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Published by Department of Veterans Affairs and Department of Defense · GRADE
This clinical practice guideline provides an evidence-based framework for evaluating and managing care for adult patients who have experienced lower limb amputation. It emphasizes a patient-centered, multidisciplinary approach to optimize functional independence, health outcomes, and quality of life.
Key Takeaways
Added 12 new recommendations, reviewed and replaced 4 recommendations, reviewed and amended 3 recommendations, carried over 1 recommendation not changed, and carried over 4 recommendations amended from the 2017 VA/DOD LLA CPG. The methodology was updated to reflect a more rigorous application of the GRADE framework.
There is insufficient evidence to recommend one surgical amputation procedure over another.
For patients with transfemoral amputation who meet eligibility criteria, we suggest osseointegration as an option to improve prosthesis use.
There is insufficient evidence to recommend for or against targeted muscle reinnervation or other peripheral nerve surgical management for phantom limb pain.
We suggest intraoperative placement of a perineural catheter for the post-operative delivery of local anesthetic to reduce pain following amputation surgery.
Post-transtibial amputation, we suggest application of a rigid or semi-rigid residual limb dressing to promote healing and early prosthesis use as soon as feasible.
We suggest providing post-operative amputation care in an inpatient rehabilitation facility (IRF) over other settings (e.g., skilled nursing facility (SNF) or home care).
We suggest assessment and treatment to improve behavioral health and psychosocial functioning.
We suggest peer support by a trained peer as a component of rehabilitation to improve psychosocial function.
We suggest cognitive assessment to inform rehabilitation goals and prosthetic candidacy.
We suggest the care team provides patient education throughout amputation rehabilitation.
We suggest mirror therapy, alone or in combination with other therapies, to improve pain, function and quality of life for individuals with phantom limb pain.
We suggest an individualized and skilled rehabilitation program with exercise and gait training to improve functional status, walking ability, and quality of life.
We suggest using patient-identified sex to inform individualized rehabilitation plans.
We suggest screening for factors associated with rehabilitation outcomes following acquired limb loss, (e.g., smoking, comorbid injuries or illnesses, psychosocial characteristics and physical function).
For community ambulators, there is insufficient evidence to recommend any specific transfemoral socket design.
For community ambulators, there is insufficient evidence to recommend for or against ischial containment or sub-ischial socket designs.
For prosthetic ambulators, we suggest prescribing microprocessor knee units over non-microprocessor knee units for reducing falls, optimizing functional mobility, and improving patient satisfaction.
For prosthetic ambulators, there is insufficient evidence to prescribe any specific energy storing and return (ESAR) or microprocessor foot and ankle component over another.
For prosthetic ambulators, we suggest energy storing and return (ESAR) or microprocessor-controlled foot and ankle components over solid ankle cushioned heel (SACH) feet to improve ambulation and patient satisfaction.
We suggest using patient-reported and performance-based measures with acceptable psychometric properties to assess function.
There is insufficient evidence to recommend for or against neurostimulation or neuroablation interventions for the management of phantom limb pain or residual limb pain.
We suggest perineural catheter delivered anesthetic for the treatment of chronic severe phantom limb pain with functional impairment.
There is insufficient evidence to recommend for or against any systemic pharmacologic intervention for the management of phantom limb pain.
For prosthesis users with hyperhidrosis, there is insufficient evidence to recommend for or against Botulinum toxin treatment to reduce sweat production, improve prosthetic function, reduce pain, and improve quality of life.
There was insufficient evidence to recommend for or against strategies to prevent re-amputation of the ipsilateral limb or amputation of the contralateral limb.
There is insufficient evidence to recommend for or against any specific intervention to improve intimacy and sexual health.
Clinical Topic
Lower Limb Amputation Rehabilitation
Objectives
To provide an evidence-based framework for evaluating and managing care for adult patients who have experienced lower limb amputation, toward improving clinical outcomes.
Target Patient Population
Adult patients, 18 years or older, who have experienced lower limb amputation
Target Providers
Therapeutic Area
RehabilitationGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
Monitoring Guidance
Provide routine care as needed and schedule follow-up at least every 12 months.
Difficulty
advanced
Learning Paths