Physiotherapy January 2003/vol 89/no 1

30

Do Rehabilitation andIntermediate Care ServicesFail Patients with PrimaryLower Limb Amputation?

Key WordsLower limb amputee,outcomes, standards,independence, intermediatecare.

by Sue EvansPenny ButtenshawGay Bineham

SummaryPurpose To review the type of follow-up service (including intermediate care) amputees receivefollowing lower limb amputation, and its influence on their resultant mobility and functional status.

Methods This multi-centre study involved 12 participating acute hospitals and two limb-fitting centres.Two questionnaires were used. The first was sent to physiotherapists at the acute participatinghospitals. They were asked to identify all patients who had undergone a lower limb amputation, over the period of the study, with their resultant mobility status, using the Harold Wood and Stanmore mobility grading scales (Hanspal et al, 1991) as shown in the appendix.The second was completed, by a research assistant, with prosthesis wearers six months after dischargefrom their acute prosthetic rehabilitation. This identified the type of follow-up received, mobility statusand amputee satisfaction with the service.

Finding� The level of functional mobility declined over the six-month period in those amputees who had

achieved up to grade III mobility at discharge (Baker, 1997; Hanspal et al, 1991). � There were major differences in the provision and standard of healthcare available even among

amputees attending the same limb-fitting centre (Baker, 1997).� A decision on amputees’ prosthetic functional outcome appears to be made early within the acute

period after surgery, and not subsequently reviewed (Austin and Clark, 1993).� Rehabilitation received by the amputees bore little resemblance to that actually planned at

discharge. The planned programme was not carried forward into the intermediate care stage andmight not allow amputees to reach their optimum functional level, as prosthesis or non-prosthesiswearers.

Conclusions A standardised co-ordinated structured approach to amputee rehabilitation for bothprosthesis and non-prosthesis wearers should be developed between the initial period of rehabilitation,intermediate care, specialist centres and the local point of service delivery. This would facilitate bestpractice, to enhance independent living for this patient group and their families.

Evans, S, Buttenshaw, P and Bineham, G (2003). ‘Do rehabilitation andintermediate care services fail patients with primary lower limbamputation?’ Physiotherapy, 89, 1, 30-38.

Physiotherapy January 2003/vol 89/no 1

31Research report

Authors

Sue EvansGradDipPhys MCSP isa lead physiotherapistat Hounslow PCT andwas the principalresearcher for thisproject.

Penny ButtenshawGradDipPhys MCSPis a clinical specialistin amputeerehabilitation at QuenMary’s HospitalRoehampton. As an expert in thisfield she advised andsupported the leadresearcher in allaspects of the project.

Gay Bineham BScRGN HV is researchand developmentfacilitator atHounslow PCT and offered a projectmanagement role aswell as advising onresearch design,ethics submissionsand collecting data.

This article wasreceived onSeptember 13, 2001,and accepted onAugust 15, 2002.

Acknowledgements

We would like tothank Steve Edwardsand Mary Pretty MBEfrom Queen Mary’sHospital Roehamptonfor their informationtechnology andadministrativesupport, and all thephysiotherapists fromthe participatinghospitals for theircontribution to thestudy.

BackgroundIt was noted by physiotherapists workingin the community and the limb fittingservice and evidenced in the literature,that the mobility grades of manyamputees decreased after completion ofgait training. (Dormandy and Ray, 1994).It was also noted that some amputeesare not referred to the local limb fittingservice because they have already beenassessed as non-limb wearers. Thesepatients rely on their wheelchairs withoutany form of follow-up or rehabilitation,and require expensive packages of carefrom local services (Dormandy and Ray,1994).

Project Aim It was therefore decided to look at theseaspects in more detail. The aim of theproject was to document the type offollow-up service amputees receivedfollowing lower limb amputation andrecord their resultant mobility status anduse of their prosthesis.

