satisfaction with
the prosthesis is significantly related to prosthetic
use (Bilodeau et al 2000)
Environment
V/2
1. Occupational therapy with older adults who have

had an amputation due to peripheral vascular
disease or diabetes mellitus should enhance
function through environmental modification
appropriate for wheelchair use (Collin et al 1992)
Psychology
V/6, V/4
1. Occupational therapists need to monitor distress for

longer than the initial postoperative phase
(Atherton and Robertson 2006, Hawamdeh et al
2008)
IV/4, V/4,
V/6
2. Occupational therapists need to assess for anxiety

throughout all episodes of care: preoperatively
(Singh et al 2007, Hawamdeh et al 2008) and in the
prosthetic phase (Atherton and Robertson 2006,
Singh et al 2007)
V/5
3. Where appropriate, referrals should be made for

psychological support for adults with lower limb
amputations (Price and Fisher 2002)
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Summary of evidence-based
recommendations
26/01/2011 14:17
Section
Prosthetic use
Assessment
tools and
outcome
measures
Evidence
level/quality
score

amputation
V/3, V/3, V/5
4. Occupational therapists should consider the

importance of body image during the rehabilitation
process (Beekman and Axtell 1987, Breakey 1997,
Price and Fisher 2002)
V/5
1. Occupational therapists need to be aware of

impaired hand function before prescription of
liners used with lower limb prostheses (Baars et al
2008)
V/3
2. Occupational therapists need to ascertain reasons

for non-prosthetic use and refer to the
multidisciplinary team as appropriate (Beekman
and Axtell 1987)
V/3
3. Older adults with above-knee or through-knee

amputations should be provided with a wheelchair
at the prosthetic and post-prosthetic stage of
rehabilitation (Beekman and Axtell 1987)
V/6
1. Occupational therapists should use the Amputee

Activity Score (AAS) with lower limb prosthetic
users to assess the level of activity a person achieves
at discharge from prosthetic rehabilitation to
review (Panesar et al 2001)
V/6
2. Occupational therapists should use the Frenchay

Activities Index (FAI) to determine the level of
participation in extended activities of daily living
following the rehabilitation and the prosthetic
phase (Miller et al 2004)
V/7
3. Occupational therapists should use the Patient

Generated Index (PGI) measure to assess quality of
life (QOL) outcomes in face-to-face assessment
(Gallaghan and Condie 2003)
V/7
4. Occupational therapists should use the Trinity

Amputation and Prosthesis Experience Amputation
Scales (TAPES) to assess adjustment to lower limb
prostheses (Gallagher and MacLachlan 2000)
V/6
5. Occupational therapists should use TAPES to

evaluate changes in QOL during the rehabilitation
process and provide a more holistic assessment
(Gallagher and MacLachlan 2004)
V/8
6. Occupational therapists should use the Amputee

Body Image Scale (ABIS) to determine the level of
body image disturbance and consider how this may
affect rehabilitation (Gallagher et al 2007)
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Section
Evidence
level/quality
score

amputation
V/6
7. Occupational therapists should use the Office of

Population Censuses and Surveys Scale (OPCS) with
lower limb prosthetic users to assess functional
capacity in the community at the inpatient stage
(Panesar et al 2001)
V/6, V/4
8. Occupational therapists should use the Clifton

Assessment Procedures for the Elderly (CAPE) to
predict mobility using a prosthesis (Hanspal and
Fisher 1991, 1997)
V/4
9. Occupational therapists should use the Kendrick

Object Learning Test (KOLT) to facilitate decisionmaking in prosthetic use (Larner et al 2003)
V/6, V/4
1. Occupational therapists should use CAPE to predict

mobility using a prosthesis (Hanspal and Fisher
1991, 1997)
V/4
2. Occupational therapists should use KOLT to

facilitate decision-making in prosthetic use (Larner
et al 2003)
Work
V/5
1. Support should be provided from the

multidisciplinary team regarding successful work
reintegration and maintenance of the work role
(Bruins et al 2003)
Leisure and
recreation
V/4
1. Occupational therapists need to assess and review

participation in recreational activities (Legro et al
2001)
Cognition
(same as
Assessment
tools and
outcome
measures 8
and 9)
These evidence-based recommendations are not intended to be taken in isolation.

They must be considered alongside the contextual information that follows in
Sections 4.14.8.
It is also strongly advisable for readers to study Appendix 5 to understand fully the
outcome of the search and the overall types of evidence found.
The reader must realise that these recommendations come from evidence of varying
quality and strength. Some recommendations come from single research studies or
come from poorer-quality work. See Appendix 4, Table 2, to understand fully the quality
of research design, methodological strengths and weaknesses, integrity of conclusions,
and the potential for generalisation of results.
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Evidence-based review and

evidence-based recommendations
4.1 Functional rehabilitation
Introduction
Rehabilitation is a key component of nursing and allied healthcare professionals roles
in most health and social care settings. Rehabilitation is a reiterative, active,
educational, problem-solving process focused on a service users behaviour or disability.
It includes assessment, goal-setting, intervention and evaluation (Wade and DeJong
2000). Hence, the ultimate aim of the rehabilitation is to promote reintegration into the
family, home, work, leisure, social and community occupations. Occupational therapy is
an integral part of this process, focusing on functional abilities and purposeful activity
as part of treatment. In the case of amputation, the goal of rehabilitation following
surgery is to facilitate functional independence and to assist integration back into the
service users home and community.
A study by Pezzin et al (2000) suggests there is a substantial effect of inpatient
rehabilitation in improving long-term physical, social and mental health outcomes of
people with trauma-related amputations. Rehabilitation is of utmost importance for
older adults, since functional decline may occur with older adult patients following
lower limb amputation (Frykberg et al 1998). Evidence for the location of rehabilitation
is mixed, and to date no UK studies have been conducted with regard to this. Klein et al
(2001) compared the rehabilitation outcome of older adults with a transtibial
amputation who had rehabilitation at home and as inpatients. This research found that
mobility and independence outcomes were the same for both groups. However,
patients who were at home had greater social support and greater satisfaction with
the rehabilitation process, because they felt more involved in the planning and
goal-setting.
It is important to consider mobility early on after amputation; this may be with a
wheelchair. Stokes et al (2008) concluded that most therapists surveyed were following
the British Association of Chartered Physiotherapists in Amputation Rehabilitation
(BACPAR) guidelines (2003). BACPAR states that wheelchair mobility is the ideal, but
specific reasons may lead therapists to teach people who have had an amputation to
ambulate with aids; however, further research is needed to determine the risk that
hopping poses to the contralateral foot. The lack of robust evidence means the risk of
hopping cannot be quantified and therefore it should be recommended with caution.
Although the prevalence of skin problems of the residual limb in people who have had
a lower limb amputation is mainly unknown, caring for the skin on the residuum is
important as skin problems can impact on the success of prosthetic rehabilitation
(Meulembelt et al 2006). Skin integrity in relation to wheelchair seating and pressurereducing cushions also needs to be considered (Gailey and Clark 1992).
Service users may find using a wheelchair preferable to using a prosthesis due to
comfort, function or energy factors. When amputation is required, the appropriate level
of amputation and future wheelchair use should be considered; ideally, an occupational
therapist and physiotherapist should be members of the multidisciplinary team
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(Houghton et al 1992). One study found that older adults with lower limb amputation
used assistive devices with greater frequency than those with either a stroke or
orthopaedic deficit (Gitlin et al 1996). Indeed, Jones et al (1993) suggest that home
modifications and quality of rehabilitation may be an important factor in people
maintaining their independence at home, although no data to support this were
offered.
Evidence
There are currently no primary research studies that have supported the efficacy of
occupational therapy rehabilitation with people with lower limb amputations.
Although there is a lack of evidence, the occupational therapy role in this area is valued
and well recognised. It is important that occupational therapists promote rehabilitation
to ensure people with an amputation achieve their greatest level of independence.
Greive and Lankhorst (1996) concluded that in most service users, functional abilities
decrease after lower limb amputation, and age seems to be a significant factor related
to functional outcome. One study examined the time taken to achieve specific
functional milestones (Ham et al 1994). This study indicated that service users achieved
bed mobility 12 weeks post-amputation; independence in upper body dressing within
4 weeks; and independence in lower body dressing within 5 weeks. It is important that
occupational therapists enable people who have had a new amputation to achieve their
greatest level of independence. The data from this study could be used to formulate an
integrated care pathway that records rehabilitation milestones. The milestones could be
useful for predicting the length of stay necessary in order to achieve functional
independence.
A Serbian study of older people with vascular disease and unilateral amputations
examined pain characteristics, functional status, social function and living conditions
(urovic et al 2007). Most participants in this study achieved significant functional
improvement and reduction of pain, in spite of their social dysfunction, the absence of
sociomedical support and inadequacy of the conditions of habitation. However, it is not
clear whether even greater improvement could have resulted if occupational therapy
had been included in rehabilitation.
Treatment approaches and outcomes will differ between prosthetic and non-prosthetic
users, with age and functional ability before amputation being instrumental (Collin et al
1992). White (1992) found that service users reported positive benefits using stump
boards; both therapists and users perceived stump boards as important for comfort and
protecting the stump. Therapists prescribed stump boards to prevent contractures and
control oedema. A study by Lachman (1993) found that people with rheumatoid
arthritis and a lower limb amputation were more likely to use an electric wheelchair
compared with those who had a lower limb amputation but did not have rheumatoid
arthritis. Beekman and Axtell (1987) found that more than half of people who wore
prostheses used their wheelchairs most of the time. These findings are discussed further
in Section 4.4.
It is essential that the reasons for not wearing prostheses are determined and each
individuals preference is taken into account during this process. Bilodeau et al (2000)
studied factors such as physical and mental health, rehabilitation, physical
independence and satisfaction with the prosthesis to understand why people who had
an amputation used or did not use their prosthesis. The study found that prosthetic use
was significantly related to the service users physical independence, better cognition,
younger age and satisfaction with the prosthesis. The frequency of occupational
therapy sessions was also statistically significant in relation to prosthetic use.
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A growing body of literature highlights the importance of falls management for people
with lower limb amputations. One study found that 20 per cent of service users are
likely to have a fall following amputation. Eighteen per cent of these resulted in injury,
and most occurred between the times of 07:00 and 15:00 (Pauley et al 2006). Another
study found that falls among service users with lower limb amputations are prevalent
(58 per cent of service users with unilateral amputations and 27 per cent with bilateral
amputations) (Kulkarni et al 1996). The largest proportion of falls (48 per cent) were
reported as intrinsically related, 22 per cent were thought to be related to
environmental reasons, 12 per cent to the prosthesis and 18 per cent to more than one
factor. Gooday and Hunter (2004) found that 32 per cent had falls; these service users
were significantly older than those who did not fall. Miller and Deathe (2004)
considered the effect of fear of falling in the prosthetic user population; they found
that asking service users about fear of falling would provide a clinician with a quick
indicator of whether or not the service user is experiencing reduced balance confidence.
Effective falls programmes are those that are multidisciplinary and are created to
customise falls intervention for each service user deemed to be at risk of falling (Dyer et
al 2008). Moreover, it is evident that people with lower limb amputation may value
being taught how to get up from a fall. Kulkarni et al (1996) found that 25 per cent of
those falling remembered being given instructions on how to get up from a fall.
1.
Occupational therapists need to adhere to key milestones with respect to bed

mobility and upper and lower body dressing (Ham et al 1994).
2.
It is recommended that stump boards are provided for people with transtibial
amputations (White 1992).
3.
Indoor electric wheelchairs should be provided for personal independence for

patients with rheumatoid arthritis (Lachman 1993).
4.
Occupational therapists need to identify falls risk factors and provide appropriate
individual interventions in collaboration with the multidisciplinary team (Kulkarni
et al 1996, Miller et al 2001, Gooday and Hunter 2004, Miller and Deathe 2004,
Pauley et al 2006, Dyer et al 2008).
5.
Frequency of occupational therapy sessions along with the service users physical
independence, better cognition, younger age and satisfaction with the prosthesis
are significantly related to prosthetic use (Bilodeau et al 2000).
4.2 Environment
Introduction
The environmental needs of the individual following lower limb amputation can change
throughout their rehabilitation. This can vary from initial wheelchair use to
independent prosthetic use. Campbell and Ridler (1996) stated that occupational
therapists provide valuable insight into a service users home situation and
circumstances and may predict potential problems after discharge. A study by Greive
and Lankhorst (1996) found that with increasing age, functional outcomes decreased
following lower limb amputation.
Diabetes neuropathy and peripheral vascular disease of the lower limbs can lead to
amputation. Diabetes as a cause of amputation currently accounts for almost a third of
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all referrals to prosthetics centres. Dysvascularity is the cause for 70 per cent of
amputations. Over half of all people who have had an amputation referred to
prosthetics centres are aged over 65 years, and more than a quarter are aged 75 years
and over (Information Services Division NHS Scotland 2009). These older service users
may have co-morbidities that indicate long-term use of a wheelchair.
For the individual with a lower limb amputation, providing an accessible environment is
key to promoting independence at home and at work (Bruins et al 2003, Campbell and
Ridler 1996, Schoppen 2001b, 2002, Van de Ven 1981). When rehabilitating people with
lower limb amputations, occupational therapy may involve assessing, adapting and
modifying the home or other external environments in order to facilitate participation
in occupation. Pernot et al (1997) suggest that independence in activities of daily living
was a key factor in predicting successful return home.
Evidence
No primary research has been conducted by occupational therapists in this area,
although Jones et al (1993) suggest that home modifications and quality of
rehabilitation may be an important factor in people maintaining their independence at
home. However, this study did not offer data to support this suggestion. Collin et al
(1992) found that partial walkers had lower kitchen and domestic activity scores, which
were due to a lack of environmental modifications for wheelchair use.
The occupational therapist needs to consider a range of factors when assessing for any
environmental adaptation. Collin et al (1992) advise that for older adults following
lower limb amputation, the occupational therapist should consider wheelchair use, with
environmental modification aimed at enhancing function.
1.
Occupational therapy with older adults who have had an amputation due to
peripheral vascular disease or diabetes mellitus should enhance function through
environmental modification appropriate for wheelchair use (Collin et al 1992).
4.3 Psychology
Introduction
Psychology is the study of the mind and soul and can involve self-concept. Self-concept
can be subdivided into identity, body image, self-esteem and self-awareness. Lower limb
amputation confronts the individual with numerous physical and psychosocial threats
and challenges, including alterations in self-concept, physical dysfunction and pain,
changes in employment/occupation status and lifestyle, and disruptions to valued
activities (Rybarczyk et al 2000, Horgan and MacLachlan 2004).
Occupational therapists use psychological theories to underpin their interventions when
promoting adaptation or integration for the individual. Interventions must address both
the physical aspects of amputation and the psychosocial adjustment needed by the
individual (Asano et al 2008). Key to understanding adjustment following lower limb
amputation is the individuals experience and the inclusion of personal preference and
perspectives, for example values, needs, emotional interests and motivations. Physical,
environmental, social and cultural factors are also paramount (Gallagher et al 2008).
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Depression and anxiety are prevalent following lower limb amputation. The need for
occupational therapy management and use of occupation in addressing issues
pertaining to depression and anxiety has been highlighted (Price and Fisher 2002,
Hawamdeh et al 2008, Singh et al 2007).
When treating people with lower limb amputation, consideration must be given to
pain, phantom pain and phantom sensation. A study by Bosmans et al (2007)
demonstrates the relationship that phantom pain and sensation has upon subjective
wellbeing, particularly when coupled with other factors such as medical history, social
support and daily activities. However, no literature identifies the occupational
therapists role within the management of phantom pain. For this reason, the group
was unable to explore the efficacy of occupational therapy with people who experience
phantom pain.
Evidence
A psychological factor specific to the individual following lower limb amputation is
body image. Studies demonstrate how satisfaction with body image relates to an
individuals anxiety, self-esteem and satisfaction with life. The therapist needs to have
an understanding of this relationship throughout the rehabilitation process (Breakley
1997, Beekman and Axtell 1987, Atherton and Robertson 2006). Interventions that
target appearance-related beliefs and self-consciousness are of particular relevance
(Atherton and Robertson 2006). Atherton and Robertson (2006) also suggest that
distress and anxiety should be monitored over a longer period of time, and not only in
the initial postoperative phase following amputation.
Depression was found to be prevalent following lower limb amputation in a study by
Price and Fisher (2002). They identified the need for the occupational therapist to work
collaboratively with the multidisciplinary team, particularly counsellors, to manage and
address depression and issues surrounding body image. Along with studies by
Hawamdeh et al (2008), Price and Fisher highlight the importance of occupation in
decreasing anxiety and depression for the individual, both through activities of daily
living and in return to work. Singh et al (2007) found that during the rehabilitation
phase, where the individual was learning new skills and regaining independence, signs
of anxiety and depression reduced significantly. Although there are tenuous links from
these studies about the value of occupational therapy, no existing research has directly
studied the occupational therapists psychological management of a person following
lower limb amputation; further research is needed in this area.
1.
Occupational therapists need to monitor distress for longer than the initial
postoperative phase (Atherton and Robertson 2006, Hawamdeh et al 2008).
2.
Occupational therapists need to assess for anxiety throughout all episodes of care:
preoperatively (Singh et al 2007, Hawamdeh et al 2008) and in the prosthetic phase
(Atherton and Robertson 2006, Singh et al 2007).
3.
Where appropriate, referrals should be made for psychological support for adults
with lower limb amputations (Price and Fisher 2002).
4.
Occupational therapists should consider the importance of body image during the
rehabilitation process (Beekman and Axtell 1987, Breakey 1997, Price and Fisher
2002).
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4.4 Prosthetic use

