Integrated Care Pathway: Amputee Care
Stream of Care: Frail Elderly/Medically Complex
Patient Population/Condition: Lower Extremity Amputation
Best Practice &
Rehabilitative
Source of
Desired Outcome
Care Setting
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
PRE-OP
I. Communication/collaboration
amongst health care providers
for patients at risk for/requiring
amputation:
a) Surgery
b) Specialized Amputee
Teams
c) Diabetic care
d) Wound care
e) Primary Care
When medically possible preoperative consultation with the
Specialized Amputee Team
(SAT) occurs allowing for:
 Clinical advice from the SAT
about the prognosis for
future prosthetic use which
may assist in decision
making in terms of level of
amputation.
 Recommendations for
preoperative intervention: ie
PT exercise prescription,
CCAC home assessment.
Patient education: Each new
amputee given a post op
information brochure.
Evidence supporting
pre-operative
assessment by the
SAT. 1,2,3,4,5,6
Evidence supporting
the benefits of
patients having
comprehensive
information
regarding the course
of care they can
anticipate. 1,3,4,15
 # Of pre-op
consultations
linked to pre-op
intervention to
maximize fitness,
level of
amputation, post
op time to
prosthetic fitting,
achievement of
functional
prosthetic use.
When possible patients
at high risk for
amputation/ scheduled
for amputation receive
pre-op assessment with
the appropriate SAT.

100 % of new amputee
receive post-op
brochure.
# of new amps
seen in SAT
reporting having
received
information.
Pre-operative
consultation between
surgeons and the
SAT’s is rare.
If not medically stable
enough to attend SAT
consultation between
surgeon and the SAT
(or individual team
members) can be
arranged.
Patients assessed in
the SAT post
amputation report
frustration at the lack
of information they
received post
operatively.
Information given is
not done so in a
structured or
consistent way.
i) Dysvascular patients: when it is identified that
amputation may be/is required a referral to
the most appropriate Specialized Amputee
Team (SAT) (Prosthetic and Orthotic
Clinic, Grand River Hospital, Amputee
Clinic at St. Joseph’s Health Centre) may
be initiates. See referral process.
ii) Elective amputation (may be related to a
traumatic orthopedic injury, congenital
impairment, cancer) patients are referred to
the amputee team prior to their surgery for
initial assessment, consultation and
education.
Appendix A: Referral Process
Appendix B: Referral Forms
(i) GRH Prosthetic and Orthotic Clinic
(ii)
SJHCG Amputee Clinic
Once identified as requiring amputation
patients/families are provided with consistent,
written information identifying possible next
steps they can anticipate.
Appendix C: Amputee Care Brochure
1
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
II. Preventative approach to
patient at high risk of lower
extremity skin breakdown.
Evidence supporting
methods to off-load
difficult wounds. 9
Communication and consultation
between the P&O Clinic /SAT’s
and the Waterloo Wellington
Regional Diabetes Coordination
Centre (WWRDCC):
- the SAT initiates referral
to the WWRDCC if this
has not already been
done.
- The WWRDCC refers
cases where diabetic
orthotics/bracing is
required to the Prosthetic
and Orthotic Clinic.
Evidence supporting
a multidisciplinary
approach for the
complex medical
lower extremity
amputee.
1,2,4,5,6,7,
13,15,20, 34



# referrals from
SAT to
WWRDCC
# of off-loading
devices
prescribed vs
dispensed
monitor reasons
that devices not
dispensed (often
is related to
patient not
having
ability/willingnes
s to pay).


Patients who may
benefit from
assessment for offloading devices,
diabetic orthotics are
offered referral to
certified foot care
providers (certified
orthotist (including
via P&O clinic,
chiropody, podiatry,
specialized nursing).
Patients with skin
breakdown are
referred for best
practice wound care
via CCAC.
Patients with lower
extremity ulceration
are referred to the
Prosthetic and
Orthotic Clinic at
Freeport regarding offloading devices
primarily as inpatients
at the Freeport site.
Community referrals
occur, but data
regarding the source
of this referral,
frequency of referral is
not currently
monitored. Referral to
either CCAC or the
Amputee clinics preamputation is rare.
Communication and consultation
between the SAT’s and wound
care services in the region: The
SAT contacts the CCAC case
manager to inform them of the
SAT assessment.


# referrals to
P&O clinic via
WWRDCC
# interventions
that occur as a
result,
Evidence of increased
communication between
the SAT’s, diabetic and
wound care services in
the region.
The SAT’s and
diabetic services have
not had substantially
robust relationship
and knowledge of
each other’s services.

Patients identified as high risk for skin
breakdown leading to ulceration and
potential amputation are provided with
information regarding foot care providers
(available via :
http://www.waterloowellingtondiabetes.ca/fo
ot-care.htm)

Patients may be referred to the Prosthetic
and Orthotic clinic for assessment regarding
offloading devices. Patients may be
identified by: family doctors, family health
care teams, primary care clinics, diabetic
clinics, orthopedic clinics, ED, renal
program.

Patients with skin breakdown seen in
Prosthetic and Orthotic Clinic who are not
already receiving wound care are referred to
CCAC for wound assessment and care.

