23/03/2017

1

Acute Amputee Physiotherapy

Management

Kate Primett

Clinical Lead Amputee and Vascular Rehabilitation (BSc, PGc, MCSP, MBACPAR )

Royal Free London NHS Foundation Trust

27/03/2017

Content

Causes/ levels of AmputationCauses/ levels of Amputation

Amputation surgeryAmputation surgery

Pre-operative therapy Pre-operative therapy

Post operative therapy Post operative therapy

Amputee Therapy GuidelinesAmputee Therapy Guidelines

Causes of Amputation

5000-6000 major LLA/yr

70,000 in UK

5000-6000 major LLA/yr

70,000 in UK

Diabetes MellitusDiabetes Mellitus

TraumaTrauma

TumourTumour

Vascular DiseaseVascular Disease

InfectionInfection

CongenitalCongenital

(NCEPOD 2014)

23/03/2017

2

Levels of UL and LL Amputation

Amputation

Level

Lower Limb

Percentage Amputation

Level

Upper Limb

Percentage

Partial foot 1.5 Partial Hand 22

Transtibial 53 Wrist

Disarticulation

3

Knee

Disarticulation

3 Trans-radial 40

Transfemoral 41 Trans- humeral 30

Hip

Disarticulation

1 Shoulder

Disarticulation

5

Hemi

Pelvectomy

0.5

% Levels of UL and LL Amputation

www.limbless-statistics.org (2011/2012)

Myodesis

muscles are anchored to the end of the bone

Myoplasty

muscles are attached to the opposing group

Amputation Surgical Terminology

23/03/2017

3

• A Skew flap

• B Equal A-P

• C Equal M-L

• D Long Post. Flap

Surgical Closure of Trans Tibial Amputations

Physiotherapy Pre-Operative

Management

“All patients admitted electively for lower limb amputation should be seen in a pre-assessment clinic to optimise medical co-

morbidities and to plan post operative rehabilitation”.

(NCEPOD, 2014)

Pre-Operative Subjective Assessment

MDT Communication

23/03/2017

4

Pre-Op Subjective Assessment

Social Situation

Social Situation

Marital Status /

Dependants(age)

Marital Status /

Dependants(age)

POCPOC

ADL’s / PADL’sADL’s / PADL’s

HousingHousing

OccupationOccupation

Hobbies / Driver

Hobbies / Driver

Alcohol / Smoker / Drug Use

Alcohol / Smoker / Drug Use

MobilityMobility

Pre –op Subjective Assessment

Discuss stages/ expectations of Rehabilitation

• Gage what the patient is thinking - Goals

• Explain Immediate post-op rehab

• Exercise programme

• Day 1 post-op review.

• Physio gym asap

• Review discharge needs

• OT - access visit/ wheelchair referral

Pre-operative Objective Assessment

Bed mobility

Bed mobility

Joint AROMJoint

AROMMobilityMobility

23/03/2017

5

Physiotherapy Post – Operative

Management

It all begins first day Post Op – No lying

about!

“Post operative physiotherapy should commence

on the first day where possible and should

include exercise, oedema management and use

of early walking aids as appropriate.”

(NCEPOD 2014)

BACPAR guidelines

(Pre and Post Op Mgmt – 2006)