Introduction
Prosthetic rehabilitation programmes are individual to each person after lower limb
amputation, but the occupational therapist should take into account the following:
level of amputation, condition of residual limb and prognosis (ability to weight-bear
and balance);
co-morbidities;
cognition;
pre-amputation lifestyle and roles.
Often the overall quality of life following a lower limb amputation has been found to
be lower than that in the general population, but much of this is secondary to restricted
mobility (Pell et al 1993, de Godoy et al 2002). New strategies and processes need to be
learnt by the service user to become mobile on their prosthesis. Achieving an
independent technique donning and doffing the prosthesis is a significant factor for the
service user to succeed with prosthetic limb wearing (Baars et al 2008). Singh et al (2008)
found that mobilising on a prosthesis requires considerable stamina.
A Cochrane review into prosthetic rehabilitation for older people with vascular disease
following a unilateral transfemoral amputation highlighted the lack of evidence from
randomised controlled studies to inform the choice of prosthetic rehabilitation
(Cumming et al 2006). There is also limited research regarding the effectiveness of
occupational therapy in this area. However, it is good practice that service users with a
lower limb amputation should be advised on how to care for their residual limb as well
as the remaining limb. Good stump care, including prevention of flexion deformities, is
an important determinant of mobility outcome (Traballesi et al 2007, Baars et al 2008).
Tsai et al (2003) compared the performance and safety of walking aids in people with
lower limb amputations. This study suggests that two-wheeled walking aids allow
prosthetic limb wearers (especially those with transtibial amputations) to walk more
quickly and with less interruption, but no less safely, compared with four-footed
walking aids.
It is important to support the service user to resume previous hobbies and leisure
activities. However, within occupational therapy, few studies have explored this.
Hanspal and Nieveen (2002) carried out a survey to obtain a national consensus for
indications and recommendations of best practice for prescription of water activity
prostheses. They suggest that every limb centre should have a written procedure and
agreed guidelines for prescription of water activity limbs. Each service users
expectations, pre-amputation lifestyle and indication of use should be individually
assessed.
Evidence
Baars et al (2008) found 70 per cent of service users with impaired hand function
experienced liner-related skin problems, compared with 32 per cent of service users with
normal hand function.
Beekman and Axtell (1987) found that 44 per cent of 23 service users with prostheses
wore their prosthesis all day every day and used wheelchairs minimally or not at all.
Over half of the service users evaluated used their wheelchairs most of the time, and 9
per cent had stopped wearing their prostheses. Over 60 per cent of the service users
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reported cosmetic problems or discomfort at follow-up, and many cited this as a reason
for not wearing their prosthesis.
Meulembelt et al (2006) completed a systematic review of literature of skin disorders of
people who had a lower limb amputation. One article highlighted the prevalence of
skin disorders in the residual limb in people with lower limb amputations. Of the 45
people in the study, 16 per cent reported skin problems. The authors suggest that skin
problems can impact on prosthetic use and could impact on activities of daily living.
1.
Occupational therapists need to be aware of impaired hand function prior to

prescription of liners used with lower limb prostheses (Baars et al 2008).
2.
Occupational therapists need to ascertain reasons for non-prosthetic use and refer
to the multidisciplinary team as appropriate (Beekman and Axtell 1987).
3.
Older adults with above-knee or through-knee amputations should be provided

with a wheelchair at the prosthetic and post-prosthetic stages of rehabilitation
(Beekman and Axtell 1987).
4.5 Assessment tools and outcome measures

Introduction
Assessment tools and outcome measures are used widely within healthcare, allowing
clinicians to determine achievements in rehabilitation or areas of performance (Ryall et
al 2003, Skinner and Turner-Stokes 2006). They are a tool used by healthcare
professionals to appraise and monitor their service to ensure effectiveness in the service
they provide (Treweek and Condie 1998, Gallaghan and Condie 2003). A study by
Stineman et al (1996) commented that a standardised outcome measurement is
essential in rehabilitation for:
assessing a service users rehabilitation needs;
setting client-centred goals;
evaluating the outcomes;
determining whether goals have been achieved.
Outcome measures will also assist the occupational therapist in assessing long-term
needs, preparing service users for their future and managing expectations (Sansam et al
2009).
Rehabilitation of the person with lower limb amputation focuses on improving function
in identified areas of occupational performance and therefore the use of functional
outcome measures are essential (Treweek and Condie 1998). Pernot et al (1997) suggest
that individuals who had undergone a functional assessment to determine whether they
were suitable for prosthetic rehabilitation had a better outcome following gait training.
To ensure that occupational therapists are using outcome measures that effectively
measure a service users function, the outcome measure should have validity and
reliability and be responsive to change (Panesar et al 2001). Ottenbacher et al (1996)
reinforced the importance of inter-rater reliability by confirming that any functional
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outcome measure should produce consistent results across raters, and over time for
therapists to measure improvement or deterioration in activities of daily living. This
ensures that change detected by the outcome measurement is not due to random error.
Evidence
The literature search highlighted the following studies assessing assessment tools and
outcome measures appropriate for occupational therapists working in rehabilitation of
the person who has had a lower limb amputation. Other commonly used assessment
tools and outcome measures are available, such as the Canadian Occupational
Performance Measure (COPM), but research evidence centred around the following
tools:
Amputee Activity Score (AAS)
Some of the evidence focused on activity levels of prosthetic users. A study by Panesar
et al (2001) compared three measures of progress in early rehabilitation of people with
lower limb amputation. The Amputee Activity Score (AAS) was directly relevant to
occupational therapy. This study used a modified version of the AAS; it assessed the
service users:
ability to don or doff the prosthesis;
hours per day wearing the prosthesis;
use of walking aids;
amount of walking;
type of house;
ability to climb stairs;
social support at home;
caring responsibilities for someone with a disability;
participation in domestic activities of daily living; and
access to their own wheelchair and frequency of wheelchair use.
The AAS does not include a section for assessing abilities with personal activities of daily
living. The study used a modified AAS version as the authors deemed it necessary to
include a score for service users who used their wheelchair indoors but preferred to
walk outdoors. There is also a section for assessing the individuals employment status
and work activities.
The AAS is a self-report tool by face-to-face interview, and the time taken to complete it
is unclear. Validity and reliability of the AAS also need to be determined. A study
describing the original AAS by Day (1981) stated that the validity and repeatability of
the AAS were reviewed, but it is unclear from the article how these where measured.
The AAS was found to be a useful tool at discharge but more difficult to use at
admission for rehabilitation (due to its layout) and in need of modification. This study
was also completed with a small sample size, and bias may have been introduced, as
scores of 23 service users were based on measurements from a previous research group.
Another measure described by Panesar et al (2001) was the Office of Population
Censuses and Surveys Scale (OPCS). They suggested that occupational therapists could
use this with lower limb prosthetic users to assess functional capacity in the community
at inpatient stage.
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Frenchay Activities Index (FAI)

One study reviewed outcome measures assessing an individuals level of participation in
instrumental activities of daily living. Miller et al (2004) reported that the Frenchay
Activities Index (FAI) had been tested as valid and reliable for use with individuals
following a stroke, but it had yet to be assessed as a reliable or valid tool for use with
individuals with a lower limb amputation. The FAI is a 15-item self-report questionnaire
assessing how often in a period of 3 months an individual has:
completed domestic activities, such as preparing meals, washing up, laundry and
shopping;
continued with hobbies and using public transport.
It also assesses in the past 6 months how often an individual has:
travelled;
gardened;
participated in DIY;
read books; and
been involved in work.
For the purpose of the study, the authors decided to add three additional activities:
sport/leisure;
management of home finances; and
socialising with family/friends.
This made it an 18-item questionnaire and expanded the assessment components for
the population of people who had an amputation.
The study assessed the reliability and validity of the FAI-15 and the FAI-18. The sample
size of the study was small, but the FAI-15 and FAI-18 were found to have 4-week testretest reliability, satisfactory internal consistency and concurrent validity; however,
further tests for reliability, construct and content validity are required. The authors
highlight that bias may have been introduced through the study methodology and that
there was no advantage found in using the FAI-18; therefore, the FAI-15 should be used.
This measure could be used to assess an individuals level of activity in domestic, work
and leisure performance components. Further assessment would be required to identify
reasons for difficulties in completion of these activities of daily living in an individual
with lower limb amputation.
Patient Generated Index (PGI)
Gallaghan and Condie (2003) adapted the Patient Generated Index (PGI) quality-of-life
measure for use with people who had a lower limb amputation. Gallagher and
Desmond (2007) and Condie et al (2006) described the PGI as a client-centred outcome
measure allowing service users to identify the five most important activities of their life
that have been affected by amputation and its treatment. Service users rate how
significantly they are affected on a chosen activity on a scale of 010. They grade the
importance of each activity; the higher the score, the higher their quality of life.
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The PGI was found to be moderately reliable in terms of repeatability during successive
follow-up interviews. Its construct validity supported a stronger relationship between
mental health and quality of life than between physical health and quality of life.
Therefore, this measure could be used to assess quality-of-life outcomes in this client
group. The measure demonstrated practical limitations related to its format, which
makes it more appropriate to be used in a face-to-face interview. It should be noted that
this study used a small sample group, and validity and reliability require further testing.
Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES)
Gallagher and MacLachlan (2000) found that the Trinity Amputation and Prosthesis
Experience Amputation Scales (TAPES) provide an initial assessment of adjustment
problems. Gallagher and Desmond (2007) expanded on the TAPES, stating that it
includes 9 subscales and contains 38 items. It assesses the following:
Psychological adjustment: general and social adjustment, adjustment to limitation
Activity restriction: functional, social and high activity levels
Prosthesis satisfaction: weight, function and cosmesis
Pain and other medical issues
The TAPES could identify service users who are experiencing adjustment difficulties and
assist in the development and evaluation of treatment approaches. Gallagher and
MacLachlan (2004) evaluated whether TAPES subscales are associated with quality of
life. The authors suggested that there is potential for clinicians to use this tool in
practice to evaluate changes in an individuals quality of life throughout the
rehabilitation process.
Gallagher and MacLachlan (2000) suggested that face and content validity of the tool
was established, but they do not clarify how it was assessed. From both studies, it is
clear that future research is required to identify the stability of the TAPES over time
(test-retest reliability), responsiveness to change, and floor to ceiling effects to look at
predictive validity. It is also acknowledged that the self-report nature of the measure
could introduce bias. At present, due to the small sample sizes of both studies, the
results cannot be generalised.
Amputations Body Image Scale (ABIS)
Gallagher et al (2007) suggested that the Amputations Body Image Scale (ABIS) could be
used in the rehabilitation of people who had an amputation to identify body image
problems. The ABIS consists of a 20-item questionnaire and is scored using a 5-level
ordinal scale. It assesses an individuals:
anxiety about their physical appearance in social situations or when alone;
physical appearance when wearing a prosthesis;
phantom limb pain experience;
concerns on how their limb loss affects them in daily living;
avoidance of certain situations;
viewing of their appearance, with and without the prosthesis.
Following Rasch analysis of the ABIS, the authors determined that a shortened version,
the ABIS-R, would be a more valid and reliable tool. The ABIS-R was developed with 14
items and a 3-level ordinal scoring scale. This version was found to have satisfactory
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internal consistency, good responsiveness to change, high separation reliability and

construct validity.
The study found that the greater the levels of satisfaction with the prosthesis, the lower
the levels of body image problems.
Kendrick Object Learning Test (KOLT)
The search also identified an outcome measure for use with individuals with cognitive
impairment. Larner et al (2003) conducted a study to determine whether the Kendrick
Object Learning Test (KOLT) could correctly predict whether an individual with a lower
limb amputation will use a prosthesis during an inpatient rehabilitation programme. It
was found to make the correct prediction in 70 per cent of cases. However, there are
highlighted concerns over the reliability and validity of the assessment, and the sample
size was small. The KOLT is now part of the Kendrick Scales of Cognitive Ageing (Kasca);
therefore, further research would be required with the Kasca.
For further information on the KOLT, see Section 4.6.
1.
Occupational therapists should use the Amputee Activity Score (AAS) with lower
limb prosthetic users to assess the level of activity a person achieves at discharge
from prosthetic rehabilitation to review (Panesar et al 2001).
2.
Occupational therapists should use the Frenchay Activities Index to determine the
level of participation in extended activities of daily living following the
rehabilitation and the prosthetic phase (Miller et al 2004).
3.
Occupational therapists should use the Patient Generated Index (PGI) measure to
assess quality-of-life outcomes in face-to-face assessment (Gallaghan and Condie
2003).
4.
Occupational therapists should use the Trinity Amputation and Prosthesis

Experience Amputation Scales (TAPES) to assess adjustment to lower limb
prostheses (Gallagher and MacLachlan 2000).
5.
Occupational therapists should use the TAPES to evaluate changes in quality of