The physician in the Prosthetic and Orthotic
Clinic refers for: special testing (ie. vascular
studies, bone scan ) as indicated ; specialist
consultation (vascular, orthopedics) as
indicated.
Patients identified at high risk for LE
ulceration requiring diabetic orthotics or offloading devices referred to the P&O clinic
via the WWRDCC referral form.
Longstanding amputees identified in the
diabetic clinics as having skin breakdown,


2
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)



III. Maximization of the fitness
level of patients at risk for
amputation. Evidence indicates
that pre-operative condition is a
significant predictor of postamputation potential for
successful prosthetic use.
a) Prevention of contracture
formation; in the
transfemoral amputee
avoiding hip flexion and
abduction contractures. In
the transtibial amputee
avoiding hip flexion and
especially, knee flexion
contractures.
b) Activity tolerance/endurance
Evidence of
predictors of
successful
prosthetic use:
2,3,6,8,10,11,12,13,
14,33



incidence of
wound healing/
prevention with
treatment
time to healing
of established
wounds
incidence of
conversion to
amputation.
Referral
frequency and
sources.
Lower extremity
ROM and
strength (pre
and post op if
able)
Timed arm
ergometry
comfort or gait issues with their prosthesis,
or breakdown risk in their remaining limb are
referred to the SAT with which they have
been previously affiliated (Prosthetic and
Orthotic Clinic at Grand River Hospital, the
Amputee Clinic at St. Joseph’s Health
Centre).
PT referral to the
outpatient program
closest to patient for
assessment:
identification of
ROM/strength/enduranc
e impairments.
Referral to CCAC if
patient is not able to
access outpatients.
Referral to either
CCAC or the Amputee
clinics pre-amputation
is rare.

Patients identified as high risk or requiring
amputation receive PT assessment,
intervention and recommendations
regarding exercise activities to maximize
fitness in preparation for potential
amputation.
 PT referral via CCAC, Geriatric Rehab
services or the SAT (to assist with
recommendations)
 Referral to additional services as required
(OT, SW, Registered Dietician).
 In cases where patient does not
demonstrate strong ability to complete
program appropriately and independently
short course intervention can occur. This
may be group format, with therapy assistant
support. Discharge planning includes
provision of home program, referral to
community programs and plan for
monitoring.
Outpatient teams, CCAC to have access to
consistent assessment, education materials and
3
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
exercise instructions for distribution to patients.
Evidence of
predictors of
successful
prosthetic use:
contractures at the
hip (particularly for
AKA) and knee
(BKA) negatively
impact successful
prosthetic fitting and
use. Severe
contracture is a
contraindication to
fitting. 3,17

-Lower extremity
ROM, strength
Hip extension ROM to
0-10 degrees on a
modified Thomas test.
Hip abduction ROM to
neutral. Knee extension
ROM 0-5 degrees.
This kind of
preventative care has
not typically occurred.
PT Intervention related to ROM/strength;

Patients are educated about the importance
of their ROM and the impact on their
potential prosthetic use.
 Patient are educated to stretch daily to avoid
the formation of contracture:
o Prone lying if tolerated
o Active hip extension in prone.
o Hip extension in standing
o Knee extension stretching
o Hip, knee and ankle strengthening
o Core strengthening.
o UE strengthening
o Home exercise prescription.
Appendix D: Above-Knee Amputation Postop Education
Appendix E: Below-Knee Amputation Postop Education
Evidence for the
 Timed tests: i.e.
impact of prewalking tests,
operative fitness and
bicycle ergometry,
activity level on the
as appropriate.
potential for
successful
prosthetic fitting.
2,3,8
PT intervention: endurance;

Patients are educated about the
importance of their endurance.
o In clinic access to endurance
training on treadmill, upright or
recumbent bicycle/elliptical, arm
ergometry as appropriate.
Recommendations re home appropriate home
activity.
4
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)

Smoking cessation counseling
(as taken from CHF pathway)
ECS Guidelines
CCS Position Paper
Throughout
the continuum
of care.
 % Of patients
identified as
smokers on
admission who are
offered
NRT/counseling
The self-management plan should include
components of the following:
 An understanding of the link between
fitness level and the potential for prosthetic
candidacy and functional prosthetic
outcome.
 Demonstrated ability to properly perform
basic ROM, strengthening and
cardiovascular activity.
 Demonstrate the ability to perform a daily
lower extremity skin inspection.
 Demonstrate and understanding of
principles of hygiene and skin care.
Counselling during admission and follow up
after discharge—“At all times, health care
providers should strongly enforce stringent
measures against active cigarette smoking”
“Minimal interventions, lasting less than 3
minutes, should systematically be offered to
every smoker with the understanding that more
intensive counselling with pharmacotherapy
results in the highest quit rates and should be
used whenever possible”
NRT provided
Referral to smokers help line (Appendix F:
Smokers Help Line)
Communicate NRT to primary care provider for
continuation post discharge
5
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Activities to Support Achievement of
Desired Outcome/Best Practice
Metric
Target Performance
Current Performance
 Incidence
amputations
performed in WW
 Frequency of
revision
amputations.
 Post-op infection
rates.
 Incidence of levels
of amputation
That the desired
practice/outcome in
terms of the contribution
level, length and
minimization of
contracture is
considered at the
operative stage.
Currently the amputee
teams have limited to
no involvement pre-op
and are not generally
consulted regarding
the factors that may
contribute to a better
prosthetic outcome.
 Determination of amputation procedure
balancing potential to heal from surgery with
optimal potential for achieving functional
prosthetic use.
 When possible, pre-op consultation with
the SAT.
 Ability for surgeons to consult remotely with
Amputee team member: physiatrist,
prosthetist, rehab assessor (physiotherapist).
That early post surgical
management includes
efforts to minimize the
formation of knee
flexion contractures in
the transtibial amputee.
That post surgical
management is
consistent.
For transtibial amputees
rigid or semi rigid
dressings with the knee
held in full extension is
identified in the
literature as best
practice.
The current post
surgical management
of amputees varies
significantly
depending on the
surgeon. This report is
consistent to all 3
acute care sites.