Good Communication Is Essential

The MDT

Local PhysioLocal PhysioSocial WorkerSocial WorkerPain TeamPain Team

Prosthetic PhysioProsthetic Physio

Occupational

Therapist

Occupational

Therapist

Rehab

Consultant

Rehab

Consultant

CounsellorCounsellor

ProsthetistProsthetistWheelchair

Service

Wheelchair

Service

DieticianDietician

Diabetic Foot

Clinic/ Podiatry

Diabetic Foot

Clinic/ Podiatry

Surgical TeamSurgical Team

NurseNurse

PATIENTPATIENT

23/03/2017

6

Monitor and

reduce

dressings

Monitor and

reduce

dressings

Bandages/ drain

removal 1-3 days

post – op

Bandages/ drain

removal 1-3 days

post – op

Pain ControlPain Control

Anticoagulation

levels and return

to normal

medication

Anticoagulation

levels and return

to normal

medication

Stitches

removed ~ 10 –

14 days

Stitches

removed ~ 10 –

14 days

Medical &

Nursing

Medical &

Nursing

Encourage gradual independence

on the ward eg. Transfers, washing

and toileting

Post Operative Management & MDT Roles

Acute Post Op Physiotherapy Management

ReassuranceReassurance

Respiratory

Care

Respiratory

Care

Maintaining

ROM/Posture

Maintaining

ROM/Posture

Prevent

contractures

Prevent

contractures

StrengtheningStrengthening

Oedema

Control

Oedema

Control

Improving

Mobility

Improving

Mobility

Residual limb

care

Residual limb

care

Education/Health

Promotion

Education/Health

Promotion

Falls

prevention

Falls

prevention

Wheelchair

use

Wheelchair

use

Goal settingGoal setting

Timetabling

Inpatient

Activity

Timetabling

Inpatient

Activity

Say What You See!

23/03/2017

7

AKA – Prevent

Hip flex/ abd

contracture

BKA – Maintain

full knee

extension

Assess all UL/LL joints

Adequate Analgesia

Positioning

Education Stretching

PNF/ Manual therapy

Splinting

Positioning – Prevention of Contractures

Psychological impact (immediate or delayed)

Normalising altered body image

• Residual limb handling

• Moving the residual limb

• Use of appropriate language

• Visual feedback

• Support Group/ Limbless

Association

Reassurance / Acceptance of new body image

Pain / Phantom Limb pain or Sensations

EducationEducation

Adequate Pain ReliefAdequate Pain Relief

Self Management:

Massage/Residual Limb Handling

Self Management:

Massage/Residual Limb Handling

AcupunctureAcupuncture

TENSTENSGraded Motor

ImageryGraded Motor

Imagery

Mind – Body InterventionsMind – Body Interventions

ReassuranceReassurance

ExerciseExercise

23/03/2017

8

Phantom Limb Pain Evidence• Davies, A (2013)• Case study: PLP post above elbow amputation. Benefit for use of short acupuncture

sessions

• Mortimer et al (2002), • Well-conducted qualitative study, using focus groups. Patients need accurate and

timely information about phantom limb pain, and this should be provided by individuals with appropriate knowledge and training.

• Mulvey et al. (2012)• Pilot study: 10 TTA. Tens reduced pain at rest and on mvmt when TENS sensation was

projected into the main site of pain which was either the phantom limb or stump.

• Moseley, G. (2006)• RCT. 51 PLP or CRPS randomly allocated to 2/52 GMI or to PT and function. GMI

reduced pain and disability.

• Clark et al. (2012)• Customised postal questionnaire. 102 responses. 85.6%

prevalence of PLP. No significant difference between DM and control group.

• Moura et al (2012)• Literature review. Only studies of hypnosis, imagery and

biofeedback were found. Studies on meditation, yoga and tai chi were missing. Mind-body approach to PLP is promising

Residual Limb Oedema Control

Management

Rigid Dressings

Compression socks

W/c stump boards

Active exercises

EWA

Prosthetic limb use

Elevation

Medication

Management

Rigid Dressings

Compression socks

W/c stump boards

Active exercises

EWA

Prosthetic limb use

Elevation

Medication

Bed Mobility / Transfers

Transfer Day One Post OpTransfer Day One Post Op

HoistHoist

Slide BoardSlide Board

Forward/BackwardForward/Backward

Pivot (With/Without side panel)Pivot (With/Without side panel)

On/Off FloorOn/Off Floor

23/03/2017

9

Exercises

Mobility

Assess Standing BalanceAssess Standing Balance

EWA - PPam aid/ FemurettEWA - PPam aid/ Femurett

Stair AssessmentStair Assessment

Prosthetic mobility (early mobilisation

– VanRoss – 2009)