life during the rehabilitation process and to provide a more holistic assessment
(Gallagher and MacLachlan 2004).
6.
Occupational therapists should use the Amputee Body Image Scale (ABIS) to
determine the level of body image disturbance and consider how this may affect
rehabilitation (Gallagher et al 2007).
7.
Occupational therapists should use the Office of Population Censuses and Surveys
Scale (OPCS) with lower limb prosthetic users to assess functional capacity in the
community at the inpatient stage (Panesar et al 2001).
8.
Occupational therapists should use the Clifton Assessment Procedures for the
Elderly (CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991,
1997).
9.
Occupational therapists should use the Kendrick Object Learning Test (KOLT) to
facilitate decision-making in prosthetic use (Larner et al 2003).
The studies by Hanspal and Fisher (1991, 1997) and Larner et al (2003) (points 8 and 9)
also form the evidence-based recommendations for Section 4.6.
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4.6 Cognition
Introduction
For successful rehabilitation with or without a prosthesis, individuals with lower limb
amputation require an ability to process information, learn and apply new knowledge
as they progress through the rehabilitation stages. Cognitive problems should be
identified at the beginning so that the team can set realistic goals and plans for
discharge. Cognition has been identified as a factor associated with deterioration in
physical ability, an inability to complete prosthetic rehabilitation, and the ability to
remain living independently (Pernot 1997, Taylor 2005, Gallagher et al 2008). Likewise,
Sansam et al (2009) found that cognitive impairment is a predictor of poor prosthetic
use following lower limb amputation. If cognitive dysfunction exists, such as impaired
reasoning, perception, comprehension, planning, attention and memory, there will be a
significant impact on the persons ability to carry out functional tasks. It will also impact
on all performance areas and affect successful prosthetic rehabilitation and long-term
use. Gallagher et al (2008) provided an example of an activity: an individual with a
transtibial amputation donning their prosthesis and then standing from a wheelchair.
The individual would have to remember the following sequence: positioning the
wheelchair, applying the brakes, removing wheelchair accessories, donning stump socks/
liner, and applying the socket and suspension sleeve. Following this, the individual
would have to check that the prosthesis was donned correctly and was comfortable
before carrying out the correct transfer technique, which involves another complex
sequence. There are many opportunities for an individual with cognitive impairment to
experience difficulties with the task.
Evidence
Clinicians working in rehabilitation with people who have had an amputation
acknowledge that a cognitive impairment can determine whether the individual will be
able to use a prosthesis safely. A study by Chun-Chieh et al (2000) found that there was
a statistically significant relationship between impaired cognitive status and the ability
to mobilise with a prosthesis. None of the service users in this study with impaired
cognition was successful in mobilising with a prosthesis; however, the sample size was
small, and so the results should be applied to the general population with caution.
Bilodeau et al (2000) found that successful prosthetic use was found to be significantly
related to cognition in people with transtibial amputation. Transtibial amputation was
almost significantly associated with increased prosthetic use. However, as this is a
correlational study (a study that describes a relationship between variables but does not
identify cause and effect), further prospective studies are required to determine which
variables influence others in this study. The relationship in this study could be due to
coincidence or there could be other factors or multiple factors influencing the variables;
this requires clarification. Taylor (2005) commented that having a transfemoral
amputation was a significant factor in the individual who is unsuccessful in prosthetic
rehabilitation.
The evidence highlighted two cognitive assessments that could be used by occupational
therapists to determine level and area of deficit. The assessments are the Kendrick
Object Learning Test (KOLT) and the Clifton Assessment Procedure for the Elderly
(CAPE). These assessments are also discussed in Section 4.5.
A study conducted by Larner et al (2003) found that the KOLT correctly predicted
whether people with lower limb amputation will use a prosthesis during the inpatient
rehabilitation programme in 70 per cent of the cases. The KOLT is a tool for assessing
older peoples cognitive abilities through immediate recall of visual and auditory
information, assessing speed of processing and recording information. However, there
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are concerns regarding the reliability and validity of the KOLT. The KOLT is also now
part of the Kendrick Scales of Cognitive Ageing (Kasca). The Kasca was based on the
Kendrick battery for the detection of dementia in older service users. The Kasca test
measures object recall, digit copying, reasoning and visuospatial ability, and tests
cognition in individuals with neuropsychological disorder; it can also be used to screen
for onset for dementia.
The CAPE is designed for use with hospital inpatients. It measures the degree of
cognitive and behavioural impairment through orientation, mental abilities,
psychomotor performance tests and behaviour rating scale. A study by Hanspal and
Fisher (1991) suggested that the CAPE could facilitate the decision on whether the
prosthesis should be prescribed. In Hanspal and Fishers 1997 study, there was a highly
significant positive correlation between the cognitive state of older service users and
mobility achieved with prosthesis. This allows professionals to carry out assessments to
ensure they make more informed decisions around prosthetic intervention and future
management needs. For both studies, it should be acknowledged that a small sample
size was used and regression analysis should have been used to strengthen their claims.
1. Occupational therapists should use the Clifton Assessment Procedures for the Elderly
(CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997).
2. Occupational therapists should use the Kendrick Object Learning Test (KOLT) to
facilitate decision-making in prosthetic use (Larner et al 2003).
4.7 Work
Introduction
Current government initiatives in the UK are aimed at supporting people with and
without disabilities to find paid or unpaid work (Black 2008). Some studies have
highlighted the perceived benefits of work, which include financial reasons as well as
social contacts with colleagues (Bruins et al 2003). Indeed, Schoppen et al (2001b) found
that people who had to stop work as a result of their amputation showed a worse
health experience than those people with an amputation who continued working.
There is evidence that people with lower limb amputations can have difficulties
returning to work (Schoppen et al 2001a, Burger and Marincek 2007). The proportion
returning to work varied from 43.5 per cent to 100 per cent, depending on age, country
and cause of amputation. Moreover, the percentage of people who returned to the
same work as pre-amputation differs in various studies and depends on the type of
work and the level of amputation. Factors that can delay or prevent return to work
include:
problems related to the stump (Bruins et al 2003);
wearing comfort of the prosthesis (Schoppen et al 2001a);
educational level (Schoppen et al 2001a);
age at the time of amputation (Schoppen et al 2001a);
co-morbidity (Schoppen et al 2002);
workplace modifications (Schoppen et al 2001b, Bruins et al 2003).
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Characteristics needed for successful job reintegration were perceived as being

motivation, good support from employers, and better co-ordination between the
multidisciplinary team, employers and companies (Bruins et al 2003). Schoppen et al
(2001a) suggested that individuals with a lower limb amputation may need to change
to less physically demanding roles following the amputation in order to successfully
return to work. The occupational therapist should routinely ask service users about their
work as part of the assessment process. The occupational therapist is well placed to
address return-to-work issues, because they help people maximise employment
opportunities by carrying out workplace assessments, task analysis, capacity and
motivation building, and management of absence. Fisher et al (2003) found that return
to work increases over time, which could suggest the need for long-term vocational
rehabilitation.
Evidence
There are no current studies to provide evidence that occupational therapy intervention
assists people with lower limb amputations to return to work, although it is clear from
the studies by Schoppen et al (2001a, b, 2002) and Bruins et al (2003) that occupational
therapists could assist in modifying the work environment. A study by Pezzin et al
(2000) suggests that following traumatic lower limb amputation, inpatient
rehabilitation was positively associated with return to work and a lower likelihood of
reduced hours of work.
1.
Support should be provided from the multidisciplinary team regarding successful

work reintegration and maintenance of the work role (Bruins et al 2003).
4.8 Leisure and recreation

Introduction
The goal of rehabilitation for people with lower limb amputations should be to
facilitate a return to independence and function in all areas of their life. Legro et al
(2001) found that people with an amputation participated in a wide range of recreation
activities. However, Collin et al (1992) found that leisure activity scores were lowest in
people with lower limb amputations who used a wheelchair. The most important
constraints on participation in leisure activities for people with lower limb amputations
were lack of accessibility, material considerations, functional abilities, affective
constraints and social constraints (Couture et al 2009).
Hanspal and Nieveen (2002) attempted to establish national consensus for indications
and recommendations for best practice for the prescription of water activity limbs.
Seventy-five per cent of respondents agreed to a water activity limb prescription for
specific water activity that necessitated the use of water activity prostheses, and where
risk analysis identified that participation in activity presented a health and safety risk
due to associated medical or physical conditions. There is evidence that participation in
leisure can provide natural opportunities for social interaction and friendship, and
provide a sense of identity and social inclusion (Lloyd et al 2000, Pegg and Moxham
2000, Taylor 2003). In addition, leisure participation can:
reduce psychological distress (Waters and Moore 2002);
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protect against and enable individuals to manage stress (Iwasaki 2001, Kleiber et al
2002);
increase self-esteem and confidence (Baxter et al 1995, Passmore and French 2000);
and
enhance physical health (Cassidy 1996).
Evidence
No studies were found that were related directly to occupational therapy. Further
research needs to be conducted to ascertain how leisure activities are incorporated into
occupational therapy programmes. Occupational therapists need to ensure that they
take into account the service users individual needs and that people of a certain age
may prefer more solitary leisure occupations and hence may not want to be referred for
group activities. Legro et al (2001) found that people aged 60 years and over were more
involved in moderate and sedentary activities than those aged 2049 years. Similar
findings are reported by Jones et al (1993), who found that watching television and
listening to the radio are the most common activities for people with lower limb
amputations (mean age 67 years, 12 years after amputation).
1.
Occupational therapists need to assess and review participation in recreational

activities (Legro et al 2001).
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Appendix 1: Guideline development

group
Expert group core members

Dr Anita Atwal PhD, MSc, Dip COT (from October 2008)
Director, Centre for Professional Practice Research; and Senior Lecturer in Occupational
Therapy, School of Health Sciences and Social Care, Brunel University
Sandra Burke Dip COT
Senior Occupational Therapist, Specialist in Prosthetics, Dorset Prosthetic Centre, Royal
Bournemouth Hospital
Fiona Carnegie Dip COT
Senior Occupational Therapist, Specialist in Prosthetics, Queen Marys Hospital
Karen Cook Dip COT, BA Hons
Senior Occupational Therapist, Specialist in Prosthetics, Bristol Disablement Services
Centre, Southmead Hospital
Jane McLaughlin (ne Hallows) BSc (Hons) (from May 2009)
Senior Occupational Therapist, Specialist in Prosthetics, Manchester Disablement
Services Centre, University Hospital South Manchester
Joy Rendell Dip COT
Clinical Specialist Occupational Therapist (Prosthetics), Prosthetics and Amputee
Rehabilitation Centre, Royal National Orthopaedic Hospital NHS Trust
Dr Georgia Spiliotopoulou PhD, PGCert LTHE, MSc, BSc, FHEA (from October 2008)
Lecturer in Occupational Therapy, School of Health Sciences and Social Care, Brunel
University
Anna Williams BSc (Hons)
Senior Occupational Therapist, Specialist in Orthopaedics, Royal Hampshire County
Hospital
Claire Wilson BSc (Hons)
Head Occupational Therapist, Clinical Specialist (Prosthetics), Belfast Regional
Disablement Service
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Appendix 1: Guideline development group
Additional original group members

Anne Ewing Dip COT (until 2008)
Senior Occupational Therapist, Specialist in Prosthetics, Newcastle Disablement Services
Centre
Claire Ireson Dip COT, DMS (until 2008)
Former Head of Occupational Therapy Services, Nuffield Orthopaedic Centre NHS Trust;
and Learning Environment Lead, Oxfordshire and Buckinghamshire Mental Health NHS
Foundation Trust
Assistants in initial stages

Lindsey Barker
Senior Occupational Therapist, Harold Wood Disablement Services Centre
Katja MacIntyre
Senior Occupational Therapist, Luton Limb Fitting Centre
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Appendix 2: Search strategies for

literature search two
Articles included after reading full paper

Search terms
OTDBASE
OT
Seeker
Medline
CINAHL
Lower limb
amputation
Lower limb
amputation
Multidisciplinary
Lower limb
amputation
Activities of daily
living
Miller et al (2001),
Gallaghan and Condie
(2003), Miller and
Deathe (2004), Miller
et al (2004), Baars et
al (2008)
Collin et al (1992),
Ham et al (1994),
Breakey (1997),
Gallagher and
MacLachlan (2000),
Panesar et al (2001)
Lower limb
amputation
Bathing
Lower limb
amputation
Self care
Lower limb
amputation
Domestic
Atherton and
Robertson (2006)
Lower limb
amputation
Quality of life
Gallagher and
MacLachlan (2000)
Gallagher and
MacLachlan (2004)
Lower limb
amputation
Rehabilitation
Lachman (1993), Price

and Fisher (2002),
Singh et al (2007)
Legro et al (2001),
Panesar et al
(2001), Larner et al
(2003), Pauley et al
(2006), Dyer et al
(2008), Hawamdeh
et al (2008)
Lower limb
amputation
Driving
28
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Search terms
OTDBASE
Medline
CINAHL
Lower limb
amputation
Housing
Lower limb
amputation
Leisure
Lower limb
amputation
Transfers
Lower limb
amputation
Prosthesis
Hanspal and Fisher

(1991, 1997),
Gallagher et al (2007)
Beekman and
Axtell (1987),
Kulkarni et al
(1996), Bilodeau et
al (2000), Gallagher
et al (2007), Baars
et al (2008)
Lower limb
amputation
Outcome
Panesar et al
(2001), Atherton
and Richards (2006)
Lower limb
amputation
Cognition
Lower limb
amputation
Falls
Kulkarni et al
(1996), Gooday and
Hunter (2004)
Lower limb
amputation
Elderly/older people
Lower limb
amputation
Home visits
Lower limb
amputation
Work
Bruins et al (2003)
Lower limb
amputation
Phantom pain
Lower limb
amputation
Wheelchair
White (1992)
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OT
Seeker
29
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Search terms
Medline
CINAHL
Lower limb
amputation
Occupation
Lower limb
amputation
Social
Gallagher et al
(2007)
Lower limb
amputation
Skin
Baars et al (2008)
30
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OTDBASE
OT
Seeker
26/01/2011 14:17
Appendix 3: Excluded papers

Twenty-nine papers were excluded as they were not relevant to occupational therapy.
Of these 29 papers, the following 26 were research papers:
Muecke et al (1992)
Rybarczyk et al (1992)
Jones et al (1993)
Pell et al (1993)
Cutson et al (1994)
Greive and Lankhorst (1996)
Schaldach (1997)
Frykberg et al (1998)
Klein et al (2001)
Schoppen et al (2001a and 2001b)
Chin et al (2002)
Gardiner et al (2002)
Hanspal and Nieven (2002)
Mortimer et al (2002)
Schoppen et al (2002)
Evans et al (2003)
Ryall et al (2003)
Tsai et al (2003)
Devlin et al (2004)
McGuire (2004)
Kulkarni et al (2005)
urovic et al (2007)
Franchignoni et al (2007)
Traballesi et al (2007)
Stokes et al (2008)
Of the 29 excluded papers, the following 3 were systematic reviews:
Cumming et al (2006)
Meulembelt et al (2006)
Van Velzen et al (2006)
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Appendix 4: How to assess the evidence

(typology)
Table 1: designation of levels of evidence

These levels of evidence ratings have been adapted from A guide to the development,
implementation and evaluation of clinical practice guidelines (National Health and
Medical Research Council, Australian Government 1999, p 56).
Level of evidence
Study design
Evidence obtained from a systematic review of all relevant

randomised controlled trials
II
Evidence obtained from at least one properly designed

randomised controlled trial
III-1
Evidence obtained from well-designed pseudo-randomised

controlled trials (alternate allocation or some other method)
III-2
Evidence obtained from comparative studies (including

systematic reviews of such studies) with concurrent controls
and allocation not randomised, cohort studies, case-control
studies, or interrupted time series with a control group
III-3
Evidence obtained from comparative studies with historical

control, two or more single-arm studies, or interrupted time
series without a parallel control group
IV
Evidence obtained from case series, either post-test or pre-test/

post-test
Surveys, correlation studies, reliability and validity studies for

outcome measure development, case studies and focus groups
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Appendix 4: How to assess the evidence (typology)
Table 2: quality assessment for qualitative and quantitative

studies
From the National Service Framework for Long-term Conditions (Department of Health
2005, p 88).
Each quality item is scored as follows:
Yes=2, In part=1, No=0
Score
1. Are the research questions/aims and design clearly stated?

2. Is the research design appropriate for the aims and objectives of the
research?
3. Are the methods clearly described?
4. Is the data adequate to support the authors interpretations/conclusions?
5. Are the results generalisable?
Total
Note:
High-quality research studies score at least 7/10
Medium-quality studies score 46/10
Poor-quality studies score 3/10 or less.
Table 3: research design is classified according to the

following categories
Extract of Table 3 from the National Service Framework for Long-term Conditions
(Department of Health 2005, p 88).
Primary research-based evidence
P1
Primary research using quantitative approaches
P2
Primary research using qualitative approaches
P3
Primary research using mixed methods (qualitative and quantitative)
Secondary research-based evidence

S1
Meta-analysis of existing data analysis
S2
Secondary analysis of existing data
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Abbreviations used in evidence-based review table

AK
BK
LL
LLA
MDT
TK
UK
USA
above knee
below knee
lower limb
lower limb amputee
multidisciplinary team
through knee
United Kingdom
United States of America
Author/year
Atherton and Robertson (2006)
Study location
UK
Study objectives
To determine prevalence of psychological morbidity in an

amputee population and identify variables associated with
increased distress
Design
P1 cross-sectional survey
Participants
N=67
Inclusion criteria: LLAs aged 18 years, amputation within past 5
years, wearing prosthesis on a daily basis
Exclusion criteria: current diagnosis of life-threatening condition
Recruitment
Through 2 artificial limb and appliance centres in the Midlands,

UK
Data collection
Verbal interviews order of presentation counterbalanced using

Latin squares
Outcome measures
1. Hospital Anxiety and Depression Scale (HADS): self-reporting,

14 items, 2 subscales on 4-point scale. Greater scores greater
level of morbidity
2. Psychological adjustment subscale of the Trinity Amputation
and Prosthesis Experience Scales (TAPES): to understand the
experience of and adjustment to both LL amputation and
wearing of a prosthesis: self-reporting, 15 items, 3 subscales
(general, social and limitation adjustment), scores for each
subscale range from 5 to 25 (higher scores better adjustment)
3. Self-Consciousness Scale (SCS): to address individual differences
in self-consciousness, 23 items, 3 subscales (self-consciousness,
public self-consciousness, social anxiety). Higher scores
greater levels of self-consciousness or anxiety
4. Appearance Schemas Inventory (ASI): to assess broad core
appearance-related cognitive assumptions without reference
to specific physical attributes: 3 subscales (body image
vulnerability, self-investment, appearance stereotyping). Higher
scores greater body dissatisfaction
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Author/year
Atherton and Robertson (2006)
Results
Opt-in rate 42.4%

Using conservative cut-off scores, prevalence of anxiety and
depression was 29.9% and 13.4%, respectively
Kendalls T-b analysis showed that total scores for appearancerelated beliefs were associated with distress (anxiety T-b=0.241,
p<0.01; depression T-b=0.296, p<0.001) and general and social
adjustment (T-b=0.222, p<0.05)
Kendalls T-b analysis showed that public but not private selfconsciousness was associated with distress (anxiety T-b=0.224,
p<0.01; depression T-b=0.199, p<0.05) and psychosocial
adjustment difficulties (T-b=0.195 to 0.242, p<0.05 to <0.01)
Study limitations
Recruitment conducted in only 2 centres in the Midlands