As noted above
immediate post op
dressings varies
significantly
depending on the
surgeon.
Wound management and shaping:
(where it exists)
I. Best practice surgical and post
surgical management;
C. ACUTE
 Where possible effort taken to
perform transtibial or through
joint amputation.
 Optimal length of amputation
(either transtibial or
transfemoral)
 Limit the potential for hip
and/or knee flexion contracture
 Best practice wound care:
prolonged wound healing is
often the primary cause of
delayed prosthetic trial and
increased the likelihood of
secondary impairments
Evidence of the
impact of level of
amputation on
successful
prosthetic use.
1,2,3,5,6,16,17,
Evidence for best
practice post-op
management of
transtibial amputees.
15,21,22,23,24,25,2
6,27,32
Evidence for best
practice post-op
management of
transtibial amputees.
15,21,22,23,24,25,2
6,27,32
Transfemoral
amputation: standard
wound care with hip
extension ROM as soon
as tolerated by the



Transtibial amputation: when resources,
time and expertise allow, the use of rigid
dressing post-operatively is beneficial.
Dressing applied with the knee in full
extension.
Other amputation levels (ie foot/forefoot,
transfemoral) and transtibial amputation
once rigid dressing removed: wound care
as directed by physician/nurse/wound care
expert.
Once rigid/semi-rigid dressings are removed
a method of edema management, residual
limb shaping and protection is introduced.
The selection of edema/shaping
management must result in the safest, most
consistent method and may change as
6
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
patient.
II. Prompt referral to the
appropriate ADP registered
SAT.
Evidence for the
early involvement of
the SAT in the
course of care for
the lower extremity
amputee.
Core members with
specialize skills and
knowledge in
amputee care:
physician (surgeon,
physiatrist or other
medical doctor with
interest and skill in


# or referrals of
new amputees
to the SAT’s
Wait time from
referral to first
visit with SAT.
Referral to the
Prosthetic Clinics
occurs in the acute care
setting unless a preoperative consultation
has already occurred
and follow-up is booked.
Referral to the Amputee
team that is going to
meet patient needs
based on their home
location occurs.
How referral to the
SAT occurs is
variable. Patients who
are discharged home
rather than to inpatient
rehabilitation are at
risk of having delayed
referral to the SAT.
Referral to the SAT
that is going to best
meet the patient’s
ongoing, life long
needs generally
occurs. However, with
the first rehab bed
patient moves from acute care to rehab and
assessment in the SAT. (Transtibial
amputees must use a stump board in their
wheelchair and be educated about the
importance of its use.
 Transfemoral amputees must be educated
to stretch hip flexors.
Appendix G: Transtibial Residual Limb
Edema/Shaping Documents
(i) Residual Limb Shaping (ACUTE)
(ii) Residual Limb Shaping (INPATIENT
REHAB)
(iii) Residual Limb Shaping (CCAC)
(iv) Residual Limb Shaping (SAT)
(v) Patient Education (Elastic
Stockinette/Manufactured Shrinker)
(vi) Patient Education Tensor Bandaging
II.i Early involvement with the appropriate
amputee clinic (SAT):


Unless it is clear that a patient is not a
prosthetic candidate, the patient is refusing
referral, or the patient was already see preoperatively referral to the appropriate SAT
team occurs as a standing referral.
The SAT sees patient as soon possible
once they are medically able to attend the
clinic. New amputee are identified as a
priority booking. (Appendix A: Referral
Process)
7
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
III. Focus of physiotherapy
/occupational therapy to include
PROM and AROM to avoid
contracture formation, to
maximize activity tolerance, to
support the patient’s knowledge
of the process and requirements
for prosthetic fitting.
Early mobilization: OT/PT to
initiate transfer training to
appropriate seating. This
includes OT assessment for
wheelchair and surface
selection. All transtibial
amputees are prescribed an
appropriate amputee board.
PT and OT also support early
discharge from the acute care
site to the appropriate setting.
the area of amputee
care), prosthetist,
physiotherapist,
nursing (with wound
care/diabetic care
specialization).
Additionally access
to occupational
therapy and social
work. 1,2,4,5,6,7,
13,15,20, 34
Evidence identifying
the key rehab focus
in the acute care
setting to maximize
safety for discharge
as well as
preparedness for
prosthetic trial. 3,4,
7,15,17,
policy patient’s are
occasionally referred
to the less appropriate
SAT.

# Patients who
receive
education
materials,
measure the
incidence of
communication
between care
providers, d/c to
community vs.
inpatients.
Exercise prescription is
consistent with preoperative education and
focuses on the identified
ROM, strength and
endurance as well as
basic mobility and ADL
functions for safe
discharge home.
Wheelchairs provided
with appropriate surface
to prevent skin
breakdown and
appropriate alignment,
including a amputee
board for all transtibial
amputees. Transfemoral
amputees do not require
an amputee board.
Current practice does
include such exercise
prescription. However
there is not consistent
written material
provided to patients.
Physiotherapy and Occupational intervention
including common educational materials across
sites.
Early mobilization; When medically stable
patients should begin mobilization. Post –op
day 1-2.

Transfer training; slider board, low pivot,
standing pivot.
 Practice single leg stance.
 ROM and stretching program as soon as
tolerated.
 UE ROM/strengthening exercise
prescription.
Increasing activity tolerance:
 Wheelchair mobility may be used as
endurance activity if tolerated.
 Hopping should be carefully assessed, likely
performed with supervision or assistance.
 Hopping independently should only occur in
cases where balance and hopping skills
8
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
demonstrated by the patient are highly
proficient due to the risk of falling.
Seating and positioning (assessment and
prescription occurs as soon as patient is
medically stable enough to begin mobilizing):
Transtibial residual limb is kept from
dangling/hanging. When sitting in a wheelchair
an amputee board is used to support the knee
in extension, thereby reducing the risk of knee
flexion contracture, assisting with edema
management, pain control, alignment and skin
integrity.
Education materials are
developed that are
consistent.
Currently the
education materials
provided to a patient
are not consistent or
collaborative across
the continuum. Better
communication
between acute care,
rehab and the SAT is
required.
The decision to refer
to rehab or discharge
Seating and positioning is complimented by
patient education regarding the importance of
elevation of the transtibial residual limb, as well
as AROM exercises, in particular for hip and
knee extension strength and ROM for all LE
amputees.
Patients educated and provided with
instructional guide. Materials provided support
and empower the patient in their self
management;
Discharge planning begins on admission with a
goal of discharge to inpatient rehabilitation or
9
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
home is based on the
functional assessment
and the needs for safe
return to the home
environment. If the
patient is not likely to
achieve these goal in
a timely manner
referral to rehab
occurs.
B. INPATIENT
I. Goals focus on safe discharge
to the community and
preparation for prosthetic fitting.