A literature search of the medical andprofessions allied to medicine public-ations using Medline and Cinahl databaseswas made using the key identifiers of‘lower limb amputation’, ‘prosthesis’,‘intermediate care’ and ‘rehabilitation’.The Chartered Society of Physiotherapy’sposition statement on rehabilitation and intermediate care in March 2001identified a large variation in healthcarestandards across the country and advisedon the need for reform. Prior to thisreport, the variation had also beenhighlighted by the Audit Commission(1995, 2000) in its reports on rehab-ilitation services for older people. Themost recent report identified that theintermediate care between hospital andhome was not uniformly available andthat services did not reflect the needs oflocal populations. It went on to say thattherapists were central to the delivery ofrehabilitation services, which was alsoacknowledged in the National ServiceFramework for older people (DoH, 2001).

The Chartered Society of Physiotherapy(2001) defined intermediate care as ‘The context in which patient focusedinterventions, including rehabilitation,can be organised and delivered by a rangeof professionals/agencies with the aim offacilitating independent living’.

Cutson and Bongiorni (1996) reviewedoutcomes over the last 25-30 years of

prosthetic rehabilitation in older patientswith a major lower limb amputation. Theysuggested that age alone should notdetermine prosthetic rehabilitation andthat despite the lack of improvement insurvival of patients with systemic vasculardisease there was a need for timelyrehabilitation to enhance the quality of theremaining years (Ward and Meyers, 1995).

Several studies have shown that goodprosthetic usage remains low in elderlypatients (Campbell et al, 1994; Haughtonet al, 1992). Buttenshaw and Dolman(1989) looked at the treatment of elderlypatients with amputation. The studyshowed that as a result of a daily treat-ment regimen the prosthesis became part of the patients’ everyday life and not just a walking device to be used in the physiotherapy department; 33% ofpatients showed improved functional useof the prosthesis six months after dis-charge from the primary rehabilitationepisode.

This project looked at people who hadundergone primary lower limb am-putation over a one-year period at acutehospitals in West London, South WestLondon and Surrey. Primary lower limbamputees were defined as any patientshaving their first unilateral or bilateralamputation of lower limbs.

MethodMulti-centre ethics approval was acquiredfor the participation of 12 acute hospitalsto be included in the study. Individualhospital local ethics approval was re-ceived. Two limb-fitting centres servedthese sites.

The project used two questionnaires,devised with the assistance of the clinicalaudit department at Queen Mary’s Hosp-ital Roehampton. The data collection toolwas also designed and formated by theaudit department. The department usedthe Formic Softwear Package, which is adata capturing computer package, withoptical character recognition andscanning facilities. The completed formswere returned to the clinical auditdepartment. The forms were scanned andthe data were validated before beingexported to a Microsoft Excel Spread-sheet and the Statistical Package for SocialSciences (SPSS version 10) for analysis.

The first questionnaire was completedby the physiotherapists in charge ofamputee rehabilitation at the part-

Physiotherapy January 2003/vol 89/no 1

32

icipating hospitals. They were asked toidentify all patients who had undergone a lower limb amputation during thedesignated study period of one year whofitted the following admission criteria:

� A primary lower limb amputee.� Over the age of 16 years (due to ethical

and consent problems).� Male and female.� All levels of lower limb amputation.� All diagnoses.� Unilateral and bilateral amputation.

Within the first questionnaire, thefactors listed below were determined.

� Sex.� Age group.� Level of amputation.� Diagnosis for amputation� Mobility status on discharge from acute

phase, using Harold Wood andStanmore mobility grades (appendix 1)(Hanspal et al, 1991).

� Discharge status (destination)� Type of follow-up predicted to be

arranged by acute trust on discharge.

The second questionnaire wascompleted during a face-to-face interviewwith the amputee by a third party who was not involved with the amputee’srehabilitation. This was carried out notless than six months after the amputee’sdischarge and following prostheticrehabilitation during the acute phase.Due to the variation in discharge proc-edure, referral and follow-up patternsacross the different centres, the acuteepisode was defined as the date on whichthe patient was discharged from initialprosthetic gait training.

The second questionnaire furtheraimed to identify:

� Diabetic status.� Current mobility status.� Type of follow-up received.� Frequency of each type of follow-up.� Patient's satisfaction with follow-up:

Helping to progress walkingChecking prosthetic fitAnswering questions, solving problemsOther areas of help/rehabilitationComments on overall experience.