Small sample size for a prevalence study
Psychometrics of the used outcome measures have not been
reported for this specific study
A previous version of the ASI has been used
Regression analysis rather than correlation analysis would have
been more effective to identify predictors of distress
Magnitude of T-b for public consciousness is not very high,
although the correlations were significant. Magnitude of T-b for
the ASI and distress is slightly higher
Cross-sectional design limits causality conclusions
Relevance for
occupational therapy
This study suggests that clinicians need to monitor amputees for

distress over a longer time period than the initial postoperative
phase and that it is particularly important to assess for anxiety. It
also suggests that interventions that target appearance-related
beliefs and private self-consciousness may be of benefit to this
population.
Level of evidence
Quality score
Reference
Atherton R, Robertson N (2006) Psychological adjustment to

lower limb amputation amongst prosthesis users. Disability and
Rehabilitation, 28(19), 12011209
Author/year
Baars et al (2008)
Study location
The Netherlands
Study objectives
To investigate the relationship between liner-related skin

problems of the stump in patients with LL amputation and
impaired hand function
Design
P1 retrospective survey
Participants
N=60 (50 transtibial and 10 knee disarticulation amputees, mean

age 62.3 years)
Recruitment
1 rehabilitation setting
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Author/year
Baars et al (2008)
Data collection
Case notes analysis on amputation, hand function, skin problems

of the stump, co-morbidity, prosthesis, liner use and mobility
score
Results
70% of patients with impaired hand function experienced

liner-related skin problems compared with 32% of patients
with normal hand function (p=0.035)
Study limitations
Data from the medical notes were not always accurate or

present to proceed with accurate statistical analysis
Relevance for
Occupational therapists need to be aware of hand function before

prescription of liners used with
prostheses.
Level of evidence
Quality score
Reference
Baars ECT, Dijkstra PU, Geertzen JHB (2008) Skin problems of the
stump and hand function in lower limb amputees. Prosthetics and
Orthotics International, 32(2), 179185
Author/year
Beekman and Axtell (1987)
Study location
USA
Study objectives
To determine factors related to prosthetic candidacy, to determine

the level of function and extent of prosthetic use in patients with
prostheses, and to establish predictors of prosthetic use
Design
P3 retrospective survey
Participants
N=55 patients (50 years, mean age 65.4 years) with

vascular insufficiency resulting in unilateral AK or TK
amputation only, or in amputation and prosthetic training
(56%)
23 of 31 patients with a prosthesis were evaluated 735 months
after receiving the prosthesis
20 patients had follow-up interview and functional follow-up
assessment
Recruitment
1 centre between 1978 and 1980
Data collection
The charts of all participants were reviewed for sex, age, diagnosis,
level of amputation and medical complications. For participants
with a prosthesis, information around the prosthesis, range of
motion, velocity, distance, equipment and transfers was also
gathered through charts. Patients with a prosthesis were evaluated
and interviewed at least 6 months after receipt of their prosthesis.
The interview included questions regarding use of prosthesis and
wheelchair, prosthetic comfort, need for prosthetic repair, status
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Author/year
Data collection (cont.)
of health, new medical or residual problems, reasons for not

wearing the prosthesis, and ambulatory equipment use. Follow-up
evaluation was omitted for patients who were not fitted with a
prosthesis.
Results
Chart review showed that the only difference between patients

who were fitted with a prosthesis and those who were not was
their respective number of medical complications (2=11.46,
df=1, p<0.005)
44% of 23 patients with a prosthesis wore their prosthesis
all day every day and used a wheelchair minimally or
not at all. Over half of the patients evaluated used their
wheelchair most of the time. 9% had stopped wearing their
prosthesis
t-test analysis showed that patients who demonstrated
increased walking distances (t=3.18, df=17, p<0.01) and
velocities (t=3.14, df=17, p<0.01) at follow-up used their
prosthesis more and their wheelchair less than other patients
Neither gait factors nor hip range of motion at discharge was
predictive of continued prosthetic use
Over 60% of patients reported cosmetic problems or discomfort
at follow-up and many cited this as a reason for not wearing
their prosthesis
Study limitations
Patients were recruited from only 1 medical centre

Ethical approval issues are not discussed
The design is not clearly described
To identify factors related to prosthetic candidacy, 2 analysis
was carried out to compare patients who had prostheses
with those that did not. A regression analysis assessing all
factors that might have led to prosthetic candidacy could have
provided more sound results
To determine the level of function and extent of prosthetic use
in patients with prostheses at discharge, descriptive analysis was
done. There was no inferential statistical analysis
To establish predictors of prosthetic use, regression analysis
would have provided more sound results. Instead, comparison
analysis between 2 groups (prosthetic use/no prosthetic use) was
carried out
The form for functional assessment was not given
Small sample, especially at follow-up evaluation
Relevance for
The results of this study may serve as a basis for clinical

determination of prosthetic candidacy and functional goals for
vascular amputees aged 50 years of TK and AK levels.
Level of evidence
Quality score
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Author/year
Reference
Beekman CE, Axtell LA (1987) Prosthetic use in elderly patients

with Dysvascular above-knee and through-knee amputations.
Physical Therapy, 67(10), 15101516
Author/year
Bilodeau et al (2000)
Study location
Canada
Study objectives
To study factors such as physical and mental health, rehabilitation,

physical independence and satisfaction with the prosthesis to
understand why amputees use or do not their prosthesis
Design
P1 cross-sectional survey with correlational elements
Participants
N=65 unilateral vascular amputees aged 60 years, without

severe cognitive problems, living at home and having received a
prosthesis
Recruitment
4 hospitals in semi-urban area of Canada
Data collection
Through postal questionnaires, medical records, telephone

interviews (20 minutes) to provide information on prosthesis use,
physical independence, cognitive status and physical health status
Outcome measures
1. Questionnaire on amputee activities developed by Day (1981)

to evaluate depressive mood and amputees satisfaction. Total
scores range from 70 (very inactive) to +50 (very active)
2. Barthel Index to measure physical independence: 10 items
on a 2-point scale for personal care and mobility. Total scores
range from 0 (complete dependence) to 100 (complete
independence)
3. Satisfaction With Prosthesis (SATPRO) (Bilodeau et al 1999):
15 questions on a 4-point ordinal scale. Total scores range from
0 (satisfaction) to 45 (dissatisfaction) and are reported on a
score out of 100 for easier interpretation
4. Short Portable Mental Status Questionnaire for the elderly
(Pfeiffer 1975) to measure cognitive status: 10 items. Total
scores range from 0 (no impairment) to 10 (severe impairment)
5. Geriatric Depression Scale (Brink et al 1982) to measure
depression: self-rated, 30 items on a 2-point scale. Total scores
range from 0 (not depressed) to 30 (depressed)
6. 4 self-perception questions from the Older Americans
Resources and Services (OARS) Multidimensional Functional
Assessment Questionnaire (OMFAQ)
Results
81% of participants wore their prosthesis every day, and 89% of

this group wore it for 6 hours a day
Bivariate analysis showed that less use of the prosthesis
significantly decreased with age (r=0.22, p=0.02)
Women used the prosthesis significantly less than men
(p=0.02)
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Author/year
Bilodeau et al (2000)
Results (cont.)
Transtibial amputation was almost significantly associated with

increased prosthesis use (p=0.07)
Possession of a wheelchair was significantly associated with less
prosthesis use (p=0.0001)
Prosthesis use was significantly related to the amputees physical
independence (r=0.28, p=0.004), better cognition (r=0.27,
p=0.006), younger age (r=0.22, p=0.01) and the amputees
satisfaction (r=0.19, p=0.04). Frequency of occupational therapy
sessions was statistically significant (r=0.59, p=0.05)
Multiple regression analysis showed that dissatisfaction with the
prosthesis, not possessing a wheelchair and cognitive integrity
explained 46% of the variance in prosthesis use
Study limitations
Ethical issues are not discussed

Definition of prosthetic use differs among different studies;
therefore, it is difficult to compare the results of this study with
others
The reliability and validity of the Day (1981) questionnaire has
not been checked for this study. Although the authors report
good testretest reliability and empirical and concurrent validity
at its development, they do not provide exact information
For the rest of the outcome measures, psychometrics are
reported but not checked for this study
A different p value is reported for the correlation with age in 2
different parts of the results
The magnitude of the coefficients is not always reported at the
results, and so it is difficult to interpret significance at times
It is not always clarified which statistical test has been used for
each reported result
Sample size is not justified
Further prospective studies are needed to determine which
variables influence others, as this is a correlational study
Relevance for
This study could be useful for occupational therapists who work

with LLAs on successful prosthetic use, as it indicates that the
frequency of occupational therapy sessions is related to prosthesis
use.
Level of evidence
Quality score
Reference
Bilodeau S, Herbert R, Desrosiers J (2000) Lower limb utilisation by

elderly amputees. Prosthetics and Orthotics International, 24(2),
126132
Author/year
Breakey (1997)
Study location
USA
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Author/year
Breakey (1997)
Study objectives
To determine whether a relationship exists between body image

and psychosocial wellbeing (anxiety and depression, self-esteem
and satisfaction with life) in LLAs
Design
P1 survey with correlational elements
Participants
N=90 males (mean age 45 years, range 2274 years), unilateral

traumatic LL amputation at least 1 year post-amputation, 60 BK,
30 AK
Recruitment
Participants identified randomly through the files of 1

specialist
Data collection
Self-report postal questionnaire completed by participants,

including 110 items consisting of 6 scales
Outcome measures
1. Self-developed Amputee Body Image Scale (ABIS) to assess

how an amputee perceives and feels about his or her body
(20 items, 5-point Likert scale, higher scores body image
problems)
2. Index of self-esteem (25 items, 0100; higher scores
problems)
3. Generalised Contentment Scale (GSC) to measure non-psychotic
depression (25 items, 0100; higher scores problems)
4. Clinical Anxiety Scale (CAS) (25 items, 0100; higher scores
problems)
5. Satisfaction with Life Scale (SWLS) (5 items, 535; higher scores
satisfaction with life)
6. Demographic data (10 items)
Results
90/110 LLA respondents

Spearman analysis showed significant positive correlations
between body image and self-esteem (rs=0.56, p<0.0001),
anxiety (rs=0.57, p<0.0001) and depression (rs=0.64,
p<0.0001)
Significant correlation between body image and life satisfaction
(rs=0.58, p<0.0001), indicating the more negative an amputee
feels about his or her body image, the less satisfied he or she is
with his or her life
No significant correlations between ABIS and time since
amputation
When the sample was divided into 2 groups (less
concerned, more concerned), the MannWhitney U test showed
significant differences in all measures at the 0.0001 level
Study limitations
Ethical approval issues and the procedure followed to

request LLAs to participate in the study are not discussed
Recruitment from the files of only 1 specialist
40
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Author/year
Breakey (1997)
Study limitations
(cont.)
Content validity of the ABIS has not been checked properly

The internal consistency of ABIS is satisfactory (Cronbachs
alpha=0.88). However, the author does not discuss the
properties of the data as to whether they meet the assumptions
for use of Cronbachs alpha. Mean inter-item correlation () has
not been calculated
The author did not discuss any type of reliability apart from
internal consistency for the ABIS, which is the main tool used
for the study. Moreover, no type of validity, apart from content
validity, was discussed
The author did not discuss the validity or reliability of the used
outcome measures with this group of patients or for this specific
study
Regression analysis would be more appropriate to analyse
relationships for this study
Relevance for
This study provides awareness on how body image relates to

an individuals satisfaction with life, self-esteem and anxiety.
Occupational therapists should be aware of this relationship and
of the psychological consequences that amputation might have on
an individual.
Level of evidence
Quality score
Reference
Breakey JW (1997) Body image: the lower limb amputee. Journal

of Prosthetics and Orthotics, 9(2), 5866
Author/year
Bruins et al (2003)
Study location
The Netherlands
Study objectives
To study the process of job reintegration and to assess experiences

of LLAs aged 1860 years
Design
P3 descriptive survey
Participants
N=24 men and 8 women (mean age 42.6 years), no more than 8
years after amputation
Recruitment
Through the large number of participants of a previous study

(Schoppen et al 2001)
Data collection
32 two semi-structured interviews
Results
Stump problems delayed the return to work (average 11.5

months)
Participants valued work as a form of spending the day and the
social contacts with colleagues and others
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Author/year
Bruins et al (2003)
Results (cont.)
11 participants reported having fewer promotion possibilities;

reasons given were related to employers being concerned about
absence due to ill health
50% returned to the same employment, 31% to an altered role
and 19% to new employment
Work-related adjustments were seldom initiated by members of
the team; 7 participants were dissatisfied with adjustments in
the workplace
Characteristics needed for successful job integration
were perceived as being: motivation and good support
from employers; and better co-ordination between
professionals, implementing bodies, companies, employers and
doctors
Study limitations
Although this is a qualitative study the researchers have used

content analysis to turn qualitative data into quantitative data.
As a result, the paper does not address the experiences of LLAs
in any great depth
Relevance for
Occupational therapists need to be actively involved in work

reintegration and to work collaboratively with work agencies,
employers, and social services regarding work adaptations.
Occupational therapists need to actively promote good stump
care for patients to enable them to participate in their chosen
occupations.
Level of evidence
Quality score
Reference
Bruins M, Geertzen JHB, Groothoff JW, Schoppen T (2003)

Vocational reintegration after lower limb amputation: a
qualitative study. Prosthetics and Orthotics International, 27(1),
410
Author/year
Collin et al (1992)
Study location
UK
Study objectives
To identify objective measures that correlate closely with the

outcome of prosthetic rehabilitation (enhanced function and
mobility, whether by the appropriate use of a wheelchair in
an adapted environment, the use of a prosthetic limb, or a
combination of methods) in order that the progress and results
of rehabilitation programmes in amputees can be identified and
monitored accurately
Design
P3 survey with correlational and comparative elements
Participants
37 patients (27 males, mean age 66.9 years; 10 females, mean age
73 years) with an amputation due to peripheral vascular disease or
diabetes mellitus and accepted for prosthetic training questioned,
of which 34 were examined
42
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Author/year
Collin et al (1992)
Recruitment
Through 1 disablement services centre (DSC)
Data collection
Questionnaire completed at home and an examination performed

either at the hospital or at the centre
Outcome measures
1. Questionnaire to gather information on hospital admissions,

medical history, use of DSC and community rehabilitation
services, prosthetic use (hours/day) and wheelchair use in
essential daily activities
2. Barthel Activities of Daily Living Index to measure
independence in essential care activities
3. Nottingham extended ADL Index (NEADL) to assess
independence in mobility, kitchen, domestic and social
activities
4. Amount of formal care input, patients status, and patients
satisfaction (2 items) with present level of function and with
the medical, prosthetic, rehabilitation and community services
was asked about
5. History of pain, and details of the other limb and infections was
taken
6. Assessment of pre-amputation walking status graded in 3
categories
7. Mini-Mental Status Examination to measure cognitive
function
8. 9-hole peg test to measure manual dexterity
9. Walking distance, cardiac fitness, respiratory peak flow,
motricity index and grip strength
Results
Based on mode of mobility, hours of use of prosthesis and

observation, participants were grouped as 14 walkers, 10 partial
walkers and 13 non-walkers
KruskalWallis test showed that the Barthel Index was
significantly different in each of the 3 groups (2=26.02,
p<0.001), wheelchair use requiring most help with personal
care. Partial walkers had lower mean scores than the other 2
groups for extended activities of daily living in the kitchen and
domestic sphere, but leisure activity scores were lowest in the
wheelchair group (p=0.04)
KruskalWallis test showed that partial walkers were slightly
older than the other 2 groups (p<0.02), had a weaker hand grip
(p<0.05) and had lower peak flows (p<0.004)
Barthel Index correlated closely with time taken to walk
(=0.664, p<0.001) and there was a significant difference in
speed between walkers and partial walkers (p<0.001)
85% of the walkers completed a 10-metre walk in <30 seconds,
whereas 90% of the partial walkers took >30 seconds
Grip strength and cardiovascular fitness correlated well with
outcome
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Author/year
Collin et al (1992)
Results (cont.)
Age was not a predictor of outcome (whether prosthetic use

training would be successful), but in those who were walking
it correlated closely with speed. Age was strongly correlated
with grip strength (p<0.001), Barthel Index (p<0.001) and social
services input (p<0.01)
Gender was related to grip strength (p<0.001)
Pre-amputation walking status correlated with overall outcome
(p<0.01)
Cognitive status and 9-hole peg test correlated with ADL scores
Partial walkers had lower kitchen and domestic activity scores,
which were due to lack of environmental modifications for
wheelchair users. These patients can easily be identified by
measuring their walking speed and Barthel Index
Study limitations