LOS for
amputees
Frequency of OP
The focus remains on
function and activities
required for safe
discharge to the home
The core aspects of
intervention occur. A
focus on transfer of
responsibility to the
home with supports in 5-7 days.
Discharge planning; transition to inpatient
rehab/restoration.
 A decision to refer to inpatient
rehab/restorative care is made based on the
multidisciplinary team assessment. Referral
occurs in a timely manner.
 Acknowledging the first bed policy attempt is
made to admit patients to the facility in which
the SAT to which they are referred.
 The patient and family are educated about
the focus of an inpatient stay: to maximize
their safe mobility and function in the home
environment prior to prosthetic fitting or in the
absence of prosthetic fitting.
 Referral to the appropriate SAT is completed.
Discharge planning: transition to care in the
community should include the following
arrangements.
 Confirmation of an appointment with the
appropriate SAT team.
 CCAC OT assessment for home safety unless
the patient has demonstrated high-level
mobility and independence in the acute care
setting (likely younger, non-dysvascular
patients).
Physiotherapy and Occupational intervention
including common educational materials across
sites. The inpatient stay continues with the
10
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
Ongoing mobilization: OT/PT to
continue transfer training,
strength, ROM, endurance
activities.
Re-assessment: OT
assessment for wheelchair and
surface selection. All transtibial
amputees are prescribed an
appropriate amputee board.


pre-gait followup on discharge
ROM and
strength.
Discharge
location.
environment There is an
opportunity to increase
the expectations of
patients in taking
responsibility for their
role in recovery and the
impact this has on their
potential to achieve
prosthetic use.
Consistent messaging
from all care providers
is required
patient is less
consistent.
goals established in acute care.
Appendix D: Below Knee Amputation Postop Education
Appendix E: Above Knee Amputation Postop Education
Mobilization;
 Transfer training; slider board, low pivot,
standing pivot.
 Practice single leg stance.
 ROM and stretching program as soon as
tolerated.
 UE ROM/strengthening exercise prescription.
Increasing activity tolerance:
 Wheelchair mobility may be used as
endurance activity if tolerated.
 Hopping should be carefully assessed, likely
performed with supervision or assistance.
Hopping independently should only occur in
cases where balance and hopping skills
demonstrated by the patient are highly proficient
due to the risk of falling.
Seating and positioning (assessment and
prescription occurs as soon as patient is
medically stable enough to begin mobilizing):
Transtibial residual limb is kept from
dangling/hanging. When sitting in a wheelchair
an amputee board is used to support the knee
in extension, thereby reducing the risk of knee
11
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
flexion contracture, assisting with edema
management, pain control, alignment and skin
integrity.
Seating and positioning is complimented by
patient education regarding the importance of
elevation of the transtibial residual limb, as well
as AROM exercises, in particular for hip and
knee extension strength and ROM for all LE
amputees.
Improved patient self management; patient to
be educated about the importance that they
take responsibility for their recovery process
should they wish to pursue prosthetic trial;
 In preparation for discharge the patient is
encouraged to complete aspects of their
exercise program independently either in their
room or with access to therapy area when
distant supervision is possible.
Discharge planning begins on admission with a
goal of discharge to home with supports in 1-3
weeks.
 Goals for d/c focus on safe ability to transfer
for ADL’s and IADL’s , education,
independence and adherence with exercise
and edema/shaping management
recommendations.
 If patient has already been assessed in SAT
follow-up outpatient PT appointment is
provided.
12
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
 If not yet assessed in the SAT patient is
provided with this appointment (1-2 weeks
post discharge).
 CCAC OT assessment for home safety
unless the patient has demonstrated highlevel mobility and independence in the acute
care setting (likely younger, non-dysvascular
patients).
Inpatient rehab for prosthetic gait training: Most
often by the time patients are ready to proceed
with prosthetic gait training they no longer have
the nursing needs that require an inpatient stay.
In the case of transfemoral amputees the skills
that are predictive of successful, functional
prosthetic use of prosthesis include higher level,
independently mobility. However there may be
times where an inpatient stay is required.
 Unilateral transtibial amputee: occasionally a
patient may be struggling with some of the
core skills (i.e. single leg stance) but the
consensus of the SAT is that introduction of a
prosthesis will allow the patient to improve
their strength, ROM and ability to achieve the
mobility required to be discharged to the
community. In such cases prosthetic casting
and fabrication should occur as soon as
possible.
 Bilateral transtibial amputees: again
consensus of the SAT may include prosthetic
prescription to facilitate independent transfers
and mobility required for safe discharge to the
13
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
II. Proper residual limb care
resulting in the best quality limb
for prosthetic fitting.
Evidence for best
practice residual
limb care.
15,21,22,23,24,25,2
6,27,32
Patients are assessed
to determine the most
appropriate and feasible
residual limb shaping
and edema control
technique.
community.
 Rurally located patients may have difficulty
accessing the specialized outpatient amputee
gait training programs. Alternative
arrangements may need to be considered.
This may involve CCAC to coordinate a
respite, restorative or inpatient rehab stay to
allow initial gait training with the support of
the SAT. The prosthesis must be ready at the
time of admission. On discharge PT care is
transitioned to outpatients or CCAC in the
patient’s community. Providers in the
community must have access to consultation
with the SAT. Arrangements for follow up in
the SAT are established as part of discharge
to the community.
See the wound management and shaping
approach identified in acute care.
Tensor bandaging
technique is
inconsistent whether
 Where proper tensoring technique is not or
performed by the
cannot occur alternative methods must be
patient or nursing
implemented. This may include a elastic
staff. The result is that
stockinette provided by the PT involved in
tensoring is often
care, or a manufactured shrinker or silicone
done by therapy staff
liner provided by the certified prosthetist.
resulting in inadequate
Appendix
G: Transtibial Residual Limb
frequency of reEdema/Shaping
Documents
wrapping.
(vii) Residual Limb Shaping (ACUTE)
(viii) Residual Limb Shaping (INPATIENT
REHAB)
(ix) Residual Limb Shaping (CCAC)
(x) Residual Limb Shaping (SAT)
(xi) Patient Education (Elastic
14
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
III. Ongoing best practice wound
care.
I. Specialized Amputee Teams
(Grand River Hospital:
Prosthetic and Orthotic Clinic,
St. Joseph’s Health Care
Amputee Clinic): Referral to the
appropriate team occurs in a
timely manner (see acute care).
C. OUTPATIENT
Regular follow-up with the SAT
occurs. For new amputees visits
are more frequent. As the
amputee gains functional
independence with their
prosthesis frequency of follow up
is reduce and may become on
an as needed basis only.
Patients identified as high risk
seen more frequently in order to
prevent serious complications
that may result in a decline in
function, inability to use their
prosthesis, higher level of care
requirements, or hospitalization.
Evidence supporting
the role of the SAT
Evidences for
benefits of
preventative care.
1,2,4,5,6,7,
13,15,20, 34
 Time from surgical
intervention to
initial assessment
in SAT.
 # New amputees
assessed
 # of new amputee
that proceed to
prosthetic trial
 # longstanding
prosthetic users
/year
 Level of new
amputations.
 # of patients on
PRN status vs
regular call back
 age of amputees.
There is an opportunity
to increase collaboration
regarding residual limb
wound management
between the inpatient
unit and the SAT’s
Amputee Patients have
prompt and ongoing
access to the SAT.
Assessment by a multidisciplinary, specialized
team occurs promptly.
The team includes
wound care expertise.
There is a standing
order for physiotherapy
within the SAT.
There is not a strategy
in place to facilitate
specific collaboration.
Follow up occurs
regularly with the SAT
Team. In high risk
patients are placed on a
This currently occurs,
but in less than
consistent manner.
Stockinette/Manufactured Shrinker)
(xii) Patient Education Tensor Bandaging
BPG’s as overseen by in hospital wound care
providers.
Develop a strategy for Communication and
collaboration with the SAT’s.
Currently there are the
two identified clinics.
The clinic Guelph
clinic has lacked
adequate physician
support as per ADP
requirements.
Grand River Hospital: Prosthetic and Orthotic
Clinic, St. Joseph’s Health Care Amputee Clinic
are both ADP registered clinics. ADP requires
the prescriber (physiatrist); authorizer /vendor
(Certified Prosthetist) and Rehabilitation
Assessor (PT/OT) in the clinic delivery model
for initial preparatory and definitive prostheses.
Neither amputee team
currently includes
nursing support.
Amputee teams have
the ability to refer to
social work, registered
dietician, via
supporting outpatient
programs.