Prosthetic mobility (early mobilisation

– VanRoss – 2009)

Wheelchair mobilityWheelchair mobility

Benefits of early walking aids

Regain Mid LineRegain Mid LineIncrease exercise

tolIncrease exercise

tol

Improve joint ROM and m/s

strength

Improve joint ROM and m/s

strength

Reduce stump volumeReduce stump volume PsychologicalPsychologicalAssess

prosthetic suitability

Assess prosthetic suitability

Skin Preparation

Skin Preparation

23/03/2017

10

PPAM Aid – Adv/ DisadvAdvantages

Easy to use

Quick to donn

Cheap

De-sensitises stump

Reduces volume

Advantages

Easy to use

Quick to donn

Cheap

De-sensitises stump

Reduces volume

Disadvantages

Poor aesthetics

Heavy

No free knee mode

Limited length options

Non-durable

Disadvantages

Poor aesthetics

Heavy

No free knee mode

Limited length options

Non-durable

Femurett – Adv/ Disadv

Advantages

Very adjustable

Free+ fixed knee mode

IT weight bearing

Variable socket sizes

Advantages

Very adjustable

Free+ fixed knee mode

IT weight bearing

Variable socket sizes

Disadvantages

Poor aesthetics

TFA only

Timely and fiddly

Expensive

Disadvantages

Poor aesthetics

TFA only

Timely and fiddly

Expensive

GAS goalsGAS goals

SIGAMSIGAM

AmpnoProAmpnoPro

Outcome Measures

23/03/2017

11

Falls Prevention

MDT ApproachMDT Approach

Environmental ModificationsEnvironmental Modifications

ExerciseExercise

Medication Review/ MgmtMedication Review/ Mgmt

Gait training / walking aids provisionGait training / walking aids provision

EducationEducation

Appropriate socket fitAppropriate socket fit

Say What You See!

23-Mar-17

Falls Guidelines

http://bacpar.csp.org.uk/publications/guidance-

falls-prevention-lower-limb-amputees

23/03/2017

12

After 1-5 years, 26-53% of the dysvascularamputee population requires a second

amputation

Care of the remaining limb guidelines

(Izumi et al. (2006)

23-Mar-17

Residual Limb Care

http://bacpar.csp.org.uk/publications/risks-contra-lateral-

foot-unilateral-lower-limb-amputees-guideline

23-Mar-17

Residual Limb Care

23/03/2017

13

Health Promotion

Guidelines• Rehabilitation process should have an educational

element that empowers the patient and carers to take an active role in their present and future management (BACPAR, 2006)

On-going service referrals- Wellness Centre- Alcohol/ Drug liaison - Smoking Cessation- Dietician/ Nutritionalist- Diabetic Team- Podiatry- Therapy - Exercise promotion/ programmes- Community Active Health Schemes

Occupational Therapy

Assess the patient

Physical ability

Cognition, memory

Assess the patient

Physical ability

Cognition, memory

Assess home environment

For wheelchair

For prosthesis

Assess home environment

For wheelchair

For prosthesis

Equipment provisionEquipment provision

Discharge Planning

Inpatient rehab – generic or amputeeInpatient rehab – generic or amputee

RepatriationRepatriation

ICT or Community therapyICT or Community therapy

DSc Referral + OPD PTDSc Referral + OPD PT

Social services OTSocial services OT

OT report for re-housingOT report for re-housing

ReferralsReferrals

23/03/2017

14

Clinical guidelines for the pre and post operative Physiotherapy management

of adults with lower limb amputation

(BACPAR - 2006)

Evidence based Clinical Guidelines for Physiotherapy management of Adults

with Lower Limb Prostheses

(BACPAR - 2006)

Lower Limb Amputation: working together. A review of the care received by

patients who underwent major lower limb amputation due to vascular disease

or diabetes

(NCEPOD 2014)

Guidance for the multi disciplinary team on the management of post operative

residuum oedema in lower limb amputees

(BACPAR, 2012)