ResultsDemographic FindingsData were collected over a 12-monthperiod to give a sample size of 166,obtained from 12 participating acutetrusts.

The demographic status of thepopulation sample was consistent with theNational Amputee Statistical Database forthe UK 1997/98 in the following criteria:

Age Patients had a median age of 71 years forwomen and 68 years for men with a min-imum age of 18 years and a maximum ageof 92 years. This compared with thenational median as demonstrated in theNational Amputee Statistical Database(UK) 1997/98.

Sex 66% of the patients were male and 33% female, which equates to thenational average of a 2:1 male: femaleratio for patients having undergone lower limb amputation (Condie et al,1996; Armstrong et al, 1997).

As shown in table 1 the highest numb-ers of patients were male aged 61-75 yearswith 44% of the sample population in this group.

DiagnosisThe reasons for amputation of the samplegroup were similar to those given in theNational Amputee Statistical Database(UK) 1997/98 as demonstrated below intable 2; 40% of the sample group haddiabetes mellitus.

Level of amputationTable 3 shows the level of amputationperformed in the sample group and thoseof the National Amputee StatisticalDatabase (NASDAB). Other papers (egDe Liccoa et al, 1992) showed similarpopulation statistics.

Table 1

Age range Male Female(years)

No % No %

16-30 6 5 3 5

31-45 8 7 3 6

46-60 77 44 4 7

61-75 48 16 18 33

76-90 30 27 27 49

90+ 1 1 0 0

Physiotherapy January 2003/vol 89/no 1

33Research report

Address forCorrespondence

Mrs S Evans,Physiotherapy,Ground Floor O Block, WestMiddlesex UniversityHospital, Isleworth,Middlesex TW7 6AF.

General Project FindingsTable 4 illustrates the number of patientswearing/not wearing their limbs, or whohad died, at discharge from the acutephase of rehabilitation.

MortalityOf the sample group of amputees 31%had died before discharge from theiracute stage of rehabilitation. From otherpapers this appears to be the highestmortality rate recorded in a study since1983 (Stewart et al, 1992).

Between 3% and 10% of patients can beexpected to die after an amputation at thetrans-tibial level and 20% at the trans-femoral level (Dormandy and Ray, 1994).

The percentage of patients who diedvaried considerably across the partic-ipating hospitals, with the lowest mortalityrate being 4% and the highest 86%. Thiswas across all age ranges, including bothpredicted limb wearers and non-limbwearers.

Discharge status From the first question-naire the discharge destination of bothlimb wearers and non-limb wearers isshown in table 5.

� The ultimate destination of amputeesgoing to community hospitals was notrecorded.

� 92% of prosthesis wearers weredischarged home independently or with carer input as compared to32% of the non-limb wearers.

� Table 5 also indicates that dependencylevel was markedly reduced in thosereceiving an initial prostheticrehabilitation package.

The findings from the non-limbwearers’ group showed that 57% weretotally dependent on a hoist or help fromone or more carers to transfer, 25% werewheelchair dependent and required helpwith transfers, and 18% were independentin wheelchair use.

Follow-up from ProstheticManagementTable 6 shows patients undergoing follow-up of their prosthetic management. Thisrefers to the planned and actual follow-upthe study population received.

Table 3: Level of amputation (percentages)

Level Study sample 1997/8 NASDAB

Bilateral transfemoral 4 4

Bilateral transtibial 3.0

Transfemoral 43 38

Knee disarticulation 1 3

Transtibial 48 51

Not recorded 1

Table 2: Reasons for amputation (percentages)

Condition Study 1997/8sample NASDAB

Vascular disease other 4

Peripheral vascular disease 79Non-diabetic 37Diabetic 40

Trauma 10 7

Infection 6 3

Carcinoma 1 3

Congenital abnormalities 2

Other 8

Table 4: Predicted mobility status (percentages)

Predicted All patients Excludingmobility status deceased patients

Limb wearer 51 75

Non-limb wearer 17 24

Not recorded 1 1

Died 31

Table 5: Percentages of patients dischargedhome to various locations

Discharge All Non-limb Limbdestination patients wearers wearers

Residential home 1 0 1

Community 12 29 6hospital with rehabilitation

Home With carer 17 21 16

Independent 60 11 76

Not recorded 3 10 -

Table 6: Follow-up percentages

Planned Actual

No follow-up 15 2

Review by doctor at 31 55limb-fitting centre

Community physiotherapy 4 1

Outpatient physiotherapy At original hospital 7 6At another hospital 28 2At limb-fitting centre 13 28

Other 1 6

Not recorded 1

Physiotherapy January 2003/vol 89/no 1

34

� The limb fitting centres followed-upthe majority of patients (83%).