Amputee Teams have access to wound care
expertise/nursing, social work, dietician, and
occupational therapy and recreation
therapy. Referrals to the services are
generated if the patient requires.
 Initial visit to the SAT team includes a
comprehensive, multi-disciplinary
assessment by the specialized team
(Appendix H: SAT Assessment)
 Referral to PT for pre-gait involvement and
for gait training is established as a standing
order from the Amputee teams.
Regular follow –up through pre-gait, gait
training, post gait, transition from the initial
preparatory device to definitive prosthesis,
regular follow post dispensation of the definitive
15
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
Current Performance
(where it exists)
call back schedule for
checkups with the SAT
in order to prevent
complications (ie poor
prosthetic fit
management, skin
breakdown issues both
in the residual limb and
remaining limb)
Pre-gait training provided in
cases where additional support
and monitoring recommended
by the SAT.
Evidence of key
predictors of
successful transition
to functional
prosthetic use.
2,3,6,8,10,11,12,13,
14,33



# of pre-gait
patients that
proceed to
fitting.
Length of time to
fitting
Cause of delay
in fitting (wound
healing,
remaining limb
status)
An individualized pregait plan is established
by the SAT to meet
patient needs.
Community partners are
engaged as needed to
support the plan.
Regular monitoring and
plan adjustment occurs
in the SAT.
particularly in higher risk case to prevent and/or
manage complications.
SAT visits:


The SAT’s currently
provide pre-gait
consultation.
Initial consultation
Follow-up pre-gait if candidacy for prosthetic
trial could not be determined at initial consult
 Follow up review once gait training has
begun (opportunity to team problem solving,
alignment adjustment, planning)
 Follow-up at 6 months post dispensation of
temporary device to determine readiness to
proceed to definitive prosthesis.
 Follow-up post dispensation of definitive
device.
 If high risk patient may place on call back
schedule.
 High functioning patients seek re-referral to
SAT (ie for prosthetic wear, new medical
changes) on a PRN basis.
Physiotherapy: Pre-gait training, focused on
ROM, strengthening, single leg stance
tolerance, and activity tolerance, edema
control/residuum shaping, monitoring of wound
healing:
A) Patient deemed an appropriate prosthetic
candidate, but has not yet healed. The
patient is identified by the SAT as high risk
for the development of secondary
impairments while waiting wound healing.
Supervision of exercise activity is therefore
16
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
recommended. Treatment can occur in a
group format and be supervised by a
therapy assistant with regular PT reassessment, particularly for wound healing
and readiness for fitting.
B) Patient deemed an appropriate prosthetic
candidate but has not yet healed. Healing is
expected to be fairly quick and the patient is
assessed to be capable of independently
completing a home program. Treatment is
more consultative with instruction regarding
home exercise program with periodic check
up with the PT to monitor wound healing
and readiness for fitting.
Once deemed appropriate for prosthetic trial
the patient in provided with the appropriate
information package.
Appendix I: BKA Prosthetic Candidate
Education
Appendix J: AKA Prosthetic Candidate
Education
Individualized therapy
plan is established and
modified to address
Occurs
C) Patient is deemed borderline appropriate for
prosthetic trial. Time bound period of
intervention (4 weeks) to determine if the
patient demonstrates progression towards
the skills required to be considered for
prosthetic trial. At the end of the PT trial
follow-up with the SAT occurs to discuss
next steps.
Physiotherapy intervention:
 ROM: stretching for hip flexors, knee flexors
17
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
patient impairments and
goals.
and other ROM’s noted as limited.
 Strengthening: UE progressive weight
program, LE AROM and progressive weights
as tolerated for hip extension, ab/adduction,
knee extension, remaining ankle and core.
 Activity tolerance activity: arm ergometry,
recumbent elliptical, parallel bar hopping,
wheelchair skills.
 Single stance with progressive reduction in
UE support.
 If the patient or family is able to demonstrate
the skills to properly tensor (technique and
frequency) than education and training is
provided.
In cases where tensoring cannot be safely
implemented, alternative shaping/edema control
must be implemented.
Appendix G: Transtibial Residual Limb
Edema/Shaping Documents
(xiii) Residual Limb Shaping (ACUTE)
(xiv) Residual Limb Shaping (INPATIENT
REHAB)
(xv) Residual Limb Shaping (CCAC)
(xvi) Residual Limb Shaping (SAT)
(xvii) Patient Education (Elastic
Stockinette/Manufactured Shrinker)
Patient Education Tensor Bandaging
Discharge planning:
A) Patient achieves wound healing and is able
to proceed to the gait training process.
18
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
III. Outpatient PT provided by
physiotherapist with specialized
skills, abilities and knowledge of
amputee care. The rehab
assessor takes the lead.
Evidence of the
benefits of the
specialized team
and care providers
with expertise and
experience in
amputee care.
Evidence supporting
outcome measures
for lower extremity
amputees: timed
 Timed walking
tests when
appropriate.
(2MWT, L-Test,
TUG, 6 MWT)
 SIGAM
 Monitoring
progression of gait
aid
 Incidence of skin
break down
 LOS (AKA vs.
The majority of patients
deemed appropriate for
prosthetic trial achieve
some functional use.
This should be
documented in the
ongoing monitoring and
care through the SAT.
Record keeping using
standardized outcome
measure: timed walking
tests (2MWT, L-test)
This target occurs
based on monitoring
by the SAT of
patients, however
quantification of this
could be more robust.
B) Patient demonstrates improved ability to
follow through on independent home
program but still does not have adequate
wound closure. Visits reduced to periodic
wound checks and assessment with PT until
ready for prosthetic fitting.
C) The patient who is borderline for prosthetic
trial is re-assessed in the SAT following 4
weeks of intervention
 Patient is now deemed a prosthetic
candidate: either continues with pre-gait
training or proceeds to prosthetic fitting.
 Patient deemed unlikely to become a
prosthetic candidate are educated why
they are not a candidate, the specific
skills required are re-iterated, referrals as
required are generated (i.e. CCAC for
wheelchair, other mobility devices, if not
already done, community programs,
social work, recreation therapy)
Physiotherapy: GAIT TRAINING: Once the
patient has been casted and fitted they are
ready to proceed with gait training. Prosthetist
attends first PT visit with patient.
 Frequency of visits are maximized in the first
month of prosthetic use .
 Visits may be group format, individual or a
combination of depending on patient needs.
Transtibial amputee typically is more easily
managed in a group setting. Transfemoral
amputee may require more individual
19
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
walking test, LCI,
SIGHAM
BKA)
 Degree of
functional
ambulation
achieved (from
limited indoor to
community)
functional/ activity
measures (LCI,