The aim could have been stated more clearly with respect to the
outcome of rehabilitation
The recruitment was done through only 1 setting
Lack of consistency on the place where the examination was
completed
It is not clarified who contacted the participants and their
relationships to participants
It is unclear what scores were used to categorise participants
into 3 groups (walkers/partial walkers/non-walkers)
The sample included both unilateral and bilateral amputees
The reliability and validity of the outcome measures used are
not discussed
The authors assess predictors by using correlations, whereas a
regression analysis would be more appropriate
The level of magnitude of the coefficients, and the significance
of some correlations, is not always reported
Relevance for
This study suggests that older adults with an amputation due to

peripheral vascular disease are unlikely to master walking again,
and in this situation resources should be directed at enhancing
function through environmental modification and appropriate
wheelchair provision. It also suggests that it is important to review
progress measuring walking speed, pulse recovery, Barthel Index
and NEADL to ensure that these patients achieve the highest level
of rehabilitation success by whatever means.
Level of evidence
Quality score
Reference
Collin C, Wade DT, Cochrane GM (1992) Functional outcome of

lower limb amputees with peripheral vascular disease. Clinical
44
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Author/year
Dyer et al (2008)
Study location
Canada
Study objectives
To identify the associated and causative factors that led to falls

in the adult amputee patient population
To develop 2 programmes from the resulting information: an
effective falls prevention programme and a falls risk assessment
specific for adult amputee patients
To report the preliminary data of the first three months of the
study
Design
P3 2-stage study including a survey and a pre-/post-treatment

design
Participants
N=24 patients. Inclusion criteria: all patients admitted to the

ward during the first 3 months of the study were qualified as
participants
Recruitment
Rehabilitation hospital in Edmonton with an 8-bed ward for

patients with LL amputation
Data collection/
intervention
Stage 1: causes of falls were explored through literature and

comparison with existing NetSAFE programme, observational
sessions with staff, and anonymised questionnaire from nursing
staff
Stage 2: interventions were selected by the project team and
assessed in terms of effectiveness in improving patients safety.
The anonymised questionnaire was recirculated to the nursing
staff at the conclusion of the study. Data regarding amputee
patient falls were retrieved from NetSAFE
Interventions: (1) Falls Assessment Tool revised to identify
patients at risk of falling and delineate a process for
intervention with these clients. (2) If a fall occurred, the MDT
identified the root cause and developed a customised plan
to prevent subsequent falls. (3) NetSAFE falls data reviewed
monthly by the MDT to monitor the effectiveness of the
interventions. (4) Nursing staff educated about the main causes
and location of falls specific to the ward patients
Results
Falls incidence in the ward was 31% in the first 9 months of

data collected through NetSAFE
14/18 patients fell while using a wheelchair. Among these falls,
poor balance was associated with 9, patients self-transfer
involving a wheelchair was associated with 10, and sitting and
reaching in the wheelchair was associated with 4
The chances of a patient who had fallen once of falling again
were 1 in 3
Within the first 3 months of the study there was a 5% decrease
in falls with only 2 patients falling once. Neither of these falls
resulted in physical injury.
The response rate of the pre-/post-intervention questionnaire
from the nursing staff was 60% (18/30)
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Author/year
Dyer et al (2008)
Results (cont.)
Initially only 25% of the nursing staff had agreed that the Falls
Assessment Tool was being used effectively; this increased to
65% after implementation of the intervention
Initially 50% had agreed that the Nursing Assessment Tool
was useful for differentiating patients at risk of falling; this
increased to 60%
The efficacy of identifying patients at risk of falling was 40%;
this increased to 65%
Post-intervention, the nursing staff indicated a 43% increase in
investigation into falls and information dissemination regarding
falls
The majority of staff reported a substantial improvement
regarding the effective reporting and discussion of NetSAFE
data (pre-intervention 8%, post-intervention 90%)
Study limitations
Small sample size

The design of the study needs further clarification
The methods of assessment need further clarification
The characteristics of the sample are not clarified; since
there were no specific inclusion criteria, the sample might be
heterogeneous
There is only descriptive analysis of the results without the
use of inferential statistics; therefore, the results cannot be
generalised
The study does not explore other factors that may be relevant
to the reduction of falls during this period, and there is no
control group
The study was based in only 1 ward of 1 hospital
Ethical clearance is not discussed
The recruitment process is not discussed
Relevance for
This study suggests that the coordinated efforts of the MDT to

create customised falls intervention for each patient deemed to
be at risk of falling were considered effective and worthwhile.
This study is relevant to occupational therapy as part of the MDT.
Level of evidence
IV
Quality score
Reference
Dyer D, Bouman B, Davey M, Ismond KP (2008) An intervention

program to reduce falls for adult in-patients following major
lower limb amputation. Healthcare Quarterly, 11(3), 117121
Author/year
Gallaghan and Condie (2003)
Study location
Glasgow, UK
Study objectives
To adapt the Patient Generated Index (PGI) Quality Of Life (QOL)

measure for use with LLAs and to conduct a test-retest reliability
and construct validity study on the adapted measure
Design
P1 outcome measure development
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Author/year
Participants
N=42 unilateral LL transfemoral amputees, aged 16 years, fitted

with a prosthesis and discharged into the community for at least
1 year following postoperative rehabilitation therapy; 39 of these
completed the second stage of the study
Recruitment
7 participating hospitals
Data collection
Repeated questionnaire interviews with a 4-week interval

administered by trained peers in the participants homes
As a first step, participants completed the PGI and SF-12; as a
second step, they completed the PGI only
Outcome measures
1. Adapted PGI to measure QOL: completed in 3 stages. Total

scores: 010
2. Short Form 12 Health Survey (SF-12): health-related
QOL measure reported as a physical and a mental
component summary on a scale between 0 and 100 (average
normal=50)
Results
Consent rate 51%

PGI testretest reliability analysis achieved an intraclass
correlation coefficient (ICC) of 0.48 (p<0.001)
ICC values for the 7 most commonly mentioned areas of life
affected by the amputation and its treatment ranged from
0.40 to 0.92, and all were statistically significant (p=0.05 to
0.001)
Construct validity was supported as the PGI and the SF-12
Health Survey physical and mental component summaries gave
Pearson correlation coefficients (r=0.12, p<0.05) and (r=0.56,
p<0.001) respectively
Multiple regression analysis showed that SF-12 physical and
mental component scores explained 31.5% of the variability in
PGI scores; the mental component scores alone explained 31.2%
Study limitations
The authors reported comparing the PGI with SF-12 to assess

construct validity, whereas they correlated the 2 measures by
using Pearson correlation analysis
Although the correlations between PGI and SF-12 were
significant, the levels of magnitude of the coefficient for the
physical component is quite low (r=0.12)
Further types of reliability and validity should be tested before
the tool can be used safely
Small sample size for this type of study
Relevance for
The PGI was adapted and this study suggests that it was found to
be moderately reliable in terms of repeatability during successive
follow-up interviews. Its construct validity supported a stronger
relationship between mental health and QOL than between
physical health and QOL.
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Author/year
Relevance for
(cont.)
This measure could be used with caution to assess QOL outcomes

in groups of LLAs. It can also be used to base treatment strategies
on the goals identified by patients in step 1 of the measure, and
then focusing care activity on those goals given low scores in step
2 with high weights in step 3. However, the measure has practical
limitations related to its format, which makes it more appropriate
to be used in a face-to-face interview.
Level of evidence
Quality score
Reference
Gallaghan BG, Condie ME (2003) A post-discharge quality of life

outcome measure for lower limb amputees: test-retest reliability
and construct validity. Clinical Rehabilitation, 17(8), 858864
Author/year
Gallagher and MacLachlan (2000)
Study location
Ireland
Study objectives
To develop a multidimensional self-report instrument to better

understand the experience of amputation and adjustment to
LL prosthesis that could supplement clinical assessment and
contribute to research in this area
Design
Participants
N=104 participants aged >18 years with LL amputation
Recruitment
1 clinic at Cappagh Orthopedic Hospital
Data collection
3-stage process: (1) review of the literature and existing measures;

(2) expert opinion (clinical and research psychologists, prosthetists,
rehabilitation and orthopaedic consultants); (3) focus groups with
LLAs (thematic analysis of data)
Outcome measures
Postal questionnaire (closed-ended questions) consisting of 3

sections: (1) psychosocial issues: 89 items rated on a 5-point Likert
scale; (2) activity restriction: 19 items rated on a 3-point scale; (3)
satisfaction with prosthesis: 10 items rated on a 5-point scale
Results
61% response rate from LLAs

Factor analysis revealed: (a) 3 psychosocial subscales (general,
social and adjustment to limitation); internal consistency
(Cronbachs alpha=0.886, 0.862, 0.833, respectively); (b) 3
activity restriction subscales (functional, social and athletic
activity restriction) (Cronbachs alpha=0.865, 0.838, 0.763,
respectively); (c) 3 satisfaction subscales (functional, aesthetic
and weight satisfaction). (Cronbachs alpha=0.854, 0.777 for
functional aesthetic scales respectively. Weight satisfaction
comprised by a single item)
48
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Author/year
Results (cont.)
Subscales displayed preliminary evidence indicating predictive

validity: (1) multiple regression analysis suggested that
adjustment to limitation and general adjustment predicted a
significant proportion in prosthetic use; (2) logistic regression
analysis (LRA) revealed that the adjustment to limitation
significantly discriminates respondents who experience stump
pain; (3) LRA indicated that the adjustment to limitation and
aesthetic satisfaction subscales significantly discriminated those
who experienced phantom limb pain from those who did not
Construct validity was established with 60 people (36% response
rate) completing the revised TAPES and: (1) World Health
Organization Quality of Life Questionnaire (WHOQOL: BREF,
1998 28 items rated on a 5-point scale); significant correlations
between TAPES subscales and WHOQOL: BREF domain scores
(r=0.392 to 0.634, p<0.001 to 0.003); (2) Impact of Event Scale:
intrusion scale 7 items, avoidance scale 8 items; significant
correlations (r= 0.265 to 0.623, p<0.05 to 0.001); no significant
correlations with activity restriction or satisfaction with the
prosthesis; (3) Trait Meta Mood Scale; Significant correlations
with the repair and clarity subscales of TMMS (r=0.337 to 0.578,
p<0.01 to 0.0001)
Final version of TAPES consists of 54 items and the
administration time is approximately 510 minutes
Study limitations
Participants recruited from only 1 hospital

For ordinal data, RASCH analysis is more appropriate than factor
analysis
The authors suggest established face and content validity but
do not clarify how this was assessed
The finding that the general adjustment and adjustment to
limitation subscales explained 19% of the variance in prosthetic
use should be treated with caution because the variance
explained is low
Future research should identify the stability of the instrument
over time (testretest reliability) and should look at predictive
validity using prospective studies
Small sample for generalisation of results
Relevance for
Occupational therapists might use this tool for clinical and

research purposes with some caution. The TAPES may provide
an initial evaluation of adjustment problems and consequently
identify patients experiencing maladjustment and the
development and evaluation of treatment approaches.
Level of evidence
Quality score
Reference
Gallagher P, MacLachlan M (2000) Development and psychometric

evaluation of the Trinity Amputation and Prosthesis Experience
Scales (TAPES). Rehabilitation Psychology, 45(2), 130154
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Author/year
Study location
Ireland
Study objectives
To investigate whether multivariate combinations of TAPES

subscales are important in predicting different domains in quality
of life
Design
P1 survey study
Participants
N=63 people (37% response rate) returned completed

questionnaires, 69.8% male, 42.9% trauma, 57.1% BKA. Inclusion
criteria: age 18 years, unilateral LLA
Recruitment
Through hospital charts from patients attending limb-fitting

centre
Data collection
Through postal questionnaires
Outcome measures
1. World Health Organization Quality of Life Questionnaire brief

version (WHOQOL-BREF): 4 scales related to QOL: physical,
psychological, social relationships and environment. 28 items on
5-point Likert scales
2. TAPES: 9 subscales in total: (a) 3 psychosocial subscales
general, social adjustment and limitation adjustment; each
contains 5 items measured with a 5-point rating scale; higher
scores indicate higher level of adjustment; (b) 3 activity
restriction subscales: function, social, athletic activity restriction;
each contains 4 items measured on a 3-point scale; higher scores
indicate higher activity restriction; (c) 3 subscales assessing
satisfaction with prosthesis measured with a 5-point scale, with
5 items in functional and aesthetic satisfaction and only 1 item
in weight satisfaction; higher scores in scales indicate higher
satisfaction with prosthesis. TAPES also considers phantom
limb pain and residual limb pain and other medical factors not
related to amputation
Results
Pearson analysis showed significant relationship between length

of time living with the prosthesis and each of physical health
(r=0.26, p>0.05), social relationships (r=0.29, p>0.05) and the
environment (r=0.33, p<0.01) scales on the WHOQOL
Significant relationship between the degree of prosthetic use
and both the psychological domain (r=0.29, p<0.05) and the
social relationships domain (r=0.50, p<0.001)
No significant relationship between age and QOL domains
ANOVA analysis did not reveal any significant differences in any
of the QOL domain scores (physical health, psychological, social
relationships, environmental) arising from age, gender, level or
cause of amputation
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Author/year
Results (cont.)
Stepwise multiple regression analysis showed that the

general adjustment scale, functional restriction subscale,
physical capabilities rating, experience of residual limb
pain, health rating and adjustment to limitation subscale
predicted 84% of the variance in the physical health domain of
QOL
The general and social adjustment subscales, level of
amputation, aesthetic satisfaction with prosthesis and physical
capabilities rating TAPES predicted 72% of the variance in the
psychological domain of QOL
TAPES ratings of social adjustment, degree of prosthetic use and
length of time with prosthesis predicted 63% of variance in the
social domain of QOL
The general adjustment subscale of TAPES predicted
a significant proportion of the 44% of variance in the
environmental domain of QOL
Study limitations
Further longitudinal research is required to explore possible

cause and effect relationships and to determine the TAPES
responsiveness to change
All participants came from a single facility
Sample size is very small for assessing this number of predictors
Further validity and reliability studies is required
Authors need to be more specific by providing more
information on reliability and validity of measures being
used
Self-report could introduce bias as there is no control over the
response
There is no information on how much of the variance is
explained by each predictor
Outcome measures responsiveness to change not
mentioned
Relevance for
TAPES could be used by occupational therapists to evaluate

changes in an individuals QOL during the rehabilitation process
and provide a more holistic assessment.
Level of evidence
Quality score
Reference
Gallagher P, MacLachlan M (2004) The Trinity Amputation and

Prosthesis Experience Scales and quality of life in people with
lower limb amputation. Archives Physical Medicine Rehabilitation,
85(5), 730736
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Author/Year
Study location
Ireland
Study objectives
To examine the validity and reliability and the quality of the

rating categories of the Amputee Body Image Scale (ABIS) using
Rasch Analysis
Design
Participants
N=145 people with LL amputation, currently wearing a prosthesis,

male 68.3%, BKA 50.3%, AKA 35.9%. Inclusion criteria: age >18
years with LL amputation
Recruitment
Through hospital charts of 2 limb-fitting centres in

Ireland
Data collection
Through postal questionnaires
Outcome measures
1. ABIS: 20 items (ratings 15) assessing how an amputee

perceives/feels about body image. Total scores range from
20 to 100 (high scores indicate high body image disturbance)
2. Trinity Amputation Prosthesis Experience Scales (TAPES):
(a) 3 psychosocial subscales (general adjustment, social
adjustment and limitation adjustment), each containing 5
items (ratings of 15, with higher scores indicating higher
level of adjustment); (b) 3 activity subscales (functional
activity restriction, social activity restriction and athletic
activity restriction), each containing 4 items measured on a
3-point scale, with higher scores indicating higher activity
restriction; (c) 3 more subscales: prosthetic satisfaction
(5-point rating scale), functional satisfaction (5 items),
aesthetic satisfaction (4 items), weight satisfaction (1 item),
with higher scores indicating higher satisfaction with prosthesis.
TAPES also assesses phantom pain and residual limb pain and
other medical problems not related to amputation, and rates
general health
Results
According to Rasch analysis and expert review, some response

categories were collapsed and 6 items were deleted. The
remaining 14 items were used to create the revised ABIS
(ABIS-R) rated with a 3-level rating scale
ABIS-R fitted the unidimensional construct that the scale was
intended to measure
ABIS-R demonstrated good reliability (Cronbachs alpha and
person separation reliability=0.87), targeting and internal
construct validity
Correlations with the 9 TAPES subscales (in particular, r=0.54
with general adjustment, r=0.43 with social activity restriction,
and r=0.40 with social adjustment) supported the convergent
validity of ABIS-R
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Author/Year
Study limitations
Participants came from only 2 facilities

