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Post-fitting management of the amputee

Original Editor - Alex Coelho and Duarte Pereira as part of the World Physiotherapy Network for Amputee Rehabilitation Project

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Post-Fitting Physiotherapy Principles

Physiotherapy in the post-fitting phase supports a person with a lower-limb amputation to achieve functional independence, building on the objectives established in the pre-prosthetic phase. As in other stages of rehabilitation, the physiotherapist works within a multidisciplinary team (MDT), and management is an ongoing process.

A comprehensive assessment incorporates subjective and objective components. It evaluates the trunk and all extremities and considers the patient's emotional and cognitive state, as well as their social and home environments. Clinicians are responsible for monitoring key indicators, including diabetic status, skin integrity, oedema, and sensory function. Relevant, validated outcome measures are essential for tracking rehabilitation progress and functional improvements.[1]

Physiotherapy treatment addresses lower limb range of motion, strength, balance, coordination, agility, and endurance, as well as postural control, weight-bearing, and proprioception, which are all needed for efficient prosthesis control. Specific strengthening and stretching programmes also help prevent and correct gait deviations.[1] Interventions should be adjusted as the patient’s physical and functional status changes.

"The aim of prosthetic rehabilitation is to achieve maximum independence and safety with minimal extra energy expenditure. The individual’s rehabilitation programme should consider their pre-amputation lifestyle, expectations and medical limitations."[1]

Range of Motion Assessment and Intervention

Joint contractures can greatly hinder efficient prosthetic ambulation, and care should be taken to avoid them. The most common contractures following transfemoral amputation are hip flexion, external rotation, and abduction. Knee flexion contracture is the most common contracture in people with transtibial amputation.[2]

Assessment

Active and passive range of motion of the residual limb is measured with a goniometer (i.e. hip flexion and extension, and, in transtibial amputation, knee flexion and extension). The trunk, upper limbs, and intact lower limb are also assessed.

During the passive range of motion assessment, the therapist should distinguish between a fixed contracture and soft-tissue tightness from immobility (which can be corrected within a relatively short period). As shown in the following video, a modified Thomas Test can be used to assess muscle length around the hip.[3]

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[3]

Intervention

The residual limb should always be properly positioned to avoid contractures that could interfere with prosthetic fit and ambulation.[4] In a transtibial amputation, the residual limb should be kept in knee extension when in bed. For a transfemoral or transtibial amputation, the residual limb should be kept in neutral alignment for adduction/abduction and internal/external rotation. At no time should a pillow be placed under the residual limb.

A stretching programme should be implemented and the patient should be educated on the importance of active exercises to help prevent contractures and, where appropriate, extension splints.[1] A prone lying programme has often been used to help to prevent hip flexion contractures. Time spent prone should be progressively increased, starting with what the patient can tolerate and progressing as tolerated (aiming for 30 minutes twice daily, if possible), but care must be taken to avoid compensatory anterior pelvic tilting. The modified Thomas test position may also be used to help maintain hip flexor length.[5] Where contractures have already formed, management strategies should be discussed with the MDT.[1]

Sensation and Pain Assessment and Intervention

Sensation and Care of the Remaining (Intact) Limb

Physiotherapists should continue to observe and document the condition of the patient's remaining limb. This is particularly important for people with a history of peripheral neuropathy, diabetes, or peripheral vascular disease (PVD). Patients and their family/carers must be taught how to monitor the condition of their remaining limb. Specific management strategies for the remaining limb include positioning, pressure relief and the use of orthoses or prescribed footwear.[1]

The monofilament test (Semmes-Weinstein sensitivity test kit) can help identify loss of protective sensation (LOPS), particularly in people with a history of diabetes, nerve injury, or peripheral vascular disease. The intact foot must also be assessed, given the high incidence of peripheral neuropathy in the contralateral limb.

Watch this video to see how to perform the Semmes Weinstein Monofilament Test:

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[6]

Sensation, Oedema, and Care of the Residual Limb

Where protective sensation is reduced in the residual limb, the focus is on preventing skin breakdown before it occurs. Physiotherapists should instruct patients on residual limb skin care, including skin checks with a mirror, sweat management, and the problems associated with poor hygiene. Heightened vigilance is needed for people with LOPS, who may not feel the pressure or pain that signals developing skin damage.[1] They should be made aware that decreased pain, temperature, and light-touch sensation increases the risk of injury and tissue breakdown.[7] Patients and carers should also be made aware that ill-fitting sockets can cause significant skin problems and pressure injuries, and should know when to seek review. Additionally, patients and their family/caregivers must be aware of how to prevent and treat scar adhesions.

