Discharge management of the amputee

Original Editor - Islem Cheriet and Ahmad Abdal Qader Hasan Al-Mosa

Top Contributors - Sheik Abdul Khadir, Admin, Jess Bell, Ewa Jaraczewska, Kim Jackson, 127.0.0.1, Tony Lowe, Tarina van der Stockt, Simisola Ajeyalemi and Karen Wilson  

Introduction

Discharge marks the point at which a patient moves from structured rehabilitation to managing life with their amputation at home. A well-planned discharge means that the patient leaves with the skills and support needed for self-care and daily function. Because prosthetic use and health status change over time, progress should be reviewed at intervals rather than only at the point of discharge.

Core Outcomes and the ICF

The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is a useful framework for discharge planning, as it considers environmental and personal factors, as well as body functions and structures, activities and participation. A core outcome set developed for people with lower-limb amputation identified the areas that matter most to this group: pain and sensory function; neuromusculoskeletal and movement function; general tasks and demands; mobility; and products and technology, including prostheses and mobility aids.

Environmental and Home Assessment

Before discharge, physiotherapists and occupational therapists should assess environmental factors. By working with the patient and their family, the team can identify any necessary home modifications, changes to daily activities, or a move to assisted living facilities.

Role of the Family and Caregivers

Family and caregivers play an important part throughout rehabilitation, and adapting to the new situation is a challenge for them as well as the patient. As discharge approaches, a shared understanding of each person's role helps the transition, so training and advice should encourage discussion and reflection on those roles. The team should also show family and caregivers the practical tasks they may need to help with, such as bandaging, transfers, and preventing complications. Involving them in exercises and home programmes supports consistent care once the patient is home. Family and caregivers may feel their own sense of loss and find the added responsibility difficult. They should be provided with psychological support as appropriate.

Managing at Home After Discharge

Discharge is the moment where day-to-day management passes from the team to the patient and, often, their family. In order to transition safely home, the rehabilitation team must ensure the patient has sufficient skills and information to stay active, care for their residual limb and prosthesis, and know which warning signs to act on. Structured patient education supports this. The following sections cover important patient education topics.

Physical Activity

Physical activity levels are typically lower in people with lower-limb amputation than in the general population, which has consequences for overall health. Encouraging the person to resume daily activities on discharge builds independence and confidence with a prosthesis. Targeted exercise can improve aerobic capacity, strength, and functional performance in this population, and also support social engagement, quality of life and psychological wellbeing. In preparation for discharge, the physiotherapist should provide an exercise plan, detailing any precautions and activity restrictions.

Residual Limb Care and Prosthetic Hygiene

The patient needs to understand how to care for their residual limb. Depending on the stage of wound healing and medical advice, they will either keep the wound clean and dry or, once dressings have been removed, wash the residual limb daily with mild soap and water and dry it well. The residual limb should be inspected daily for redness or skin changes, with attention to hygiene and sweat management. The patient also needs to understand how to look after their prosthesis, including how long to wear it, how to build wear time up, and how changing footwear can affect socket fit and alignment. Patients should be aware that an ill-fitting socket can cause skin problems and should be reported. They should also be taught to manage phantom limb pain and sensation, to understand the factors that affect wound healing, and to prevent and manage scar adhesion.

Care of the Remaining Limb

For people with diabetes, careful monitoring of the remaining foot, appropriate footwear, and early referral to podiatry or orthotics are important. For more information on the role of the physiotherapist in footcare, see: Risks to the Contra-lateral Foot of Unilateral Lower Limb Amputees.

Falls and Falls Prevention

Falls are common after lower-limb amputation. Before discharge, the person should understand that their falls risk is raised, and rehabilitation should include how to prevent falls, how to get up from the floor, and what to do if they cannot. Anyone reporting falls or a fear of falling should be offered further balance training.

Emergency and Follow-Up Care

Following discharge, the patient should know when to contact the medical team or doctor. Signs to watch for include:

• A residual limb that looks more red
• Skin around the residual limb that feels warmer
• Swelling or bleeding around the wound
• A foul smell from the wound
• Other signs of infection, such as fever or chills
• Pain not well controlled by the prescribed medication
• Medication side effects, such as dizziness, nausea, or confusion
• Any further questions about the amputation or residual limb care

Social Inclusion

Reintegrating into social networks is an important part of recovery and should not be overlooked. Social inclusion can be considered across three levels: the home and private environment, work and school, and the wider community. Advice and support can be tailored to each level, and a person's wellbeing, self-esteem, and sense of being respected depend on how these levels come together.

Return to Work or School

Employment is an important social determinant of health, yet return-to-work rates after lower limb amputation vary widely, with reported rates between 48% and 89% in civilian populations. Return to work is linked to greater daily prosthetic use and is influenced mainly by physical functioning, demographics, and vocational history. People with dysvascular amputations have particular difficulty, with fewer than one-third returning to work. This reflects physical limitations and socioeconomic barriers, such as access to healthcare.

Factors influencing return to work are described in the following table.

Factors influencing return to work

Factors	Description
General factors	Age Gender Educational levels
Disability-related factors linked to the amputation	Amputation level Comorbidities Persistent residual limb issues Comfort with the prosthesis Walking distance or other mobility restrictions
Work-related factors	Salary Job involvement Support network provided by the employer

Because returning to work is a common goal and a marker of successful rehabilitation, healthcare teams should provide vocational counselling and rehabilitation to support the person's return. This works best when rehabilitation professionals, occupational health physicians, and employers work together.

The Vocational Rehabilitation Association of the UK uses a cyclical process: assessing skills and readiness, setting goals, and providing psychosocial support to manage the impact of the disability; then career counselling or job placement, which may include further training; followed by reassessment of work capacity, with further adjustment as needed.

For younger patients, a similar approach supports a safe return to school and daily activities. It involves assessing the physical and psychosocial environment and working with parents to support life with the new prosthesis.

Community and Sports Activities

Sport and social activity help people with lower-limb amputation stay active and support wellbeing, confidence, and social reintegration. They can also help prevent secondary health complications and connect people with others, which for some builds the confidence to take on wider roles in their communities. Discharge planning should therefore connect the person with local support groups and adaptive sport, whatever their age or level of independence.

Psychological Support

Grief and bereavement are common after limb loss. Physiotherapists can help by actively listening and referring individuals to mental health counselling and psychological support when needed. Peer support groups give people a chance to share experiences and connect with others facing similar challenges, which can offer fresh perspective and a sense of belonging at a time when limb loss can otherwise bring isolation. Organisations such as the Amputee Coalition connect people with amputation and their caregivers to others. The following video looks at daily life with a prosthesis and the importance of mutual support.

BACPAR Discharge Recommendations

The British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) has published clinical guidelines for the physiotherapy management of adults with lower-limb prostheses, including recommendations on discharge and maintenance.

• There should be a process for regular review using outcome measures within the first year of discharge from physiotherapy
• The person should have a clear route to self-refer to physiotherapy after initial rehabilitation
• The person should be aware of the benefits of regular physical activity and encouraged to access community services
• Physiotherapists should be aware that patients may develop secondary musculoskeletal conditions (e.g. low back pain), and understand how this can affect prosthetic use
• A person should be able to access further assessment and intervention if their circumstances change

Additional Resources

• Amputee Coalition. Publication Library