Amputee Rehabilitation Guidelines

Blundell, R., Bow, D., Donald, J., Drury, S. and Hurst, L. (2007) Guidelines for the prevention of falls in Lower limb amputees.BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/Amputee%20guidline1.pdf [accessed on 29th March 2016]

Brett, F., Burton. C., Brown. M., Clark, K., Duguid, M., Randell. And Thomas. D. (2012) Risks to the contra-lateral foot of unilateral lower limb amputees: A therapists guide to identification and management. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/secure/ka-final_contra_foot_guideline.pdf [accessed on 29th March 2016]

Broomhead, P., Dawes, D., Hancock, A., Unia, P., Blundell, A. and Davies, V. (2006) Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. London: Chartered Society of Physiotherapy [NB: review of guidelines currently underway]

Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert, A., Quinlivan, D., Randell, T., Shepherd,R. and Withpetersen, J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses. 2nd Edition. Chartered Society of Physiotherapy: London.

Bouch, E., Burns, K., Geer, E., Fuller, M. and Rose, A. (2012) Guidance for the multi disciplinary team on the management of post operative residuum oedema in lower limb amputees. London: Chartered Society of Physiotherapy

Hale, C., Shepherd, R., McBrearty, J. and Fletcher-Cook, P. (2008) Amputee Rehabiliation: A guideline for the education of undergraduate physiotherapy students. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/BACPAR%20student%20guidelines%20082.pdf [accessed on 29th March 2016]

Lower Limb Amputation: working together. A review of the care received by patients who underwent major lower limb amputation due to vascular disease or diabetes. Available from: http://www.ncepod.org.uk/2014report2/downloads/WorkingTogetherFullReport.pdf [accessed on 2nd March 2016]

Occupational therapy with people who have had lower limb amputations. Evidence-based guidelines (2011) http://www.cot.co.uk/sites/default/files/publications/public/Lower-Limb-Guidelines[1].pdf [accessed on 29th March 2016]

Ortho Europe. Introducing PPam Aid the pneutmatic post-amputation mobility aid. Hampshire: Ortho Europe. Available from: http://www.ortho-europe.com/products/PPAM/ppam-aid-brochure-2010.pdf [accessed on 29th March 2016]

MDT Guidelines References

1. Moxey PW, Gogalniceanu P, Hinchliffe RJ, Loftus IM, Jones KJ, Thompson MM, et al. Lower

extremity amputations--a review of global variability in incidence. Diabetic medicine : a journal of

the British Diabetic Association. 2011;28(10):1144-53.

2. Scott MH, Patel R and Hebenton J. A Survey of the Lower Limb Amputee Population in

Scotland, 2012. Scottish Physiotherapy Amputee Research Group, Glasgow. 2015

3. Papazafiropoulou A, Tentolouris N, Soldatos RP, Liapis CD, Dounis E, Kostakis AG, et al.

Mortality in diabetic and nondiabetic patients after amputations performed from 1996 to 2005 in a

tertiary hospital population: a 3-year follow-up study. Journal of diabetes and its complications.

2009;23(1):7-11.

4. Coffey L, Gallagher P, Horgan O, Desmond D, MacLachlan M. Psychosocial adjustment to

diabetes-related lower limb amputation. Diabetic medicine : a journal of the British Diabetic

Association. 2009;26(10):1063-7.

5. Ostler C, Ellis-Hill C, Donovan-Hall M. Expectations of rehabilitation following lower limb

amputation: a qualitative study. Disability and rehabilitation. 2014;36(14):1169-75.

6. Moxey PW, Hofman D, Hinchliffe RJ, Jones K, Thompson MM, Holt PJ. Epidemiological study

of lower limb amputation in England between 2003 and 2008. The British journal of surgery.

2010;97(9):1348-53.

References

23/03/2017

15

References

7. Mayor S. Less than half of people undergoing leg amputation get good care, inquiry warns.

BMJ (Clinical research ed). 2014;349:g6757.