Self-report could introduce bias as there is no control over the
response
Further aspects of validity and reliability should be explored
Although this is a satisfactory sample for this type of study, a
larger sample would be required
Relevance for
This tool could be used by occupational therapists to determine

the level of body image disturbance in patients with LL
amputation and consider how this may affect rehabilitation.
Level of evidence
Quality score
Reference
Gallagher P, Horgan O, Franchignoni F, Giordano A, MacLachlan

M (2007) Body image in people with lower limb amputation:
a Rasch Analysis of the Amputee Body Image Scale. American
Journal of Physical Medicine Rehabilitation, 86(3), 205215
Author/year
Gooday and Hunter (2004)
Study location
Edinburgh, UK
Study objectives
To study the factors contributing to falls among recent LLAs, and

to check whether there will be a reduction to the number of
falls during inpatient rehabilitation and to resulting injuries by
intervention
Design
P1 3-stage study. Retrospective, followed by prospective,

historical cohort study. Then a follow-up study conducted after
interventions
Participants
Stage 1: N=200 LLAs who had an accident during their inpatient

rehabilitation within 2 years
Stage 2: N=113 patients (mean age 69 years, range 3494 years)
admitted to the unit over a 15-month period
Stage 3: N=62 consecutive patients
Recruitment
20-bedded inpatient rehabilitation unit for amputees
Data collection/
Intervention
Stage 1: retrospective audit of incident forms carried out

Stage 2: prospective study undertaken. Comparison between
patients who had a fall or other accidents and patients who
did not was also undertaken to identify patients who were at
higher risk of falling. At this stage intervention was carried out,
aiming to reduce falls
Stage 3: patients studied using simple risk assessment sheet so
that interventions in stage 3 could be targeted at patients who
were at particularly high risk of falling and sustaining injury. All
measures apart from Hospital Anxiety and Depression (HAD)
were applied as per stage 2
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Author/year
Gooday and Hunter (2004)
Outcome measures
Outcome measures used at stage 2:

1. Mini-Mental State Examination
2. HAD score
3. Office of Population Censuses and Surveys (OPCS) measure of
disability
4. Specialist registrar in rehabilitation medicine working at
the ward collected additional information related to the
circumstances of the accident
5. Number of falls and other accidents and resulting injuries
Results
Audit at stage 1 showed that approximately a third of

admissions (32%) were complicated by an accident. Most
accidents were falls
Stage 2 showed that patients who fell were significantly
older than those who did not (p<0.0001). Patients who were
employed before admission were shown to be statistically
significantly less likely to have an accident (p=0.004)
Stage 3 showed there were 37 accidents in total, of which 35
were falls. Compared with the stage 2 study (using 2 analysis),
there was no reduction in the proportion of patients who had
a fall or other accident in stage 3, but significantly fewer falls
resulted in any injury (p=0.05)
Study limitations

Unclear research question; methods are not described very
clearly
The recruitment was done through only 1 unit
It is not always specified what statistical test has been used to
determine significant or non-significant outcomes
The authors talk about relationship, but they have used only
comparative tests
A regression analysis in each stage might have been more
suitable to identify predictors, rather than a comparison and
descriptive analysis
The sample size on stage 3 is small and so the absence of stump
injuries could have occurred by chance
Relevance for
This study suggests that although the interventions employed

did not reduce the proportion of patients who had falls or
other accidents, significantly fewer falls resulted in injuries. This
study could be relevant to occupational therapists who work
with patients at a high risk for falls in the rehabilitation phase,
particularly while transferring.
Level of evidence
III-3
Quality score
Reference
Gooday HML, Hunter J (2004) Preventing falls and stump

injuries in lower limb amputees during inpatient rehabilitation:
completion of the audit cycle. Clinical Rehabilitation, 18(4),
379390
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Author/year
Ham et al (1994)
Study location
UK
Study objectives
To ascertain functional recovery patterns of lower limb amputees
Design
P1 survey study
Participants
N=459
Data collection
Case note analysis using non-standardised structured

questionnaire over 12 weeks treated for a 12-month period
between October 1987 and September 1988
Results
Postoperatively (12 weeks) LLAs were able to move about the

bed, move from lying to sitting position and sit up unaided. This
was achieved by over 80% of the participants
Upper body dressing independently took 34 weeks, and lower
body dressing independently took 35 weeks
Study limitations
The design is not discussed in any specific detail

The validity and reliability of the nine functional activities used
on the form are not reported sufficiently
Other variables could have impacted upon the milestones.
Availability of rehabilitation professionals the type and amount
of therapy received are not discussed; therefore, the milestones
may not be accurate
The research is dependent upon physiotherapists completing
the forms accurately. There is no evidence that data were
verified for accuracy
Data for the whole of the study are not available
Research ethics are not discussed
Relevance for
The data from this study could be used to formulate an integrated

care pathway that records rehabilitation milestones. The
milestones could be useful for predicting length of stay to achieve
functional independence.
Level of evidence
Quality score
Reference
Ham R, de Trafford J, Van de Ven C (1994) Patterns of recovery for

lower limb amputation. Clinical Rehabilitation, 8(4),
320328
Author/year
Hanspal and Fisher (1991)
Study location
UK
Study objectives
To study the relation between the success of rehabilitation

and the intellectual state of elderly patients after amputation
Design
P1 correlation study
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Author/year
Participants
N=100 unilateral amputees (49 BK, 51 AK) aged 60 years who

had achieved maximum mobility and were attending the clinic
only for maintenance of the prosthesis
Recruitment
1 clinic
Data collection
Mobility achieved was identified through a complete clinical

examination
Outcome measures
Clifton assessment procedures for the elderly to assess

cognitive and psychomotor functions: 1 score for
orientation, 1 score for mental ability, 1 score for time taken,
1 score for errors, 1 score for psychomotor task and 1 total
score can be used by therapists and nurses without special
training
Results
Pearson correlation analysis showed that there was a highly

significant positive correlation between scores obtained on the
intellectual assessment and the mobility of elderly patients with
a prosthesis (r=0.82, p<0.01)
A total score on the cognitive assessment scale of at least 30
was associated with the ability to walk indoors and outdoors
in patients without medical factors limiting mobility. Only 4%
of all participants achieved this score and were unable to walk
outdoors. Only 2% of the participants could walk outdoors and
scored less than 30
A t-test showed that the level of amputation had no significant
effect on the variables under consideration
The time taken to complete the psychomotor task was related
to age (p<0.01)
Study limitations
No information on how recruitment was achieved or on

ethics
The recruitment was done through only 1 clinic
The psychometrics of the Clifton assessment are not reported
for this study
No information on who completed the study and their
relationships with the patients that might affect data
collection
At the conclusion, the authors talk about prediction of mobility.
In this case, a regression analysis should have been performed
instead of correlation analysis. If this had been done, the
contribution of each of the 5 factors to predict mobility could
have been evaluated
Relevance for
This study suggests that a patients score on the cognitive

assessment scale could facilitate the decision on whether a
prosthesis should be prescribed. It also suggests that predicting
the mobility allows a rehabilitation package to be planned
(including home adaptations, wheelchair provision and
training).
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Author/year
Level of evidence
Quality score
Reference
Hanspal RS, Fisher K (1991) Assessment of cognitive and

psychomotor function and rehabilitation of elderly people with
prostheses. British Medical Journal, 302(6782), 940
Author/Year
Study location
UK
Study objectives
To test the hypothesis that cognitive state would reliably

predict achieved mobility following standard limb fitting and
rehabilitation practices
To compare the results of this study with those of a previous
study with the same cohort
Design
Participants
N=32 patients of an original cohort of 50, mean age 66.4

years (range 5472 years); 20 of these had co-existing medical
complications affecting mobility, in contrast to those of the
previous study
Recruitment
Through the original cohort of a previous study
Data collection
All patients were tested by one of the authors at 24 weeks and

again at 814 months post-amputation when final mobility was
achieved. A complete clinical examination was carried out to help
grade the mobility achieved
Outcome measures
Clifton Assessment Procedures for the Elderly (CAPE) to assess

cognitive and psychomotor functions: 1 score for orientation,
1 score for mental ability, 1 score for time taken, 1 score for
errors, 1 score for psychomotor task and 1 total score possible
score 035 can be used by therapists and nurses without special
training
Results
Pearson correlation showed that the scores of the CAPE at first

assessment with those of the second assessment were highly
correlated (r=0.93, p<0.001)
The correlation between mobility grade achieved and the final
CAS scores was r=0.45 (p<0.01), whereas in the previous study it
was r=0.81
In the 12 patients who had no medical complications the
correlation was r=0.92 (p<0.001)
The results were compared with the previous study on
established patients
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Author/Year
Study limitations
The authors suggest that the CAS scores achieved on the first
and second assessments were compared by Pearson correlation,
whereas these were correlated
The authors suggest that since the correlation between
mobility and CAS (total scores) was r=0.45, then the intellectual
status accounts for about 20% of the explained variance in
mobility even when co-existing medical conditions affected it.
Such claims cannot be supported by correlation analysis, but
regression analysis would be needed
The same applies to the claims about the 12 patients who had
no medical conditions, for whom the authors suggest that
intellectual ability accounts for the 85% of mobility
Regression analysis would be more appropriate in identifying
predictors rather than doing simple correlation analysis
The authors do not explain why they conducted Pearson
correlations instead of Spearmans, since the mobility grades are
of an ordinal level
No ethical issues or consent are discussed
The authors do not explain the recruitment process
The assessments were done by the authors. If these were the
specialists in the clinic who were regularly treating the patients,
then the data collected might be biased
The psychometrics of the CAS, which is the main outcome
measure, are not presented
Small sample size
Relevance for
This study suggests that there is a highly significant positive

correlation between the cognitive state of elderly patients
and the mobility achieved with the prosthesis. Therefore, it could
be possible to use intellectual assessment in order to be aware
of possible expectations about a patients future mobility and
therefore make more informed intervention decisions.
Level of evidence
Quality score
Reference
Hanspal RS, Fisher K (1997) Prediction of achieved mobility

in prosthetic rehabilitation of the elderly using cognitive and
psychomotor assessment. International Journal of Rehabilitation
Research, 20(3), 315318
Author/Year
Hawamdeh et al (2008)
Study location
Jordan
Study objectives
To assess the prevalence of anxiety and depression among

Jordanian LLAs with different clinical characteristics and
sociodemographic data
Design
P1 survey
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Author/Year
Participants
N=56 patients with unilateral LL amputation (22 AK, 34 BK) with

mean duration 8.45.75 years
Recruitment
3 settings in Jordan
Data collection
Face-to-face interviews using questionnaires to assess

sociodemographic information and clinical data
Outcome measures
Level of depression and anxiety: Hospital Anxiety and

Depression Scale (HADS) possible total score 021 (07 is
considered normal)
Results
Prevalence of depressive and anxiety symptoms was 20% and

37%, respectively
More females than males had reactive depression and anxiety
symptoms
More traumatic amputees had depression and anxiety
compared with those who had their amputation because of
disease
More single patients and patients with no social support had
psychological symptoms
More BK amputees had depression compared with AK
amputees
More unemployed or patients with low income had
psychological symptoms
Study limitations
Recruitment process is not fully clarified

Reliance on self-reports
The authors suggest a negative relationship between length
of time since amputation and prevalence of psychological
abnormalities (anxiety or depression). However, this could not
be supported as there was no correlational analysis between
these variables. Instead, a comparison of percentages is implied
between patients with psychological abnormalities or not as
categorised by length of time since amputation
Small sample
Wide variety in age
Patients were not followed longitudinally
Subjects with surgical amputations may have associated
illnesses, which may contribute to their symptoms
Comparison between only 2 variables was carried out
separately, whereas other types of inferential statistics
controlling for the assessed factors could provide more
conclusive results
Relevance for
Occupational therapists as part of the multidisciplinary team

may work toward psychologically preparing patients before
amputation and contribute to their vocational rehabilitation
and sense of wellbeing to decrease anxiety and depression
levels.
Level of evidence
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Author/Year
Quality score
Reference
Hawamdeh ZM, Othman YS, Ibrahim AI (2008) Assessment of

anxiety and depression after lower limb amputation in Jordanian
patients. Neuropsychiatric Disease and Treatment, 4(3), 627633
Author/year
Study location
UK
Study objectives
To establish the prevalence of falls in patients with LL amputations

in a given 12-months period and to identify any factors which
contributed to those falls, as well as the effect of falls on their
quality of life
Design
P1 prospective survey
Participants
N=164 LLAs of all ages seen by the consultant (all of them agreed
to participate)
Recruitment
Through a subregional DSC providing prosthetic rehabilitation

by a clinical team consisting of a consultant, a prosthetist and a
physiotherapist
Data collection
Through structured questionnaires with LLAs completed by a

member of the team based on self-reports
Results
Data was analysed mostly by using descriptive statistics.

Comparisons between groups were carried out using 2 test,
MannWhitney U-test and 2-sample t-test
Falls among patients with amputations are prevalent (58% of
patients with unilateral amputations and 27% with bilateral
amputations)
There was no difference in the proportion reporting a fall
between AK and BK amputations in unilateral patients (2=3.7,
p=0.054)
48% of falls were reported as intrinsically related, 22% related
to environmental reasons, 12% related to the prosthesis and
18% related to more than 1 factor
88% of patients with AK amputations had their first fall while
wearing a prosthesis compared with 48% with BK amputation
25% of patients falling remembered being given instructions on
how to get up from a fall
Study limitations
Study carried out in only 1 setting

No information on how ethical approval was achieved or how
patients were invited to participate in the study
The reasons for falls were reported by patients (and not
investigated by the team)
Since the patients were interviewed by a member of their
intervention team, one might question the authenticity of their
reports
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Author/year
Study limitations
(cont.)
There is no clarification on whether the data characteristics

were appropriate for the use of these statistical tests
Generalisations are difficult since mostly descriptive statistics
were used
The results are indicative but not conclusive, because when
comparisons between groups were made there was no control
of other factors, such as group activity
Relevance for
This study suggests that therapists working in a multidisciplinary

team and LLAs need to be aware of factors leading to falls. In this
way, they would be able to achieve the reduction in incidence by
identifying preventative strategies. Therapists might be able to
intervene in environmental factors to prevent falls and provide
clear and documented instructions on how to get up from a fall.
Level of evidence
Quality score
Reference
Kulkarni J, Toole C, Hirons R, Wright S, Morris J (1996) Falls

in patients with lower limb amputations: prevalence and
contributing factors. Physiotherapy, 82(2), 130136
Author/Year
Lachmann (1993)
Study location
UK
Study objectives
To investigate reasons for amputation of LL in patients with

rheumatoid arthritis (RA)
Design
P3 comparative retrospective case studies
Participants
N=11 LLAs with RA and a control group
Data collection
Through medical records to ascertain the onset, course and drug

treatment of the disease
Cause of amputation, postoperative progress, limb fitting and
rehabilitation was recorded
Mobility scores were recorded using the mobility guide
framework devised by Hanspal et al (1991) for people with
amputations
Results
High incidence of complicated knee arthroplasty in RA

amputees
Walking training exacerbated symptoms of RA
Delayed stump healing occurred in 6 of the patients with RA
compared with 2 patients in the control group
Patients with RA had poor mobility compared with the control
group
Patients with RA valued being fitted with prostheses as it also
assisted with transfers and they attached importance to the
cosmetic effect of the prosthesis
8 patients with RA used an electric wheelchair compared with
none of the control group
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Author/Year
Lachmann (1993)
Study limitations
It is difficult to make comparisons with the control group

regarding issues about quality of life and prosthesis use as the
data are not available for the control group
The sample size is small
Relevance for
Therapists and patients need to ensure that rehabilitation and

training programmes are modified to take into account the
symptoms of RA. Provision of an indoor electric wheelchair is
important for personal independence for patients with RA.
Patients with RA valued a prosthesis to assist with transfers and
for their cosmetic effect.
Level of evidence
III-2
Quality score
Reference
Lachman SM (1993) The mobility outcome for amputees with

rheumatoid arthritis is poor. Journal of Rheumatology, 32(12),
10831088
Author/Year
Larner et al (2003)
Study location
UK
Study objectives
To determine whether psychological tests during admission to

rehabilitation ward predicts use of prostheses during the inpatient
rehabilitation programme
Design
Participants
N=43 LLAs (mean age 66.35 years)
Recruitment
Inpatient rehabilitation unit in the UK offering prosthetic

provision
Data collection
Participants were assessed using psychological measures
Outcome measures
1. Hospital and Depression Scale (HADs)