� Only a small percentage received anyintermediate care delivered in theprimary care setting (1%) even thoughalmost 4% of patients were planned touse these services. (This in itself is avery low percentage.)

The second questionnaire administeredat six months after discharge from theacute stage looked at the actual follow-upthe patients received.

Table 7 demonstrates the frequency offollow-up that actually occurred, as rep-orted by the patient.

The frequency of follow-up received inthe acute outpatient physiotherapyservices, both at the limb-fitting centresand in the hospital setting, showed afrequent intensive service of once a weekor more.

Mobility Status FindingsFigures 1 and 2 show that: � Using the Harold Wood and Stanmore

mobility grades (Hanspal et al, 1991)the resultant functional mobility of thepatients at six months had declined inthose initially reaching grade III atdischarge.

� The above is more evident in olderpatients.

� Those achieving grade IV initially (upto the age of 60) tend to maintain orimprove their mobility status.

� For 12 patients mobility status haddecreased at six months.

� In 34 patients mobility was unchanged.� Only 18 patients’ mobility improved.

The majority of these patients were lessthan 45 years old.

Figure 3 shows the changes in mobilitystatus of patients reaching grade lllmobility and below in age groups 61 yearsand above, between discharge from theacute phase and six months later.

Patients’ Comment AnalysisThe second part of the final question-naire evaluated patients’ satisfaction withthe service they received and allowed forfree text comments.

A manual thematic analysis identifiedthemes of general satisfaction, levels ofintermediate care support, and ongoingadvice.

Table 7: Frequency of follow-up

Type of review More Weekly 2-3 times Monthly Every than per month six

weekly months

Review by doctor at 1 1 5 54 9limb-fitting centre*

Community physiotherapy 0 0 2 0 0

Outpatient physiotherapy At original hospital 2 3 0 0 0At another hospital 22 0 1 0 0At limb-fitting centre 22 2 0 2 0

Other prosthetist 0 0 4 10 0

* NB This form of follow-up is not an active rehabilitative treatment.

Mobility grades

16-30 years

Nu

mb

er o

f p

atie

nts

0I II III IV V

2

4

6

8

10

12

14

�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y31-45 years

46-60 years

61-75 years

76-90 years

�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y90+ years

�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�yMobility grades

16-30 years

Nu

mb

er o

f p

atie

nts

0I II IIIIII V VI

14

12

10

8

6

4

2

��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��@@��ÀÀ��yy�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y31-45 years

46-60 years

61-75 years

76-90 years

�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�y90+ years

�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�@�À�yFig 2: Mobility status at six months after discharge

Mobility grades

Discharge

Nu

mb

er o

f p

atie

nts

0Grade I Grade II Grade III Grade IV Grade IV Grade VI

25

20

15

10

5

6 months after discharge

Fig 3: Mobility status at discharge, and at six months, of patients in agegroups 61 years and above

Fig 1: Mobility status at discharge

Physiotherapy January 2003/vol 89/no 1

35Research report

In general patients reported being veryhappy with their initial rehabilitation(bearing in mind the patients interviewedwere only those who had received pros-thetic rehabilitation).

One patient commented: ‘I received excellent help and firmencouragement. I am now leading anormal life at a slower pace.’

However another patient noted: ‘Everybody does a good job but theyare very stretched.’

Although those interviewed were happywith their initial rehabilitation, manyraised concerns regarding the lack ofsupport and rehabilitation in theirintermediate care stage and felt that thesystem did not support them. Thesecomments were consistent with thefindings of the study.

Some individual comments included: ‘I needed more advice from thephysiotherapist regarding fit of limband problem solving.’