8. Clark, R., Bowling, F., Jepson, F., and Rajbhandari, S. (2013) Phantom Limb Pain after amputation in diabetic patients does not differ from that after amputation in non diabetic patients. Pain, 154, pp. 729-732

9. Davies, A . (2013) Acupuncture treatment of Phantom Limb Pain and Phantom Limb Sensation in a primary care setting. Acupunct Med. 31, pp. 101-104

10. Mortimer, C. et al. (2002) Patient information on Phantom Limb Pain: a focus group study of patient experiences, perceptions and opinions. Health Educ Res. 17 (3) pp. 291-304.

11. Moura, V. L., Faurot, K., Gaylord, S., Mann, J., Still, M., Lynch, C., and Lee, MY (2012) Mind- body Interventions for Treatment of Phantom Limb Pain in Persons with Amputation

12. Mulvey, M., Radford, H., Fawkner, H., Hirst, L., Neumann, V and Johnson, M. (2012) Tanscutaneous Electrical Nerve Stimulation for Phantom Pain and Stump Pain in Adult Amputees. Pain Practise, 13, (4), pp.289-296.

13. VanRoss, E., Johnson, S., and Abbott, C. (2009) Effects of early mobilisation on unhealed dysvascular transtibial amputation stumps: A Clinical Trial. Arch Phys Med Rehab. 90, pp.610-617

Early Prosthetic Physiotherapy

ManagementKate Primett

Clinical Lead Amputee and Vascular Rehabilitation (BSc, PGc, MCSP, MBACPAR )

Royal Free London NHS Foundation Trust

27/03/2017

Prosthetic suitabilityProsthetic suitability

Prosthetic terminologyProsthetic terminology

Prosthetic suspensionProsthetic suspension

Socket designSocket design

Aims of prosthetic rehabilitationAims of prosthetic rehabilitation

Normal gaitNormal gait

Prosthetic gait training Prosthetic gait training

ContentsContents

23/03/2017

16

Not Suitable

Cognitive impairment

Hip contracture > 20 TFA

Knee contracture > 30 TT

Large open wound

Patient does not want one

Unable to sit – stand Ind.

Unable to stand for > 5 minsin bars – TFA only

Not used EWA

Medically unstable

Oedematous stump

Suitable

Wound healed

No contractures

Sit – stand Indep

Indep. Transfers

Medically stable

Has successfully used

EWA

Understanding of

prosthesis

When are patients ready for a prosthesis?When are patients ready for a prosthesis?

Proximal part of the prosthesis. Has direct contact with the residual limb

Used for TT prostheses to protect the skin. Made

from a variety of materials including polyurethane and silicone

The hardwear eg. the knee, foot and tibial tubes

Prosthetic TerminologyProsthetic Terminology

Socket

Liner

Componentry

Transtibial Prosthetic FittingTranstibial Prosthetic Fitting

23/03/2017

17

• Several techniques used to

capture the residual limb:

• POP casting

1. Hand casting

2. Pressure casting

3. Vacuum casting

• Scanning using Tracer Cad

Making a ProsthesisMaking a Prosthesis

Tolerant Areas

Patella tendon

Popliteal fossa

Para-tibial areas

Distal post aspect of stump

Pressure Relieving Areas

Patella

Tibial shaft, tibial tubercle

and cut end of tibia

Fibula head

Pressure Areas for TTAPressure Areas for TTA

Transtibial socket suspensionTranstibial socket suspension

How does the prosthesis stay on?

• Cuff strap

• Supracondylar

• Elastic rubber/gel/silicone

or suction sleeve

• Seal in liner

• Pin Lock system

• Belts

23/03/2017

18

Transfemoral ProstheticsTransfemoral Prosthetics

Ischial tuberosity weight bearing Ischial tuberosity weight bearing

Ischial containmentIschial containment

QuadrilateralQuadrilateral

TF and Knee Disarticulation Socket DesignTF and Knee Disarticulation Socket Design

How the prosthesis stays on?