SIGHAM). Data
collection represents
opportunity to
participate and
collaborate with larger
teaching centres in
research.
sessions.
 Progressive gait training; as patient skin
integrity and tolerance allows the patient is
progressed through a variety of gait aids,
balance activities, functional gait activity.
o Ambulation in parallel bars
o 2WW or rollator
o single point canes, quad canes.
o Balance activities; weight shifting on level
ground, on soft surfaces, stepping task,
step up tasks, reaching
o Stair climbing, uneven ground, inclines,
curbs
 Activity tolerance.
 Sock ply management.
 Skin care and monitoring: residuum and
remaining limb.
 Falls education, floor to chair transfers.
 Home use is gradually introduced when the
patient is safely able to do so. Specific
instructions are sent home with the patient.
As patient independence increases and home
use is initiated PT visits are reduced. and then
to periodic follow-up visits.
Discharge planning: individualize goals are set
with each patient. There is significant variability
amongst the amputee population depending on
the patient’s age, level of amputation, etiology
of amputation, number of co-morbidities. The
level of anticipated functional prosthetic use is
therefore also variable from limited indoor
20
Rehabilitative
Care Setting
Desired Outcome
Best Practice &
Source of
Evidence
Metric
Target Performance
Current Performance
Activities to Support Achievement of
Desired Outcome/Best Practice
(where it exists)
prosthetic use with a gait aid, to full community
ambulation and re-integration without a device.
 As a patient reaches their individualized goals
Active PT intervention is reduced.
 A follow-up plan with the Amputee Team is
established (see section re Prosthetic teams
above.)
Links to community programs as appropriate
are established.
IV. Ongoing best practice wound
care.
I. Referral to community
programs for ongoing exercise,
leisure and social activity.
COMMUNITY
Wound Care Provided by CCAC as per their
BPG’s
Messaging and
information sharing
regarding ongoing
community activities is
consistently provided to
all patients as they
prepare for discharge
from active intervention.
Currently this happens
on a case by case
basis.
Communication and Collaboration with the
community providers of wound care and the
SAT’s.
 Caredove as a resource. Patient provided a
list of suggested activities and community
programs that would be appropriate for them
to participate in to maintain their fitness and
participation.
21
Additional Notes:
1) Pre-operative/Acute Education for Patients and Families Facing Amputation.
Patients preparing to undergo amputation are facing a lifelong change, with ongoing care management issues. The provision of consistent information to the patient (and
their families) will help support a more seamless journey through the continuum of care. It is also an opportunity to introduce, support and develop the concepts of patient self
management (http://www.wwselfmanagement.ca)
There may be a risk of overwhelming the patient with information so whenever possible the documents should be delivered and explained to family as well. The document
should include:
 Early post-op course; early mobilization procedure, dressings, post-op bed exercises.
 d/c planning; when patient will be referred to rehab/restoration vs. when patient will be discharged home.
 Referral to speacialized amputee clinic; which clinic they will be referred to (and if time and medical stability allows pre-op visit with the amputee team)
o This includes information about the role of the clinic in determining a patient’s suitability for prosthetic trial, process if deemed appropriate and long-term follow up.
o ADP program information.
o Peer support services.
o Web based resources.
 CCAC services that may be required.
 Post-op follow-up with surgeon
2) Residual Limb Management in the transtibial amputation (for additional information see the Transtibial (Below Knee) Residual Limb Edema and Shape
Management Recommendation documents.)
3) The impact of hip and knee flexion contractures on fitness for prosthetic trial:
 The presence of hip and knee flexion contractures complicates the ability to comfortably and successfully fit an amputee with prosthesis.
 In the transfemoral amputee hip flexion contractures of greater than 10-20 degrees negatively impact the amputee’s ability to achieve mid-stance alignment and to
control the prosthetic knee joint. The patient is more likely to have difficulty locking the prosthetic knee in stance and is therefore at greater fall risk. Patients will
compensate for the contracture by using hip retraction in stance and or increasing lumbar extension. This results in altered gait mechanics and poorer comfort.
 In the transtibial amputee the presence of hip flexion contractures has similar impacts in increasing hip retraction and lumbar extension in stance. Knee flexion
contractures result in increased pressure to the distal residuum, increased potential for skin breakdown, decreased comfort. The presence of significant contracture to
both joints negatively impacts a patient’s ability to achieve safe standing balance, thereby limiting the potential to progress away from gait aids for safe ambulation,
limiting the scope of standing tasks they can safely perform.
 Contracture, once present in an amputee are difficulty to resolve due to the reduce lever arm for stretching that results post amputation. Pre-operative maximization
of ROM, surgical procedures to avoid contracture formation and early post-surgical intervention to prevent contracture formation are key.
4) Multi-disciplinary Amputee Team Assessment: Initial assessment document in Appendices
 Current History as it relates to the amputation or potential amputation.
22