‘The home occupational therapyservices for adaptations were very slowand a fight to receive. The perceptionwas that [if] the patient has aprosthesis, he is going to walkregardless of other medical conditions.’(This patient’s mobility was severelyhampered following a stroke threemonths after his amputation.)

‘I was very pleased with the help Ireceived while on the unit and school,but once I went home, I did not get asmuch attention. I felt I could have donewith more back-up at home.’

‘Once having left the centre thepersonal attention disappears and youbecome another statistic/number.’

Discussion and RecommendationsAt the beginning of the study whenvisiting the participating hospitals it wasapparent during observation and dis-cussion with the local physiotherapiststhat a diversity of rehabilitation structureswas offered to amputees. Some centresreferred all patients who had undergoneamputation to be assessed after surgery bya limb-fitting service, while others usedlocally set criteria to make an informeddecision about referral. There was noevidence from the limb-fitting centres ofpatients who were designated at an early

stage as non-limb wearers ever havingfurther review of their prosthetic status.There also appeared to be no localprovision of further rehabilitation of non-limb wearers following acute hospitaldischarge, to reduce their dependency onlong-term care.

The demographic and diagnostic datacollected were similar to those recordedon the National Amputee StatisticalDatabase (1997-98), which suggests arepresentative sample and therefore givesvalidity and allows tentative general-isations to be made. Of the 64 patients forwhom comparative data were available,the patients’ functional mobility at sixmonths was very disappointing when com-pared to their mobility status on discharge.

It is acknowledged that although avalidated tool for assessment of mobilitygrading was used (Harold Wood andStanmore Grading Scale); the grading inthe two questionnaires used in our studywas by different clinicians, which mayhave caused some slight subjectiveassessment differences.

Rehabilitation/therapy services need toensure that indicators such as mobilitygrades are documented and used in theformulation of intermediate rehabil-itation programmes. The results suggestthat the ‘at risk group’ – those scoringgrade III and below on the mobility scales – would need a more intensiverehabilitation programme to facilitatetheir independent living and reducedependency on high cost care packages.

What would have happened to thepatient mobility outcomes if the plannedintermediate care services had beenadministered? Would this have made animpact on the resultant functionalmobility of the patients at six months,which showed a decline in the older ageranges initially reaching Harold Woodand Stanmore mobility levels of grade III(Hanspal et al, 1991) and below atdischarge. If a structured co-ordinatedapproach to amputee rehabilitation wereapplied at this intermediate stage, thispatient group might be more likely toremain functionally independent.

The findings appear to indicate thatthere are no standards adopted for theintermediate stage of care for theseamputees. The care they receive dependson local service provision and the localcriteria for referral to regional limb-fittingcentres.

Physiotherapy January 2003/vol 89/no 1

36

There are no standardised care guide-lines (Baker, 1997) for patients withprimary lower limb amputation. All thehospitals appeared to use differentcriteria when assessing patients’ suitabilityfor limb-fitting referral. Some hospitalsreferred all patients and others only thepatients deemed to be potential limbwearers by a physiotherapist, oftendecided at an early stage after surgery.Although not specifically addressed by thequestionnaire, there appeared to be noprovision for reviewing the limb-wearingstatus of non-limb wearers either by limb-fitting centre staff or by professionals atthe original hospital after a period oftherapeutic treatment. This put thepatients classified as non-limb wearers at adisadvantage, with no opportunity forreview.

Standardised guidelines for referral ofpatients to limb-fitting centres, withreview of those seen as non-limb wearers,need to be agreed and implemented toenable an equitable service to be offeredto this patient group (Little and Sapp,1995). Local rehabilitation services needto be available to non-limb wearers toreduce their possible dependency level on long-term care and allow them theopportunity to return to their own homes.The Chartered Society of Physiotherapyand the Audit Commission (CSP, 2001;AC, 1995) would consider this the role ofintermediate care.

The Audit Commission’s report in 2000stated that it is vital that access to rehab-ilitation programmes is available to allpeople who present with a potential tobenefit from intervention. The serviceshould be organised in a flexible way sothat it is accessible through differentroutes. If this approach is to be adopted,co-ordination within the rehabilitationteam becomes paramount to minimiseduplication of effort, or prevent patientsfrom becoming lost in the system. In itsposition statement, The Chartered Societyof Physiotherapy conclusions mirror thesefindings.