• RPB (Rigid Pelvic Band)• Silesian RSS (Roehampton soft

suspension)• TES (Total Elastic Suspension) belt• Skin fit suction• Liner – Seal-in or pin lock• Self suspending

Transfemoral socket suspensionTransfemoral socket suspension

23/03/2017

19

Knees UnitsKnees Units

Locking –SAKL, HOKLLocking –

SAKL, HOKL

Uniaxial–safety

Uniaxial–safety

PolycentricPolycentric

Transfemoral Prosthetic ComponentryTransfemoral Prosthetic Componentry

Teach safe &correct donning & doffing until independentTeach safe &correct donning & doffing until independent

Close monitoring of skin / woundsClose monitoring of skin / wounds

Liaise with prosthetist re socket fitLiaise with prosthetist re socket fit

Set functional goals with patientsSet functional goals with patients

Progress mobility using prosthesisProgress mobility using prosthesis

Increase time prosthesis wornIncrease time prosthesis worn

Teach on / off floor with and without prosthesis onTeach on / off floor with and without prosthesis on

Teach stump hygieneTeach stump hygiene

Aims of prosthetic PhysiotherapyAims of prosthetic Physiotherapy

23-Mar-17

NO PULLING UP

NO SWIVELLING

NO HOPPING

23/03/2017

20

•A series of rhythmical, alternating movements of the trunk and limbs which result in the forward progression of the centre of gravity

•A series of controlled falls

DEFINED AS;DEFINED AS;

Normal GaitNormal Gait

Normal Gait Cycle

Pelvic rotationPelvic rotation Pelvic tiltingPelvic tiltingKnee

flexion/ExtensionKnee

flexion/Extension

Hip flexion/extension

Hip flexion/extension

Foot/Ankle mechanismFoot/Ankle mechanism

Lateral displacement of

the body

Lateral displacement of

the body

Minor: Neck and upper limb movement

Minor: Neck and upper limb movement

Determinants of Normal GaitDeterminants of Normal Gait

23/03/2017

21

Be aware of

normal gait patterns

Be aware of

normal gait patterns

Two vantage

points: Sagittal and Coronal

Two vantage

points: Sagittal and Coronal

Consider muscle

length and strength, joint

ROM, balance

and CV fitness

Consider muscle

length and strength, joint

ROM, balance

and CV fitness

Consideration

of symmetry

Consideration

of symmetry

Observe sitting,

standing, mobility and the

transition between each of

these

Observe sitting,

standing, mobility and the

transition between each of

these

Consider

prosthesis, patient biomechanics and

psychology

Consider

prosthesis, patient biomechanics and

psychology

Start at the base

of support and work up

towards head

Start at the base

of support and work up

towards head

Assessing GaitAssessing Gait

General condition

(pain, ex tol)

General condition

(pain, ex tol)

Shape, length, size of

residual limb

Shape, length, size of

residual limb

The prosthesis. Prosthesis Vs. Person

The prosthesis. Prosthesis Vs. Person

Inadequate re-educationInadequate

re-education

Psychological factors

Psychological factors

Bad habitBad habit

Compensatory patterns

Compensatory patterns

Amputee Gait ConsiderationsAmputee Gait Considerations

Say What You See!

23/03/2017

22

Weight transfer onto prosthesis –hip stability

Weight transfer onto prosthesis –hip stability

Equal stride length

Equal stride length

Rhythmical gait patternRhythmical gait pattern

Minimiseaccessory

m/s

Minimiseaccessory

m/s

Gait re-education (Transtibial)Gait re-education (Transtibial)