Phantom Limb Pain and Residual Limb Pain

Post-amputation pain affects a large percentage of patients early on and can continue to affect quality of life, sleep, and mood. Assessing pain should be integrated into routine clinical assessment, and pain should be adequately controlled prior to physical treatment sessions. Management strategies for phantom limb pain include graded motor imagery (GMI), mirror therapy (as a standalone treatment or as part of GMI), phantom limb exercises, progressive muscle relaxation, and mental imagery.[8][1] Patients should also be made aware of the increased risk of falls due to phantom limb sensation.[1]

For more information on managing PLP, please see: Phantom Limb Pain Management.

Strength Assessment and Intervention

Assessing and improving muscle strength is important throughout the continuum of care, as optimal strength supports prosthesis use and overall functional capacity.

Assessment

Strength across all the major muscle groups in the residual limb, intact limb and trunk is usually assessed by manual muscle testing. If an isokinetic device is available, it can provide more precise and reliable measurement, even where muscular capacity is limited. This helps determine the patient's potential ability to perform activities such as transfers, wheelchair management, and ambulation with and without their prosthesis.[1]

Intervention

Physiotherapists should prescribe a personalised programme, which includes strengthening and stretching exercises, to maintain and improve joint mobility and maximise functional use of the prosthesis. This programme should target all limbs and the trunk, including the rotator cuff and elbow extensors, the abdominal muscles, hip extensors, hip abductors and adductors, and knee extensors.[9][1] Low back pain is common among prosthesis users, so the physiotherapist should work with the MDT to ensure optimal prosthetic alignment and fit and to reduce postural asymmetries.[1]

A systematic review by Rosario et al. describes a progressive resistance training protocol. Training is two to three times per week, prioritising closed-chain exercises on weight machines: one to three sets of 10 to 15 repetitions, two to three minutes' rest between sets, at an initial intensity of 40–50% of 1RM (estimated via a 10RM test). The programme should target the hips, lower limbs, and lumbar region to improve balance and gait.[10] While the review noted that it could not establish whether resistance training was responsible for these gains, as it was generally delivered alongside other exercise, these parameters provide a useful starting point. However, any programme should be tailored to the individual's needs, goals, and capacity, and progressed over the long term.

Balance and Coordination

Good balance and coordination are essential for daily activities, independent living, and an efficient gait. Impairments increase the risk of falls.[11] [12] [13]

Assessment

The balance assessment evaluates a person's ability to maintain their centre of gravity over their base of support, in both sitting and standing. Balance should be reassessed throughout the post-fitting rehabilitation period. Useful objective measures include:[14]

Intervention

Balance training, with and without a prosthesis, should start with simpler tasks (sitting balance, sitting weight shifts, the sit-to-stand transition, supported standing, and single-limb balance without support), before progressing to more complex dynamic balance training (weight shifting on a soft surface, a rocker board, or a ball rolling under the intact foot, step-ups and lunges). Some of these more advanced balance activities can be used to help equalise weight across both lower limbs when the patient wears a prosthesis.

Unless there are documented reasons to use an alternative approach, gait re-education should begin within parallel bars. This training should progress from walking in a supported rehabilitation environment to navigating the home setting. Appropriate walking aids should be provided to support progression towards full weight-bearing where possible.[1]

Endurance

“During rehabilitation, the physiotherapist should take into account that gait with a prosthesis demands higher energy expenditure than physiological gait.”[1]

For individuals with lower-limb amputation, the energy required to walk with a prosthesis is much higher than for people without limb loss. Energy demand increases with the level of amputation. As energy demand increases, so too does the load on the cardiorespiratory system. Different strategies can help to address this increased load. Advances in prosthetics, such as active transtibial prostheses with biomechanical energy regeneration and transfemoral prostheses using hydraulic or compressed-air actuation, may reduce the energy needed to walk with a prosthesis.[15] Improving the person's physical fitness reduces the demand further.

Assessment

During the initial chart review, the physiotherapist should identify any history of cardiovascular or peripheral vascular disease, including coronary artery disease, heart failure, hypertension, angina, arrhythmias, or previous events and procedures such as myocardial infarction, angioplasty, or arterial bypass surgery, as well as any cardiovascular medications that may affect blood pressure and heart rate.