From our finding there is a decline inmobility status of those achieving gradeIII following initial rehabilitation,particularly in older patients. Whenplanning follow-up care few therapistsplanned for community/primary careservices to be involved in intermediatecare of these patients. This may bebecause there is a lack of therapy

resources in these settings for amputees.Alternatively there may be a lack ofspecialist support for therapists dealingwith a patient group who require spec-ialist input to meet their rehabilitationneeds.

Prosthetics provision and long-termcare packages are expensive, so it isimperative that intermediate rehab-ilitation is adequately resourced andstructured. This will help to ensure thatprosthesis wearers can reach theirfunctional optimum to allow for long-term prosthetic use and that expensiveprostheses are not used just for hospitaloutpatient appointments or lodged incupboards. It may help to ensure thatnon-prosthesis wearers will be followed-up, reviewed, and directed to appropriaterehabilitation, thereby reducing depend-ency on long-term care packages.

Our findings mirror those of the AuditCommission’s reports on rehabilitationservices for older people (AC, 1995,2000). The report stated that inter-mediate settings between hospital andhome, which provide more activerehabilitation and confidence building,cost half as much as hospitals, but werenot uniformly available. This is alsoreflected in the comments made by theservice users. The Audit Commission’sreport states that therapists are central tothe delivery of rehabilitation services, yetstaffing is often based on a historicalstructure rather than a service beingcommissioned to reflect the needs of thelocal population. This may explain whythe follow-up care offered in an acutehospital outpatient setting gives a highfrequency of 1-2 outpatient treatmentsper week. This could reinforce patients’dependency on the medical system andnot promote a rehabilitative philosophyof empowerment and facilitation of ind-ependence, as promoted by intermediatecare.

The findings identify a need toformulate guidelines for ongoing multi-disciplinary team review of these patientsas to their suitability for limb fittingthroughout a 12-month period followingamputation. There is also a need toensure intermediate rehabilitation andreview is ongoing. If we are to achievethese important changes to the serviceprovided to this patient group, there is aneed to cascade expert knowledge fromspecialist centres to local services pro-

Physiotherapy January 2003/vol 89/no 1

37Research report

viding intermediate rehabilitation. Regional clinical amputee specialist

posts could achieve this provision. Theirrole might include:� Dissemination of knowledge and best

practice.� Co-ordinating the structure of

intermediate rehabilitation for thispatient group.

� Standardisation of quality care toensure equality of service to all patientsregardless of location, as highlightedin the media as the ‘post code lottery’.

� Organisation of network groups fortherapists across the primary andsecondary care settings.

� Reflective practice experience with thispatient group to develop local servicesprogressively.

� Helping locally based therapists tofacilitate involvement of service userswithin these networking groups.

Throughout this study, it was of concernthat a high percentage of the total groupdied before acute hospital discharge.There was such a wide variation in survivalrates between hospitals, particularly as themajority of these patients were seen as

prosthetic limb wearers, that it can be assumed that most of these patients werenot predicted to have any major post-operative complications at the time thedecision was made. However no furtherdata are available to determine likelycauses. This needs to be addressedthrough the local hospital's audit process.

This study demonstrates the need for amulti-agency structured team approach tointermediate rehabilitation services forthis vulnerable patient group. There is aneed for the adoption of nationalstandards to inform the plan of care for these patients. Collaborative servicesneed to be established between primaryand secondary care to enable patients toreceive seamless rehabilitation in anappropriate setting. Professionals requireaccess to continuing professional dev-elopment programmes for this specialistpatient group which could be delivered bya clinical amputee specialist whose rolewould be one of setting and monitoringstandards as well as education and train-ing.

This group of patients should be giventhe opportunity to achieve their optimumfunctional ability either as prosthesis ornon-prosthesis wearers.