2. Recovery Locus Scale (RLOC)
3. Kendrick Object Learning Test (KOLT)
Results
31 patients did not learn how to use the prosthesis. Of these, 12

were either medically unsuitable or had tried and failed to learn
how to use a prosthesis
Logistic regression analysis showed that the KOLT correctly
predicted outcome in 70% of cases
Anxiety, depression and recovery locus of control were not
significant predictors of functional prosthetic use
Study limitations
It is unclear from the paper how professionals decisions were

recorded regarding a patients ability to use the prosthesis.
Moreover, it is unknown which professionals were asked to
record their decisions
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Author/Year
Larner et al (2003)
Study limitations
(cont.)
The sample size is small and it is unclear why the KOLT was
considered to be appropriate, especially in view of concerns
about the reliability and validity of this test
Relevance for
Occupational therapists may wish to consider whether

psychological tests such as the KOLT may support clinical decisionmaking regarding patients who may need additional support to
use prosthesis.
Level of evidence
Quality score
Reference
Larner S, van Ross E, Hale C (2003) Do psychological measures

predict the ability of lower limb amputees to learn how to use a
prosthesis? Clinical Rehabilitation, 17(5), 493498
Author/year
Legro et al (2001)
Study location
USA
Study objectives
To ascertain preferred recreational activities of people with LL

amputation
Design
P3 survey
Participants
N=92 people with LL amputation in the community (mean age 55

years).
Recruitment
Sample identified through 2 hospitals in Seattle, WA
Data collection
Questionnaire that included participants naming 2 favourite

recreational activities important to them, and stating how well
they perform the activity with or without prostheses
Results
Ability to perform an activity was judged much higher using a

prosthesis than not using a prosthesis
Activities that required high energy were more problematic to
perform
Participants aged 6083 years chose more moderate and
sedentary activities than those aged 2049 years
Amputees participated in a wide range of activities
Study limitations
The activities named by the participants could only be

generalised to the USA and to males (86% of respondents were
male)
The questionnaire was lengthy, and data were missing
Relevance for
When considering participation in social occupations,

occupational therapists need to take into account that people
aged 6083 years may participate in more sedentary activities than
those aged 1859 years.
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Author/year
Legro et al (2001)
Relevance for
(cont.)
LLAs participate in a variety of activities, and each person requires

an individual assessment of their needs. Occupational therapists
need to consider the impact level of the activity and prosthesis
use.
Level of evidence
Quality score
Reference
Legro MW, Reiber GE, Czerniecki JM, Sangeorzan J (2001)

Recreational activities of lower limb amputees with prostheses.
Journal of Rehabilitation Research and Development, 38(3),
319325
Author/year
Miller and Deathe (2004)
Study location
Canada
Study objectives
To determine whether balance confidence scores change

significantly over a 2-year period of time in a cohort of people
with LL amputation
To determine the longitudinal predictors of balance confidence
and to examine predictors of change in balance confidence
between baseline and follow-up
Design
P1 prospective longitudinal correlational study
Participants
N=A convenience sample of 245 community-living unilateral LLAs,

either BK or AK. Participants wore their prosthesis for at least 6
months on a daily basis before first data collection
Recruitment
Through 1 university clinic
Data collection
Through postal questionnaires to collect data at 2 time points

3 years apart
Demographic and amputation specific variables were
collected from the subjects charts and linked with survey
data
Outcome measures
1. Balance confidence: 16-item Activities-specific Balance

Confidence (ABC) scale (0100)
2. Social support: 6-item version of the Interpersonal Support
Evaluation List (ISEL) (4-point scale)
3. Disability status: Postal Barthel Index
4. Level of depressive symptomatology: Centre for Epidemiologic
Studies Depression Scale (CESD) (4-point Likert Scale)
5. Adaptations: Prosthetic Profile of Amputees (binary)
6. Fear of falling (yes/no)
7. Perceived health status (4 categories), medication, pain, falls:
patient reports
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Author/year
Miller and Deathe (2004)
Results
80% response rate

Difference between ABC summary scores at baseline and followup was not statistically significant (t(244)=0.418, p=0.68)
Being younger, being male, having good perceived health,
being able to ambulate without thinking (automatic walking)
and without the use of a mobility device, having fewer
symptoms of depression and not being afraid of falling were
all independently related to having higher balance confidence
(accounted for 55% of the variance in balance confidence). The
strongest predictors were mobility device use, followed by age
and fear of falling
Change in balance confidence between baseline and follow-up
was predicted by gender (improvement in scores for women)
and perceived health was very close to being significant
(p=0.05) (accounted for 15% of the variance)
Study limitations
Recruitment from only 1 university clinic

The reliability and validity of the used tools were not reported
for this specific study
Causality cannot be suggested as this was a correlational study
Reliance on self-reports for many variables
Relevance for
This study suggests that asking patients about fear of falling

would provide a clinician with a quick indicator of whether or
not the patient is experiencing reduced balance confidence. The
predictors identified are those to be considered by clinicians of
patients who are more likely to have either high or low levels of
balance confidence and therefore require additional treatment.
Balance confidence can be associated with further reduction in
function, which might be preventable or modifiable by using
appropriate strategies and interventions.
Level of evidence
Quality score
Reference
Miller WC, Deathe AB (2004) A prospective study examining

balance confidence among individuals with lower limb
amputation. Disability and Rehabilitation, 26(1415), 875881
Author/year
Miller et al (2004)
Study location
Canada
Study objectives
To examine the test-retest reliability and validity of the original

and modified version of the Frenchay Activities Index (FAI) in
individuals with LL amputation
Design
P1 outcome measure development 2 weeks test-retest design
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Author/year
Miller et al (2004)
Participants
N=84 individuals, primarily men (78.6%), mean age 56.5 years,

with a unilateral transtibial (71.4%) or transfemoral amputation
related to traumatic (59.5%) or vascular causes. Inclusion criteria:
age 19 years, unilateral transtibial/transfemoral due to trauma
or vascular insufficiency, having a prosthesis for at least 6 months,
medically and prosthetically stable
Recruitment
Through a rehabilitation amputee programme between June and

December 2001
Data collection
All participants completed a questionnaire containing the FAI

and other scales, the 2-minute walk, and timed up and go tests
during a regularly scheduled clinic visit
55 participants completed a second FAI posted to them 2 weeks
later
29 participants completed the second FAI upon return for
testing related to another project
Outcome measures
1. FAI: 15-item self-report measure to assess the frequency

of participation in extended ADLs. 3 further items added by
the authors to represent the LLA population (18 items in
total)
2. Activity-specific Balance Confidence Scale: rates balance
confidence between 0% and 100% on 16 mobility activities
3. Prosthetic Evaluation Questionnaire-Mobility Scale 13-item
self-report scale to assess perceived potential for mobility over
past 4 weeks (0 cannot do activity; 10 no problem)
4. 2-minute walk: measures distance an individual can walk at
usual pace in 2 minutes
5. Timed up and go test: the time taken for an individual to stand
from sitting, walk 3 metres, turn, walk back to the chair and sit
down is recorded
6. Walking device aid use
Results
Relative reliability for the FAI (intraclass correlation coefficient

(ICC)=0.79) and FAI-18 (ICC=0.78) was satisfactory
Hypothesised relationships (p=0.001) between both FAI versions
and the Activity-specific Balance Confidence Scale, Prosthetic
Evaluation Questionnaire-Mobility Scale, 2-minute walk and
timed up and go test were observed
Negative correlation between FAI and timed up and go test
(r=0.49), whereas all other tests had a positive correlation with
FAI
Significant mean differences evident for amputation cause, use
of mobility device, median age and median number of years as
an amputee
Neither version distinguished between amputee level or gender
groups
Study limitations
Validity and reliability of outcome measures used could have

been provided in more detail
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Author/year
Miller et al (2004)
Study limitations
(cont.)
More information is needed to justify the need for adding 3

items to the FAI
Half of the sample completed reports at the clinic; the
others were sent the reports by post this could introduce bias
Construct/content validity not clarified
It is not clarified whether the data meet the assumptions for the
use of parametric tests
Recruitment through only 1 setting
Relevance for
This is an outcome measure that in its original format could be

used to determine the level of participation in extended ADL
following rehabilitation and the prosthetic phase.
Level of evidence
Quality score
Reference
Miller WC, Deathe AB, Harris J (2004) Measurement properties of

the Frenchay Activities Index among individuals with a lower limb
amputation. Clinical Rehabilitation, 18(4), 414422
Author/Year
Miller et al (2001)
Study location
Canada
Study objectives
To determine in amputee patients whether having fallen in

the past 12 months, fear of falling and balance confidence are
important factors with respect to 3 indicators of quality of life:
mobility capability, mobility performance, and participation in
social activities
Design
P1 population-based survey and chart review with correlation

elements
Participants
N=435 community living unilateral LLAs who had their prosthesis

for at least 6 months and wore it on a daily basis, and who
attended 1 of 2 outpatient amputee programmes in 1998
Recruitment
2 university affiliated outpatient amputee programmes in southwestern Ontario
Data collection
Through postal questionnaires and chart reviews
Outcome measures
1. Postal survey questionnaire to collect data related to mobility

device use, automatism, problems with the unimpaired leg,
and problems with the residual limb and prosthesis, perceived
health status, co-morbidity, medication, pain and alcoholic
intake
2. Modified 6-item version of Interpersonal Support Evaluation
list (ISEL) to determine social support: 4-point scale, total scores
range from 0 to 18 (stronger instrumental and emotional
support)
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Author/Year
Miller et al (2001)
Outcome measures
(cont.)
3. Modified version of Barthel Index to measure activity of daily

living, including 2 items on independence with donning and
doffing the prosthesis
4. Center for Epidemiologic Studies-Depression Scale (CES-D) to
assess depression: 4-point scale, total scores range from 0 to 60
(greater level of distress)
5. Single-question items tapping adaptation to amputation
and to the prosthesis taken from the Prosthetic Profile of
Amputees: 5-point scale
6. Falling in the past 12 months and fear of falling recorded as
nominal data
7. 16-item Activities-Specific Balance Confidence (ABC)
Scale to determine balance confidence: scale from 0% to
100%
8. 13-item self-report Prosthetic Evaluation Questionnaire
mobility subscale (PEQ-MS) to evaluate the perceived mobility
capability in the past 4 weeks: 11-point scale, total scores
range from 0 to 10 (no problem)
9. 6-item self-report Houghton Scale to assess prosthetic
use
10. Frenchay Activities Index (FAI) to measure frequency
of participation in activities, 18 items (Cronbachs
alpha=0.87)
Results
77% response rate

Post hoc analysis revealed no difference between responders
and non-responders based on age, gender, years since
amputation, cause or level of amputation
Falling experiences in the past 12 months were not significantly
related with any outcome
Fear of falling was important in univariate relationships in all
3 outcomes, but not when balance confidence was included in
multivariable modelling
Balance confidence was statistically significant with each of
the outcomes and remained significant with inclusion of the
covariates
Statistical interaction (balance confidence automatism;
balance confidence medication count) in modelling
mobility capability and in modelling mobility performance
(balance confidence pain + balance confidence amputation
level)
Final models accounted for 70%, 60% and 55% of the variation
in mobility capability, mobility performance and social activity,
respectively
Study limitations
Recruitment done through the records of only 2 hospitals

Participants had to complete lots of assessments, which might
have affected the quality of the responses
The data are determined from self-reports, which might be
limited by recall bias, which might affect the accuracy of the
results
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Author/Year
Miller et al (2001)
Study limitations
(cont.)
By sampling only individuals who wore their prosthesis

daily, generalisability is affected. By eliminating those who
did not wear the prostheses daily, there is a danger of
underrepresenting individuals who had more falls, a greater
fear of falling, a lower balance confidence score, and perhaps
lower mobility capability and performance and social activity
scores
One might argue that by measuring mobility performance using
the Houghton Scale, one would measure performance related
to use and not to capability or skills
Causality cannot be established with this cross-sectional study,
and further prospective studies would be needed
Relevance for
This study suggests that balance confidence was the only factor
associated with mobility capability and performance and social
activity in the final adjusted models. Clinicians and researchers
could consider this variable in the rehabilitation of amputee
patients.
Level of evidence
Quality score
Reference
Miller WC, Deathe AB, Speechley M, Koval J (2001) The influence

of falling, fear of falling, and balance confidence on prosthetic
mobility and social activity among individuals with a lower
extremity amputation. Archives of Physical Medicine and
Author/year
Study location
UK
Study objectives
To assess the responsiveness to change in overall function and

specific areas of function between admission and discharge and
between discharge and follow-up, and concurrent and predictive
validity of 3 established outcome measures in relation to early
LL vascular amputee rehabilitation: Functional Independence
Measure (FIM), Office of Population Censuses and Surveys Scale
(OPCS) and Amputee Activity Score (AAS)
Design
P1 prospective observational study with comparative and

correlational elements
Participants
N=34 consecutive patients (median age 67 years, range 4485

years) admitted for rehabilitation following LL amputation for
vascular disease
Recruitment
1 inpatient rehabilitation unit
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Author/year
Data collection
An occupational therapist and doctor in training completed the

assessments
FIM: for the inpatient stage the scores were based on specialists
observation; at follow-up, the scores were based on patients or
their carers testimonies
Locomotor Index (LI): for 23 patients, scores were retrieved from
the Scottish Physiotherapy Amputee Research Group
Differences between total scores and between subsection scores
at different times were analysed using the Wilcoxon sign rank
test to study the responsiveness to change
Comparisons of the total scores were made with each other, and
the total scores for each measure were compared with other
outcomes to assess validity
Outcome measures
1. FIM: to assess burden of care (amount of support a person

requires) in inpatient rehabilitation
2. OPCS: to assess disability (functional capacity) in the community
3. AAS: to assess disability (actual level of activity a person
achieves) for outpatient amputees with a prosthetic limb
4. Locomotor Index: recommended for amputee rehabilitation
5. Duration of stay
6. Discharge placement
Results
34 of 51 patients completed all measures

All measures showed significant change between admission and
discharge (p<0.00001)
Only the AAS showed significant change between discharge and
follow-up (p<0.0001)
Subsection analysis revealed expected improvements in mobility
between discharge and follow-up (AAS)
During the inpatient stage, progress was detected in certain
activities of daily living (bathing, dressing lower, toileting) in
the FIM and OPCS (personal care, intellectual functioning)
The measures correlated with each other at the 3 assessment
periods (p<0.001) using the Kendal coefficient of concordance.
There was significant correlation of the 3 measures with the LI
(p<0.01)
All of the measures admission scores correlated with duration of
stay (OPCS p<0.005, AAS p<0.006, FIM p<0.009), and admission
OPCS also correlated with discharge placement (p<0.036)
Study limitations
Recruitment achieved through only 1 inpatient rehabilitation

unit
It is not clarified how the participants were approached to
participate in the study, or the relationship of the assessors with
the patients
For the LI, scores for 23 patients were based on previous
measurements from a different research group, which may have
caused bias in measurements
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Author/year
Study limitations
(cont.)
Small sample size

Reliability measures were not assessed for any measure for this
specific study
Relevance for
This study suggests that the FIM and the OPCS are suitable for
the inpatient stage and are fairly straightforward to use. The AAS
would appear to be the best measure at time of discharge and
thereafter, but its layout makes it more awkward to use at time of
admission.
Level of evidence
Quality score
Reference
Panesar BS, Morrison P, Hunter J (2001) A comparison of three

measures of progress in early lower limb amputee rehabilitation.
Clinical Rehabilitation, 15(2), 157171
Author/year
Pauley et al (2006)
Study location
Canada
Study objectives
To identify risk factors for falling and fall-related injury among a

group of inpatients undergoing rehabilitation after major lower
limb amputation
Design
P1 retrospective cohort study without control group
Participants
N=1267 participants, all inpatient rehabilitation patients with an

admitting diagnosis of amputation
Recruitment
Through 1 centre
Data collection
Patients were categorised into 3 groups: (1) those who did not
sustain a fall during their rehabilitation stay (non-fallers), (2)
those who fell once (single fallers) and (3) those who fell 2
times (multiple fallers)
Review of patient clinical records and electronic databases
to gather data on demographics, length of stay, nature of
amputation, daily and as-needed medication use, time/location
of falls, types of injuries sustained, co-morbidities, scores on the
Houghton scale of prosthetic use, scores on FIM
Outcome measures
1. Houghton scale of prosthetic use