Intervention

The endurance programme should aim to increase cardiovascular fitness and maximise gait efficiency, with or without a prosthesis. Heart rate and blood pressure should be closely monitored during initial training and as training intensity increases.[16]

If the patient experiences persistent symptoms, such as shortness of breath, pallor, diaphoresis (profuse/abnormal sweating), chest pain, headache, or peripheral oedema, further medical evaluation is strongly recommended. Referral to a cardiac rehabilitation programme should be considered, particularly in patients with known cardiopulmonary disease or dysvascular amputation.[17]

A tailored cardiovascular training programme should be initiated as soon as possible in the postoperative phase and continue throughout rehabilitation. The programme should include upper-body ergometry, indoor and outdoor gait training with an appropriate assistive device, and, for younger people with traumatic amputation, higher-level sporting activities to supplement routine cardiovascular fitness. Physiotherapists and the wider multidisciplinary team should also educate the patient on reducing risk factors, such as smoking and heavy drinking.[18]

Activities of Daily Living

Where feasible, physiotherapists guide patients through functional tasks tailored to their objectives, with the aim of increasing community participation. Early on, interventions and tasks should be based around tasks that the patient can safely perform, and progress from there.[1]

Assessment

The following outcome measures assess how lower-limb amputation affects a patient's daily living activities:[19]

Intervention

People with lower-limb amputations should remain as active as possible to prevent deconditioning and improve functional capacity.

The goal of functional training is to maximise independence in everyday activities, integrated into the patient's daily life. These include self-care (dressing, donning and doffing the prosthesis, grooming, bathing, and toileting), managing limb volume with prosthetic socks, and household tasks such as cooking. More demanding tasks include indoor and outdoor ambulation, rising from the floor, negotiating obstacles, stairs, curbs, ramps, and uneven surfaces, getting in and out of a vehicle, carrying items while walking, changing speed and direction, and using public transport and escalators. Activities should be taught, observed, refined, and progressed in difficulty over time.[1]

Social and Leisure Integration/Return to Work

Participation in Social and Leisure Activities

Patients should be encouraged to return to their usual activities where possible, such as sport and recreational or leisure pursuits. As well as serving as a form of exercise therapy, these activities can contribute to the psychosocial wellbeing of a person with limb loss. The family should be included in this process.[21][22]

Return to Work

Returning to work is an important part of reintegration.[23] A graded return to work is advisable, with hours and duties increased over time. Any need for workplace adjustments should be assessed and appropriate recommendations made.[24]