Appendix

Harold Wood and Stanmore Grading Scale

I Cosmetic Limb wearing abandoned, or use of cosmetic limb only

II (incl IIa) Therapeutic Wears the prosthesis only for transfer for up to 3 hours per day

(III incl IIIa-c) Indoors Walks only with a therapist or carer for less than a quarter of that time

(IV incl IVa-c) Outdoor

V Independent Uses the prosthesis between 3-14+ hours per day walking indoors one- to three-quarters of the time worn. Uses the prosthesis 3-14+ hours per day walking between one-quarter and 3 miles. Independent indoors and outdoor walking with no walking aids except for occasional confidence or to cover difficult conditions

VI Normal Normal or near normal gait

Physiotherapy January 2003/vol 89/no 1

38

References

Armstrong, D G, Lavery, L A, Harklegs, L Band Von Hontum, W H (1997). ‘The impact ofgender on amputation’, Journal of Foot andAnkle Surgery, 36, 1, 66-69.

Audit Commission (1995). RehabilitationServices for Older People, HMSO.

Audit Commission (2000). The Way to Go Home:Rehabilitation and remedial services for older people,HMSO.

Austin, C and Clark, C R (1993). ‘Measures ofoutcome for whom?’ Journal of OccupationalTherapy, 56, 1, page nos?

Baker, R (1997). ‘What is the role of evidence-based guidelines?’ Health Care Risk Report,February.

Buttenshaw, P and Dolman, ? (1992). ‘TheRoehampton approach to rehabilitation: A retrospective survey of prosthetic use inpatients with primary unilateral lower limbamputation’, Topics in Geriatric Medicine, 1, 72-78.

Chartered Society of Physiotherapy (2001).Rehabilitation and Intermediate Care, positionstatement, CSP, London.

Condie, E, Jones, D, Treweek, S and Scott, H(1996). ‘A one-year national survey of patientshaving a lower limb amputation’, Physiotherapy,82, 1, page nos?

Cutson, T M and Bongiorni, D R (1996).‘Rehabilitation of the older lower-limbamputee: A brief overview’, Journal of theAmerican Geriatrics Society, 44, 11, 1388-93.

Campbell, W B, St Jognson, J A, Kernick, V Fand Rutter, E A (1994). Lower limb amput-ation: Striking the balance, Annals of the RoyalCollege of Surgeons of England, 76, 3, 205-2099.

De Liccoa, N, Desouza Pinto, M A G, Guedes,J P B and Alkers, M T V (1992). ‘Rehabilitationafter amputation for vascular disease: A follow-up study’, Prosthetics and Orthoties International,16, 124-128.

Department of Health (2001). The NationalService Framework for Older People, StationeryOffice.

Dormandy, J A and Ray, S A (1994). ‘The fateof amputees’, Medical Review, 5, 331-346.

Hanspal, R S, Fisher, K, Chakraberty, B,Morton, M and Roberts, A (1991). ‘Mobilitygrades in amputee rehabilitation’, ClinicalRehabilitation, 5, 331-344.

Haughton, A D, Taylor, P R, Thurlow, S,Rootes, E and MColl, I (1989). ‘Success ratesfor rehabilitation of vascular amputee:Implications for pre-operative assessment andamputation level’, British Journal of Surgery, volno?, 753-755.

Little, C G and Sapp, L (1995). ‘Functionaloutcomes in a lower limb amputeepopulation’, Prosthetics and OrthoticsInternational, 19, 92-96.

National Amputee Statistical (UK) DatabaseAnnual Report 1997/8, ISD, Scotland.

Stewart, G P U, Jain, A S and Ogstow, S A(1992). ‘Lower limb amputee survival’,Prosthetics and Orthotics International, 16, 11-18.

Ward, K H and Meyers, M C (1995). ‘Exerciseperformance of lower extremity amputee’,Sports Medicine, 20, 4, 207-214.

Key Messages

� There is inconsistency in theintermediate care for this patientgroup.

� There are discrepancies inrehabilitation service provision evenin the small geographical sample areaof the study.

� Function and mobility gradesdecrease over the following sixmonths for those achieving mobilitygrade III and below at discharge.

� There is little evidence thatphysiotherapy services offer re-assessment facilities to reviewpatients’ needs.

� Dissemination of specialist knowledgeis needed to enable local standards tobe met for co-ordinatedrehabilitation.