2. FIM
Results
260 (20.5%) of 1267 patients fell at least once

There were a total of 374 falls, 67 (17.9%) of which resulted in
1 injuries
Of the 374 falls, 29% occurred during transfers without
assistance typically between the wheelchair and bed or
toilet, 20.3% from the sitting position, 9.9% from standing,
8.3% from leaning/reaching, 3.7% during transfers with
assistance, 3.7% during transfers walking, and 1.6% other
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Author/year
Pauley et al (2006)
Results (cont.)
Falls most commonly occurred in the patients room (63%),

followed by the washroom (24.1%), hallway (3.4%) and
rehabilitation area (2.9%)
Adjusted odds ratio (OR) and 95% confidence intervals (CI)
were calculated for factors significantly associated with falling.
These factors included age 71 years (OR=1.40, 95% CI=1.02
1.89), length of stay 2235 days (OR=2.97, 95% CI=1.147.72)
or >5 weeks (OR=6.07, 95% CI=2.3415.71), 4 co-morbidities
(OR=1.93, 95% CI=1.093.41), cognitive impairment (OR=1.68,
95% CI=1.023.21), use of benzodiazepines (OR=2.22, 95%
CI=1.243.96) and use of opiates (OR=5.76, 95% CI=3.2910.09)
Factors significantly associated with fall-related injuries included
bilateral amputation (OR=3.68, 95% CI=1.499.05) and falls
during the day shift (OR=2.63, 95%
CI=1.245.57)
Study limitations
Only 1 setting used for data collection

Retrospective collection of data has a potential bias over
missing data and accuracy on data collection
The study suggests a link between factors and falls, but does
not prove causality
The study lacks information on ambulatory frequency and
capacity of patients throughout their rehabilitation stay.
Looking at falls without considering functional ability may be
misleading
The author does not present psychometrics of the assessment
tools used
No use of control group
No information on how the measurement/data collection was
initially done
Relevance for
This study suggests that 1 in 5 patients with lower limb

amputation is likely to experience at least 1 fall during
inpatient rehabilitation, with 18% sustaining an injury. This study
is of relevance to occupational therapy, as it indicates that further
research should be conducted to develop appropriate intervention
strategies or environmental adaptations to minimise risk of falling
during inpatient rehabilitation.
Level of evidence
Quality score
Reference
Pauley T, Devlin M, Heslin K (2006) Falls sustained during

inpatient rehabilitation after lower limb amputation: prevalence
and predictors. American Journal of Physical Medicine and
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Author/year
Price and Fisher (2002)
Study location
UK
Study objectives
To explore the nature of problems presented spontaneously to

the counsellor.
To evaluate the effect counselling offered in the first few weeks
after amputation
Design
P3 survey (2 studies reported)
Participants
N=133 patients overall who had at least 1 counselling session

Study 1: N=100 patients who raised emotional problems
during the counselling session within 2 years postamputation; 58 men, 42 women, mean age 56.5 years (range
1793 years)
Study 2: N=122 of 133 valid responses from participants for
postal questionnaire 1, of whom 58 participants also responded
in postal questionnaire 2 (44 males, 14 females, mean age 64
years, range 2391 years, 6 had lost 1 arm, 49 had lost 1 leg, and
3 had lost 2 legs)
Recruitment
Through 1 centre
Data collection
Study 1: analysis of the counselling records to assess which

problems were most frequently reported, categorised according
to main subject headings
Study 2: first round of postal questionnaires to all patients.
Second round of postal questionnaires to those who had
responded effectively in round 1
Between rounds 1 and 2, a counselling session was offered to
participants
18 (31%) of these patients elected to have counselling; their
follow-up responses were compared with those who declined
counselling
Results
Descriptive statistics used to analyse data

Issues raised spontaneously by 100 patients showed that the
main emotional problems were depression
Patients who had been counselled were less worried about
performing household tasks and housing matters than they had
been at first
Patients who were not counselled expressed greater concern
about these issues at a later stage
All patients at the follow-up stage expressed greater concern
about employment and their prosthesis
Depression, body image and anger showed an increase in both
groups: the increase for the counselled patients was larger for
depression and body image and smaller for anger than those
who were not counselled
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Author/year
Price and Fisher (2002)
Study limitations
The authors do not explain in detail how the data were

extracted from the counselling notes or, more importantly, how
the data from the surveys were analysed and formulated
Comparisons are difficult as little information is given about the
patients demographics, the length of the counselling sessions
and whether the patients who refused counselling had input
from other professionals
Relevance for
The study highlights the need to manage depression and issues

around body image with amputees. It shows that occupational
therapists need to collaborate with counsellors and to ensure that
patients receive ongoing rehabilitation to reach their own goals
within activities of daily living and work.
Level of evidence
Quality score
Reference
Price EM, Fisher K (2002) How does counselling help people

with amputation? Journal of Prosthetics and Orthotics, 14(3),
102106
Author/year
Singh et al (2007)
Study location
UK
Study objectives
To ascertain the course of depressive and anxiety symptoms

shortly after LL amputation after a period of inpatient
rehabilitation
Design
P1 case series pre-test/post-test study
Participants
N=105 successive admissions over a 1-year period with unilateral

or bilateral amputation secondary to peripheral vascular disease
and/or diabetes mellitus, trauma or malignancy; mean age 62.9
years
Recruitment
Inpatients admitted to a rehabilitation ward after LL

amputation
Intervention
A period of rehabilitation teaching new skills and improving

patient independence
Outcome measures
1. Hospital Anxiety and Depression Scale (HADS) on admission and

discharge. Self-report measure; score >8 identifies significant
symptoms
2. Data were also collected on time from operation to admission,
time to limb-fitting, length of stay, gender, age, co-morbidities
and social details
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Author/year
Singh et al (2007)
Results
At admission, 28 (26.7%) and 26 (24.8%) patients had symptoms

of depression and anxiety, respectively. This dropped to 4 (3.8%)
and 5 (4.8%), respectively, by time of discharge, a mean of 54.3
days later. t-test analysis showed that these reductions were
statistically significant (depression, p<0.001; anxiety, p<0.03)
There was statistically significant correlation between patients
with symptoms of both depression and anxiety (p<0.001)
t-test analysis showed that patient stay was longer in those with
symptoms (depression p<0.03, anxiety
p<0.001)
Pearsons correlation showed that there was no association with
level of amputation, success of limb-fitting, age or gender
Pearsons correlation analysis showed that depressive symptoms
were associated with presence of other medical conditions
(p<0.01) and anxiety scores with living in isolation (p<0.05)
Study limitations
HADS is a self-reporting measure, which might result in biased

results
There is no clear information on how data were collected,
who and how recruitment was achieved, or the rehabilitation
programme
The authors did not clarify why they used Pearsons correlation
instead of Spearmans test for checking associations among
variables
Recruitment was done through 1 inpatient unit in the UK,
whereas most amputee rehabilitation units in the UK are
outpatient-based
Levels of anxiety and depression were checked again at
discharge, which is a period that may be falsely reassuring to
patients who gain confidence and expectations that will be
drastically altered on discharge home; therefore, follow-up
measurements should be checked
Relevance for
This study suggests that levels of both depression and anxiety

resolve rapidly. It is possible that a period of rehabilitation
teaching new skills and improving patient independence and
mobility may modify the previous bleak outlook of amputees. This
finding may be useful in the rehabilitation of the most distressed
amputees.
Level of evidence
IV
Quality score
Reference
Singh R, Hunter J, Philip A (2007) The rapid resolution of

depression and anxiety symptoms after lower limb amputation.
Clinical Rehabilitation, 21(8), 754759
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Author/year
White (1992)
Study location
UK
Study objectives
To investigate the supply of wheelchair stump boards by the

Disablement Services Authority (DSA) and their use by therapists
and patients with amputation
Design
P3 3-part survey
Participants
Part 1: N=14 regional managers (return rate 86%) of DSA

Part 2: N=30 (return rate 86%) head occupational therapists
Part 3: N=12 older adult (return rate 100%) amputees
Data collection
Part 1: letters to regional managers of DSA to supply

information on policies and supply of stump boards
Part 2: postal questionnaires to head occupational therapists
about stump board use
Part 3: postal questionnaires to older adult amputees regarding
stump board use
Results
Highlights the importance of early supply of Kings stump

board
All therapists used stump boards with patients having BK
amputations, and 50% of therapists used them with TK
amputations
Stump boards were prescribed for the prevention of
contractures and the control of oedema. Comfort and
protection of stump were also considered to be important
factors
Kings mark II most commonly used. However, there are many
disadvantages: the board was too short to support belowknee stumps; when swung to the side for transfers, the board
may obscure the brake lever; the board cannot be tilted to
accommodate flexion contractures
No reported problems from older adults regarding problems
with transfers using Kings board. Older adults perceived
that using a stump board had increased their comfort in a
wheelchair, offered protection to the stump and encouraged
them to accept their amputation
Organisational issues were identified
Study limitations
Sample size, particularly of older adults and therapists, is small,

which impacts upon the trustworthiness of the research
findings
Descriptive statistics only used. Percentages are not always
given from findings
The methods are not clearly described and not enough detail is
given about the patient group or the postal surveys
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Author/year
White (1992)
Relevance for
Patients reported positive benefits about using a stump board.

Therapists and patients perceived that stump boards are useful
for protecting the stump and for comfort. Therapists prescribed
stump boards for BK amputations. Therapists prescribed stump
boards to prevent contractures and the control of oedema
Kings mark II stump board was perceived to have many
advantages, but also some negative perceptions were reported
regarding its design.
Level of evidence
Quality score
Reference
White E (1992) Wheelchair stump boards and their use with lower
limb amputees. British Journal of Occupational Therapy, 55(5),
174178
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Appendix 6: Stakeholders
Associate Parliamentary Limb Loss Group
British Association of Chartered Physiotherapists in Amputee Rehabilitation
British Association of Prosthetists and Orthotists
British Association of Rehabilitation Medicine
Diabetes Association
Douglas Bader Foundation
emPower The Charities Consortium of Users of Prostheses, Orthoses, Wheelchairs,
Electronic Assistive Technology and Rehabilitation Services
International Society of Orthotics and Prosthetics, UK
Limbless Association
Meningitis Trust
National Amputee Nurses
National Association for Amputee Rehabilitation Counsellors
Peggy & Friends
Peer reviewers
Dr Shelley Crawford, Lead Occupational Therapist, Belfast Health and Social Services
Trust
Dr Avril Drummond, Associate Professor and Reader in Rehabilitation Research; and
Research Occupational Therapist, University of Nottingham
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Stakeholder and peer reviewer consultation feedback form

Document title: Evidence-based guidelines for occupational therapy with people who have
had lower limb amputation.
Consultation date:
Name
Work location, e.g. Somewhere
General Hospital, UK
Role
Email
Preferred telephone number
Preferred time of day to be
contacted if needed
1. Is the purpose and use of the evidence-based document adequately explained?
2. Would a new practitioner be able to pick up the document and know what it was for?
3. Is the language used accessible and user-friendly?
4. Are there any sections that are unclear or difficult to understand?
5. Is the text inclusive of all people who may use it, e.g. students, practitioners, educators,
researchers?
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6. Is the text generally applicable to your field of practice/your location?
7. Is the text/terminology sensitive in terms of gender, race and culture etc?
8. Do you agree with the definitions given under the glossary?
9. Are there any other words that you think should be defined in the glossary?
10. Where possible we have cross-referenced other potentially useful documents. Is this
helpful?
11. If you have any other comments or suggestions, please take the opportunity to make
them here (continue on a separate sheet if necessary).
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Assistive device
Device that assists a person to perform a

particular task, for example aids, adaptations
and equipment such as crutches, wheelchairs
and chair-raisers
Bilateral
Two-sided, for example both legs involved
Body image
A persons perception of their physical

appearance, or the interpretation of the body
by the brain
Doffing/doff
Removing the prosthesis
Donning/don
Putting on the prosthesis
Inter-rater reliability
Extent to which a measure produces consistent

results across different raters and over time
Liner
Covers the residual limb; used as a method of

suspension
Literature search
Detailed, organised, step-by-step search for all

literature available on a topic
Literature review
Summary of previous research on a topic (found

from the literature search)
Methodology
Procedures carried out in the collection and

analysis of the data
Outcome measure
Determination and evaluation of the results of

a process, and their comparison with the
intended results; for example, the measure of
change from before intervention to after
intervention
Prosthesis
Artificial replacement of a body part, in this

case the leg
Qualitative research
Cover term for research originating from

psychology, sociology and philosophy;
concerned with how people come to know the
world in which they live
Quantitative research
Research technique that collects numerical

information; concerned with precise
measurement, replicability, prediction and
control
Reliability
Extent to which an instrument consistently

measures what it is designed to measure
Research
Systematic process of investigation with the

purpose of contributing to the body of
knowledge that shapes and guides practice
Residual limb/residuum/stump
Remaining part of the amputated limb
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Socket
Component of the prosthesis containing the

residual limb
Suspension
Component of the prosthesis attaching it to the

body
Through-knee amputation
Amputation through the knee joint
Transfemoral/above-knee amputation
Amputation through the femur bone
Transtibial/below-knee amputation
Amputation through the tibia bone
Unilateral
One-sided, for example one leg involved
Validity
Extent to which an instrument accurately

measures what it is designed to measure
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RISK MANAGEMENT (2nd edn).indd iv
17/11/2010 14:46
Occupational therapy with people

who have had lower limb amputations

limb amputations
This publication is an evidence-based resource to support
occupational therapists working with adults with acquired unilateral
or bilateral lower limb amputation. It provides best practice guidance
for those occupational therapists currently working in this specialism,
as well as offering a useful reference document for students and
newly qualified occupational therapists. It can also be used to inform
service users, carers and other professionals working with people
with lower limb amputation about the roles and responsibilities of the
occupational therapist in this clinical area.
Available
for Download
Available
for Download
ISBN 978-1-905944-25-5
Available
for Download
Available
for Download
Download for
BAOT members
www.COT.org.uk
Tel: 020 7357 6480 Fax: 020 7450 2299
Download for
BAOT members
2010 College of Occupational Therapists Ltd. A registered

charity in England and Wales (No. 275119) and in Scotland
(No. SCO39573) and a company registered in England (No. 1347374)
Download for
9 781905 9 4 4 2 5 5
Specialist Section
Trauma
and
Orthopaedics
Specialist Section
Trauma
and
Orthopaedics

Occupational Therapy & Lower Limb Amputee

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Occupational Therapy & Lower Limb Amputee

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Occupational therapy with people

who have had lower limb amputations

Occupational therapy with

College of Occupational Therapists

2010 College of Occupational Therapists Ltd. A registered

Front cover photograph Mike Prior

About the publisher

Occupational therapy with

First published in 2011

Summary of evidence-based recommendations

Evidence-based review and evidence-based recommendations

Appendix 1: Guideline development group

College of Occupational Therapists

LOWER LIMB.indd iii

College of Occupational Therapists

1.1 The national population

1.3 The development process

1.4 Aims of the evidence-based guidelines

1.5 Overview of the evidence-based guidelines document

College of Occupational Therapists

2.1 Evidence-based guidelines question

2.2 Literature search

2.3 Literature search findings

2.4 Critical appraisal of articles

Methodology for appraising the evidence

College of Occupational Therapists

Therefore, in order to produce evidence-based markers for occupational therapy with

environment, psychology, prosthetic use, assessment tools and outcome measures,

2.5 Research priorities

2.6 Peer reviewers and stakeholders

College of Occupational Therapists

Evidence-based recommendation for occupational

1. Occupational therapists need to adhere to key

2. It is recommended that stump boards are provided

3. Indoor electric wheelchairs should be provided for

V/4, V/6, III3/4, V/8, V/6,

4. Occupational therapists need to identify falls risk

5. Frequency of occupational therapy sessions along

1. Occupational therapy with older adults who have

1. Occupational therapists need to monitor distress for

2. Occupational therapists need to assess for anxiety

3. Where appropriate, referrals should be made for

Summary of evidence-based recommendations

Evidence-based recommendation for occupational

V/3, V/3, V/5

4. Occupational therapists should consider the

1. Occupational therapists need to be aware of

2. Occupational therapists need to ascertain reasons

3. Older adults with above-knee or through-knee

1. Occupational therapists should use the Amputee

2. Occupational therapists should use the Frenchay

3. Occupational therapists should use the Patient

4. Occupational therapists should use the Trinity

5. Occupational therapists should use TAPES to

6. Occupational therapists should use the Amputee

College of Occupational Therapists

Summary of evidence-based recommendations

Evidence-based recommendation for occupational

7. Occupational therapists should use the Office of