Resources

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 British Association of Chartered Physiotherapists in limb Absence Rehabilitation. Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputations - third edition.2026 Available from https://www.bacpar.org/resources/healthcare-professionals-resources/pre-and-post-op-guidelines/ [last accessed 15.6.2026]
  2. ↑ Black M, Rábago CA, Highsmith MJ. Physical Therapy for the Patient with Amputation. In Prosthetics and Orthotics for Physical Therapists 2025 Jun 17 (pp. 91-112). Routledge.
  3. ↑ 3.0 3.1 Ottobock Professionals. Genium X4. Determining the hip flexion contracture (Thomas-Test). | Ottobock Professionals. Available from: https://www.youtube.com/watch?v=X79ppEzFyd0[last accessed 15/6/2026]
  4. ↑ Choo YJ, Kim DH, Chang MC. Amputation stump management: A narrative review. World J Clin Cases. 2022 May 6;10(13):3981-3988.
  5. ↑ Reed JJ, Tinker JN, Hackney JM, Shaw JL, Suess DJ, Vandeloecht KS. Is maximum available hip extension range of motion of the residual limb reached during passive prone lying in the acute stage after dysvascular transtibial amputation?. JPO Journal of Prosthetics and Orthotics. 2022;34(3):165-73.
  6. ↑ Professor Klein’s College Human Anatomy&Physiology. How to Perform the Semmes Weinstein Monofilament Test - Ohio University - Anatomy. Available from: https://www.youtube.com/watch?v=AbkZdfkNjGA [last accessed 15/6/2026]
  7. ↑ Aithal V, Bhat S. Semmes Weinstein monofilament test for detection of diabetic peripheral neuropathy: sensitivity and specificity. The Egyptian Journal of Neurology, Psychiatry and Neurosurgery. 2024 Jan 10;60(1):6.
  8. ↑ Limakatso K, Parker R. Treatment recommendations for phantom limb pain in people with amputations: an expert consensus delphi study. PM R. 2021 Nov;13(11):1216-1226.
  9. ↑ Parr TE, Farrokhi S, Hendershot BD, Butowicz CM. Low back pain influences medial-lateral trunk movement variations during sit-to-stand tasks in persons with transtibial amputation. Clin Biomech (Bristol). 2025 Aug;128:106623.
  10. ↑ Rosario MLVV, Costa PB, da Silveira ALB, Florentino KRC, Casimiro-Lopes G, Pimenta RA, Dias I, Bentes CM. Effects of Resistance Training in Individuals with Lower Limb Amputation: A Systematic Review. J Funct Morphol Kinesiol. 2023 Feb 10;8(1):23.
  11. ↑ Hunter SW, Batchelor F, Hill KD, Hill AM, Mackintosh S, Payne M. Risk factors for falls in people with a lower limb amputation: a systematic review. Pm&r. 2017 Feb 1;9(2):170-80.
  12. ↑ Steinberg N, Gottlieb A, Siev-Ner I, Plotnik M. Fall incidence and associated risk factors among people with a lower limb amputation during various stages of recovery-A systematic review. Disabil Rehabil. 2019;41(15):1778-87.
  13. ↑ Damayanti Sethy M, Kujur ES, Sau K. Effect of balance exercise on balance control in unilateral lower limb amputees. Indian J Occup Ther. 2009 Sep;41(3):63-8.
  14. ↑ Rosenblatt NJ, Schneider KL, Miller SA, Hagopian K, Hagg S, Reddin C, Churchill R, Dams GM, Calamari JE, Stachowiak A, Major MJ. Mixed methods analysis of an interdisciplinary intervention to promote balance confidence in lower limb prosthesis users. Frontiers in Rehabilitation Sciences. 2025 Sep 1;6:1626051.
  15. ↑ Tomovic A, Damjanovic M, Tomovic R, Rasovic N. Advances in the development of active lower limb prostheses for improving people with amputation locomotion: A review. Robotics and Autonomous Systems. 2026 Apr 20:105487.
  16. ↑ Garcia MM, Lima JR, Costa JD, Freire HA, Mazilão JD, Vicente EJ. Energy expenditure and cardiovascular response to traumatic lower limb amputees’ gait. Fisioterapia em Movimento. 2015;28(2):259-68.
  17. ↑ Marzolini S, Brunne A, Hébert AA, Mayo AL, MacKay C. Barriers and Facilitators to Cardiovascular Rehabilitation Programmes for People with Lower Limb Amputation: A Survey of Clinical Practice in Canada. Physiother Can. 2024 May 8;76(2):199-208.
  18. ↑ Turner AP, Williams RM, Norvell DC, Henderson AW, Hakimi KN, Blake DJ, Czerniecki JM. Prevalence and 1-year course of alcohol misuse and smoking in persons with lower extremity amputation as a result of peripheral arterial disease. Am J Phys Med Rehabil. 2014 Jun;93(6):493-502.
  19. ↑ Gailey R, Gaunaurd I, Raya M, Kirk-Sanchez N, Prieto-Sanchez LM, Roach K. Effectiveness of an Evidence-Based Amputee Rehabilitation Program: A Pilot Randomized Controlled Trial. Phys Ther. 2020 May 18;100(5):773-787.
  20. ↑ Legro MW, Reiber GD, Smith DG, del Aguila M, Larsen J, Boone D. Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life. Arch Phys Med Rehabil. 1998 Aug;79(8):931-8.
  21. ↑ Visser A, Kriel C, Swanepoel M, Cockeran M. Leisure participation and leisure constraints of individuals with lower-limb amputations in SA. South African Journal for Research in Sport, Physical Education and Recreation. 2024 Nov 15;46(1):41-60.
  22. ↑ Havlin H, Molyneaux V, Murray CD. Identity and Sport Participation Following Limb Loss: A Qualitative Study. Prosthesis. 2025 May 8;7(3):49.
  23. ↑ Al Qaroot B, Sobuh M, Al-Imyan F, Al-Laham E, Hawamdeh Z, Khanfar A. Return to Work After Lower Limb Amputation: A Critical Challenge in Jordan’s Socioeconomic and Healthcare Context. Journal of Occupational Rehabilitation. 2026 Apr 11:1-9.
  24. ↑ Lee SP, Chien LC, Shih HT, Ho S, Clemens S. Returning to work after dysvascular lower limb amputation-A novel multivariate approach to examine relative contributions of biopsychosocial predictors. Prosthet Orthot Int. 2025 Feb 1;49(1):30-37.
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