Walking indoors

Turning, twisting, carpet, stepping over

Mobilizing Outdoors

PavementsSlopesCurbsGrass

As above with frame, crutches and sticks

Impact loading and running for the more active patient

Single Leg Standing Exercises

- Ball rolling

- Step ups

- Trampette

- Hurdles

Dynamic Exercises

- Directional/ speed change

- Fuctional Tasks

- CV exercise training

Transtibial Gait Re-education ExercisesTranstibial Gait Re-education Exercises

Donning –sitting or standing

Donning –sitting or standing

Sit – standSit – stand

Weight transfer onto

prosthesis

Weight transfer onto

prosthesis

Swing through - ? Knee type

Swing through - ? Knee type

Transfemoral RehabilitationTransfemoral Rehabilitation

23/03/2017

23

Functional Activities Functional Activities

Return to HobbiesReturn to Hobbies

Return to Functional ADL’sReturn to Functional ADL’s

23/03/2017

24

Musculo –skeletal

Musculo –skeletal

Neurological -Normal

Movement

Neurological -Normal

MovementRespiratoryRespiratory

OrthopaedicOrthopaedic PsychologyPsychologyCommunication with other MDT

members

Communication with other MDT

members

Pathology/ Anatomy

Pathology/ Anatomy

Use your other core Physiotherapy skillsUse your other core Physiotherapy skills

There are a number of outcome measures validated for amputee rehab : There are a number of outcome measures validated for amputee rehab :

Activities-specific Balance Confidence Scale-UK Activities-specific Balance Confidence Scale-UK

Amputee Mobility Predictor Amputee Mobility Predictor

Houghton Scale Houghton Scale

Locomotor Capabilities Index-5 Locomotor Capabilities Index-5

Trinity Amputation and Prosthesis Experiences Scales Timed Up and Go Trinity Amputation and Prosthesis Experiences Scales Timed Up and Go

L-Test 28 Timed walk tests L-Test 28 Timed walk tests

Berg Balance ScaleBerg Balance Scale

BACPAR Toolbox of Outcome Measures. Version 2 (2014)BACPAR Toolbox of Outcome Measures. Version 2 (2014)

Outcome measuresOutcome measures

Broomhead, P., Clark, K., Dawes, D., Hale, C., Lambert, A., Quinlivan, D., Randell, T., Shepherd,R. and Withpetersen, J. (2012) Evidence Based Clinical Guidelines for the Managements of Adults with Lower Limb Prostheses. 2nd Edition. Chartered Society of Physiotherapy: London.

MJ Cole et al. (2014) BACPAR outcome measure toolbox version 2. Available from: file:///V:/GoogleChromeDownloads/toolbox_version_2.pdf [accessed on 29th March 2016]

Undergraduate physiotherapy students. BACPAR. Available from: http://www.csp.org.uk/sites/files/csp/BACPAR%20student%20guidelines%20082.pdf [accessed on 19th November 2013]

Prosthetic rehabilitation GuidelinesProsthetic rehabilitation Guidelines

23/03/2017

25

• Perry et al. (1992) Gait analysis: normal and pathological function. 2nd Edition

• Jeans et al (2011) Effect of amputation level on energy expenditure during

overground walking by children with an amputation. J Bone Joint Surg Am, Jan 5;

93 (1), pp 49-56.

• http://www.physio-pedia.com/Gait_Cycle

• Saunders, M, Inman, V, and Eberhart, H (1953) The major determinants in normal

and pathological gait. The Journal of Bone and Joint Surgery. 35, p. 543 – 558.

• Lord, S, Halligan, P, Wade, T (1998) Visual Gait Analysis: The Development of a

clinical assessment and scale. Clinical Rehabilitation. 12: 107 – 109.

• Engstrom, B and Van de Ven, C (2005) Therapy for amputees. 3rd edition. Churchill

Livingstone: London.

• Trew, M and Everett, T (1997) Human Movement. An introductory text. 3rd Edition.

Churchill Livingstone: London.

• Palastanga, N, Field, D and Soames, R (1998). Anatomy & Human Movement.

Structure and function. 3rd Edition. Butterworth-Heinemann: Oxford.

• http://plexuspandr.co.uk/uncategorized/gait-a-simple-break-down/

• VanRoss, E., Johnson, S., and Abbott, C. (2009) Effects of early mobilisation

on unhealed dysvascular transtibial amputation stumps: A Clinical Trial.

Arch Phys Med Rehab. 90, pp.610-617

ReferencesReferences

Any Questions?