Amputee Rehabilitation

Original Editor - Liezel Wegner and Caroline Cater as part of the World Physiotherapy Network for Amputee Rehabilitation Project

Top Contributors - Admin, Stacy Schiurring, Sheik Abdul Khadir, Jess Bell, Tony Lowe, Chrysolite Jyothi Kommu, Kim Jackson, Aminat Abolade, Alexandra Stead, Olajumoke Ogunleye, Shaimaa Eldib, Karen Wilson, Simisola Ajeyalemi, Tarina van der Stockt, Richard Benes, Naomi O'Reilly and Oyemi Sillo

Page Summary

• Lower limb amputation rehabilitation follows nine phases, from pre-operative assessment through surgery, pre-prosthetic and prosthetic training to community integration, vocational rehabilitation and lifelong follow-up.
• The rehabilitation team includes physiotherapists, prosthetists, occupational therapists, nurses, psychologists, physicians, social workers and surgeons, with the patient and carers as central members.
• TInterdisciplinary teams share goals and engage in joint problem-solving with overlapping practice, and many limb centres are shifting towards this from parallel multidisciplinary working.
• Outcomes after amputation depend more on team coordination than any single profession’s input.

Introduction

The loss of a lower limb has significant implications for a person’s mobility and ability to perform activities of daily living, negatively impacting their participation and integration into society. The ultimate goal of rehabilitation after lower limb loss is the highest achievable level of mobility, which for many people is ambulation with a prosthesis, and a high level of social reintegration. However, many people experience poor physical function and psychosocial outcomes after lower limb amputation, which can be worsened by under-informed prosthesis-user expectations. Prosthetic rehabilitation is a complex task best delivered by a transdisciplinary rehabilitation team.

The Nine Phases of Rehabilitation After Lower Limb Amputation

The rehabilitation process for a person with a lower limb amputation is traditionally described in nine phases. These phases were first proposed by Esquenazi & Meier and are still widely used as the organising framework for amputation rehabilitation services. The roles and responsibilities of the physiotherapist across this pathway are now set out in detail in the British Association of Chartered Physiotherapists in Limb Absence Rehabilitation (BACPAR) evidence-graded clinical guideline (3rd edition, 2025).

Table 1. Phases of amputee rehabilitation, modified from Esquenazi & Meier

Phase	Hallmark
Pre-operative	Assess body condition, patient education, surgical level discussion, postoperative prosthetic planning
Amputation surgery/reconstruction	Length, myoplastic closure, soft tissue coverage, nerve handling, rigid dressing
Acute post-surgical	Wound healing, pain control, proximal body motion, emotional support
Pre-prosthetic	Shaping, shrinking, increasing muscle strength, restoring patient locus of control
Prosthetic prescription	Team consensus on prosthetic prescription and fabrication
Prosthetic training	Increasing prosthetic wearing time and functional utilisation
Community integration	Resumption of family/community roles, emotional equilibrium, coping strategies, recreation
Vocational rehabilitation	Assess and plan future work activities; may need further education, training, or job modification
Follow-up	Life-long prosthetic, functional, medical, and emotional review

Throughout all nine phases, the rehabilitation treatment plan guides care. This plan is based on assessments from each specialty involved, and the whole team uses it to track the goals agreed with the patient and their family. The scope of the rehabilitation intervention is considered from hospital admission, refined after surgery, and finalised before discharge. It covers ongoing medical assessment of impairments, and therapy interventions addressing disability and activity limitation.

The Rehabilitation Team

Rehabilitation for limb loss is a multidisciplinary undertaking. Professionals commonly involved are listed in Table 2.

Table 2. Multidisciplinary team in rehabilitation for limb loss

Professional	Role
Physiatrist / rehabilitation physician	Medical oversight of rehabilitation. In some models, also leads the team and the rehabilitation process
Physiotherapist	Pre-operative assessment and education, early mobility and transfers, residual limb management, strengthening and balance, pre-prosthetic and prosthetic gait training, and contralateral limb care. In some models, also coordinates the team
Prosthetist	Casting, fabrication, and ongoing management of the prosthesis
Occupational therapist	Home/work environment assessment and adaptation, ADL retraining
Nurse	Specialist wound care
Psychologist/counsellor	Cognitive support, psychological adjustment support
Dietitian	Nutrition education, particularly with poorly controlled diabetes
Physician	Medical management, including phantom pain
Social worker	Financial/disability support, discharge planning, case management
Podiatrist/foot care specialist	Contralateral limb risk management
Vascular/plastic/orthopaedic surgeon	Surgical planning and management, wound coverage
Recreational therapist / adaptive sports provider	Return to leisure and sport
Amputation support group	Peer support
Patient and carer(s)	Central members of the team; goal-setting, decision-making, and day-to-day self-management

The exact composition of the team, and who leads at each phase, varies by setting and resourcing. For examples of how this pathway can be adapted where specialist resources are limited, please see Physical Disabilities Rehabilitation in Africa and Rehabilitation of Amputations in Disasters and Conflicts.