Past medical history; previous referrals and related health care supports (i.e. diabetic services), renal care,
Social history
Observation: circulatory assessment, LE and UE sensation, wound description and measurement (document with photo), strength and ROM assessment,
identification of contractures, particularly at hip and knee, stump shape, length,
Analysis; multidisciplinary analysis to establish recommendations regarding;
o Orthotic prescription to minimize risk of skin breakdown, support alignment (i.e. in case of a Charcot joint), off-load and promote healing In a LE with open
areas
o Pre-amputation, pre- prosthetic need for PT assessment and intervention to maximize fitness and preparedness for potential gait training.
o Fitness for prosthetic trial.
o For longstanding amputees; need to adjustments, repair, and replacement of prosthesis.
Plan; multidisciplinary team provides:
o Referral to other supports: diabetic clinic (via central referral), wound care services (CCAC)
o Completion of ADP documentation for devices.
o Referral to PT as required for pre-amputation, pre-gait and gait training.
23
Resources for Best Practice and Source of Evidence for Amputee Care:
1. British Society of Rehabilitation Medicine, Standards and Guidelines in Amputee and Prosthetic Rehabilitation, October 2003.
2. Bates, B.E., Hallenback, R., Ferrario, T., Kwong, P.L., Kurichi, J.E., Steineman, M.G., Xie, D., Patient-, Treatment-, and Facility-Level Structural Characteristics Associated
With the Receipt of Preoperative Lower Extremity Amputation Rehabilitation. M R. 2013 January ; 5(1): 16–23.
3. Brigham & Women’s Hospital, Department of Rehbilitation Services, Physical Therapy; Standard of Care: Lower Extremity Amputation, 2011.
4. Model of Amputee Rehabilitation in South Australia; Statewide Rehabilitation Clinical Network
5. Demey, D., Post-amputation rehabilitation in an emergency crisis: from preoperative to the community, International Orthopasdices 2012; 36: 2003-2005.
6. Johannesson A, Larsson G-U, Ramstrand N, Lauge-Pedersen H, Wagner P, Atroshi I: Outcomes of a standardized surgical and rehabilitation program in transtibial
amputation for peripheral vascular disease: A prospective cohort study. Am J Phys Med Rehabil 2010;89:293–303.
7. GTA Rehab Network: Amputee Definition Framework, 2007.
8. Hakimi, K.N., Pre-operative rehabilitation evaluation of the dysvascular patient prior to amputation. Phys Med Rehabil Clin N Am. 2009
9. Synder, R. J. Diabetes: Offloading difficult wounds. Lower Extremity Review, November 2009.
10. Spruit-van Eijk, M., van der Linde, H., Buijck, B. Geurts, A., Zuidema, S., Koopmans, R., Predicting prosthetic use in elderly patients after major lower limb amputation.
Prosthet Orthot Int 2012 36: 45-52.
11. Hamamura, S., Chin, T., Kuroda, T., Akisue, T., Iguchi, T., Kohno, H., A Kitagawa, A., Tsumura, N., Kurosaka, M. Factors Affecting Prosthetic Rehabilitation Outcomes in
Amputees of Age 60 Years and Over.
Journal of International Medical Research 2009 37: 1921
12. Sanson, K., O’Connor, R.J., Neumann, V., Bhakata, B., Can simple clinical tests predict walking ability after prosthetic rehabilitation. J Rehabil Med 2012; 44: 968–974.
13. Fleury, A.M., Salih, A.S., Peel N.M., Rehabilitation of the older vascular amputee: A review of the literature. Geriatr Gerontol Int 2013; 13: 264–273.
14. Chin, T., Sawamura, S., Shiba, R., Effect of physical fitness on prosthetic ambulation in elderly amputees. Am J Phys Med Rehabil 2006; 85: 992-996.
15. Uustal, H., Prosthetic Rehabilitation Issues in the Diabetic and Dysvascular Amputee, Phys Med Rehabil Clin N Am 2009; (20) 689-703
16. Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch Phys Med Rehabil 2006;87(3 Suppl 1):S34-43.
17. Knetsche, R.P., Leopold, S.S., Brage, M.E., Inpatient Management of Lower Extremity Amputations, Orthotics and Prosthetics for the Foot and Ankle, June 2001; 6(2):
229-241.
18. Nawijn, S.E., van der Linde, S.E., Emmelot, C.H., Hofstad, C.J., Stump management after trans-tibial amputation: A systemtatic review. Prothet Orthot Int, 2005; 29(13): 1326.
19. Woodburn, K.R., Sockalingham, S., Gilmore, H., Condie, M. E., Ruckley, C.V., A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral
arterial insufficiency
, Prosthet Orthot Int 2004 28: 22
20. Deutsch, A., ENGLISH, R.D., Vermeer, T.C., PAMELA S. Murray, P.S., Condous, M., Removable rigid dressings versus soft dressings: a randomized, controlled study with
dysvascular, trans-tibial amputees, Prosthetics and Orthotics International August 2005; 29(2): 193 – 200
21. Janchai, S., Boonhong, J. Tiamprasit, J., Comparison of Removable Rigid Dressing and Elastic Bandage in Reducing the Residual Limb Volume of below Knee Amputees.
J Med Assoc Thai 2008; 91 (9): 1441-6.
22. Louie, S., Lai, F., Poon, C., Leung, S., Wan, I., Wong, S., Residual Limb Management for Persons With Transtibial Amputation: Comparison of Bandaging Technique and
Residual Limb Sock. JPD, 2010, 22(3): 194-201.
23. Alsancak, S., Kose, S.K., Altinkaynak, H., Effect of elastic bandaging and prosthesis on the decrease in stump volume, Acta Orthop Traumatol Turc 2011;45(1):14-22
24. Wong, C.K., Edelstein, J.E., Unna and Elastic Dressing: Comparison of their Effects on Function of Adult With Amputation and Vascular Disease, Arch Phys Med Rehabil,
Sept 2000, 81(9): 1191-8.
24
25. MacLean, N., Fick, G.H., The Effect of Semirigid Dressing on Below-Knee Amputations, PHYS THER. 1994; 74:668-673.
26. Vigier, S., Casillas, J., Dulieu, V., Rouhier-Marcer, I., D’Athis, P., Didier, J., Healing of Open Stump Wounds After Vascular Below-knee Amputation: Plaster Cast Socket
with Silicon Sleeve Versus Elastic Compression, Arch Phys Med Rehabil, 1999; 80: 1327-30.
27. Smith, D.G., McFarland, L.V., Sangeorzan, B.J., Reiber, G.E., Czerniecki, J.M., Postoperative dressing and management strategies for transtibial amputation: A critical
review. JRRD 2003, 40 (3)213-224.
28. Henry, A.J., Hevelone, N.D., Hawkins, A.T., Watkins, M.T. , Belkin, M., Nguyen, L.L., Factors predicting resource utilization and survival after major amputation. J.
Vasc.Surg. 2013; 57: 784-790.
29. Frlan-Vrgoc, L., Vrbanic, T.S., Kraguljac, D., Kovacevic, M., Functional Outcaom Assessment of Lower Limb Amputees and Prosthetic Users with a 2- Minute Walk Test,
Coll. Antropol 2011: 35 (4) 1215-1218.
30. Larsson, B., Johannesson, A., Andersson, I.H., Atroshi, I., The Locomotor Capabilities Index; Validity and reliability of the Swedish version in adults with lower limb
amputation. Health and Quality of Life Outcomes 2009: 7(44)
31. Deathe, A.B., Wolfe, D.L., Devlin, M., Hebert, J.S., Miller, W.C., Pallaveshi, L., Selection of outcome measures in lower extremity amputation rehabilitation: ICF activities.
Disability and Rehabilitation, 2009: 3118) 1455-1273.
32. Bouch, E., Burns, K., Geer, E. Fuller, M., Rose, A., Rehabilitation, Guidance for the multidisciplinary team on the management of post-operative oedema in lower limb
amputees.
33. Sansam, K., Neumann, V., O’Connor, R., Bhakta, B., Predicting walking ability following lower limb amputation: A systematic review of the literature, J Rehabil Med 2009;
41:593-603.
34. Limb Prostheses Policy and Administration Manual, Assistive Devices Porgram, Ministry of Health and Long-Term Care, September 2012.
35. Sibbald, R.D., Ayello, E.A., Alavi, A., Ostrow, B., Lowe, J., Botros, M., Goodman, L., Woo, K., Smart, H., Screening for the High-Risk Diabetic Foot: A 60-Second Tool
(2012) Clinical Management Extra, October 2012.
25