Two Leadership Models: Physiotherapist vs Physiatrist

Learners working internationally will encounter two different models of who formally leads the team, and it is worth recognising both rather than assuming one is universal. In some services, the physiotherapist coordinates rehabilitation care across the pathway, and the BACPAR guideline sets out the physiotherapist’s role at each phase. Others, including the current VA/DoD amputation care team model used across the US Veterans Affairs and Department of Defense systems, position a physiatrist (a physical medicine and rehabilitation physician) as team leader, responsible for the rehabilitation process from assessment through lifelong management. In this model, physiotherapy and occupational therapy operate in close collaboration under that leadership. Neither model is "correct" in an absolute sense. Rather, they reflect different national healthcare structures and scopes of practice. What matters clinically is that every team member understands who holds coordinating responsibility in their own service, since ambiguity about this role is itself a recognised source of poor communication and delayed care.

Multidisciplinary vs Interdisciplinary Working

Two working models are described in the literature:

Multidisciplinary team (MDT): professionals from different disciplines work in parallel, each setting their own discipline-specific goals and communicating outcomes to the rest of the team where relevant.

Interdisciplinary team (IDT): goals are shared and practice overlaps rather than running in parallel; professionals engage in joint problem-solving, with regular communication built into the process rather than added afterwards.

Many limb centres are shifting from MDT towards IDT working, on the premise that closer, overlapping collaboration between prosthetists, physiotherapists, and physicians produces better outcomes than coordinated-but-separate input.

Communication Within the Team

Regular, structured communication is what turns a list of professionals into a functioning team. Common mechanisms to improve communication are discussed below.

Goal-setting meetings, typically fortnightly (every two weeks) or monthly, where the team reviews progress against patient-defined goals, using a formal outcome measure where the service has one in place. Please see Outcome Measures for Patients with Lower Limb Amputation to learn more.

Regular case conferences, particularly during inpatient and early prosthetic phases, to surface concerns early and agree a joint approach to problem-solving.

Shared digital systems (e.g. secure messaging, shared records, video conferencing) for teams spread across satellite clinics or multiple sites. However, this option will only be successful if every team member is trained on the system and checks it consistently.

Whichever mechanism is used, the underlying principle is the same: without a reliable channel for referral and information-sharing, even a well-staffed team can produce delays and missed referrals.

Clinical Implications

Outcomes after lower limb amputation are shaped less by any single profession's input than by how well the team coordinates across phases. A patient can receive excellent surgical care and still have a poor functional outcome if pre-prosthetic shaping is inadequate or if psychosocial adjustment is missed. Poorly timed handover between phases is likewise associated with delayed discharge and missed referrals. Recognising where you sit in this nine-phase pathway, and who else needs to be involved at each stage, is not a peripheral administrative concern. It is as central to good clinical practice as any individual technical skill. Strong team coordination drives successful interventions.

Additional Resources

This video highlights the role of the multidisciplinary team in rehabilitation for limb loss using case study examples.

Clinical Resources

• Beckley AA, Wong CK. Implementation of an evidence-based multidisciplinary post-operative lower extremity amputation protocol (LEAP): barriers, facilitators, and strategies. Implementation Science Communications. 2025 Nov 18;6(1):125.
• Burii O, Oliinyk R, Dushenko S, Nahornyi D, Kosovska M, Lykhach V, Soroka N. The role of a multidisciplinary team in the rehabilitation of a patient with quadruple amputation. Journal of Rehabilitation Medicine. 2026 Jan 14;58:jrm44843-.
• Clinical guidelines for the pre- and post-operative physiotherapy management of adults with lower limb amputations. 3rd ed. (BACPAR, 2025)
• Multidisciplinary Care of Lower Limb Amputations webinar presentation slides (Gary Clark, MD; Paradigm Medical Director)