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Ongoing Project

Rehabilitation for Amputees

Informing British and Dutch national clinical guidelines on rehabilitation of patients following limb amputation, and improving the lives of people with limb loss.

Project summary

The Challenge

Structured exercise programmes following lower limb amputation (LLA), and clinical trials investigating prosthetics therapies, are lacking in the UK

The Approach

Pioneering research to improve mobility and reduce falls for people following a LLA focused on two key areas: exercise and prosthetics therapies.

The Outcome

Our research has improved the quality of life of people with lower limb amputation through enhanced physical, mental and social health and wellbeing.

Lead academics

Funded by

Project partners

The Challenge

The Hull & East Riding multidisciplinary healthcare team in prosthetics rehabilitation (including physiotherapists, occupational therapists and prosthetists, within the Hull University Teaching Hospitals NHS Trust) treats around 80 new patients with a major lower limb amputation (LLA) from across East Yorkshire and North Lincolnshire each year. A gap in service provision meant that there was no facilitated, structured exercise programme in place for people with a LLA, leading to patients experiencing more sedentary lifestyles and being isolated from other people with limb loss.

More functional prostheses may improve function and quality of life. In the UK, there are few clinical trials investigating ankle-foot prostheses within prosthetics services. There is also a lack of research involving participants who have had a non-traumatic (e.g. vascular-related) amputation, and yet the majority of people having a major lower limb amputation are aged over 50 years because of long-term diabetes mellitus, coronary and peripheral vascular diseases.

The full research team

The Approach

Research at Hull - Improving Health Outcomes

People with lower limb amputation (LLA) are under-represented in health research.

Natalie Vanicek, Professor of Clinical Biomechanics at the University of Hull, has led pioneering research aimed at improving mobility and reducing falls for people following a LLA. Her work focused on two key areas: exercise and prosthetics therapies.

BACPAR fully endorses the approaches to coping strategies following falls for people with a lower limb amputation as recommended and validated by Natalie and her colleagues’ research. We greatly value the benefits these research-based exercise interventions bring to our patients in terms of improved physical and mental health and better balance confidence

The British Association of Chartered Physiotherapists in Amputee Rehabilitation (BACPAR) Guidelines Coordinator, Rachel Humpherson

Firstly, the research developed a framework for identifying biomechanical factors that distinguished fallers from non-fallers. As a direct result, evidence-based recommendations for falls prevention through structured exercise were established for people with LLA.

Initially, the research team designed a personalised 12-week exercise programme for adults with LLA, delivered in a group setting combined with home-based exercise, and saw a significant and long-lasting reduction in falls. In addition, the results indicated that the programme significantly improved walking speed and balance.

Prof Vanicek’s research was one of only eight studies to be included in our revised guidelines. More research like that of Professor Vanicek’s is needed to continue advancements in the field of prosthetics rehabilitation.

President of the International Society for Prosthetics & Orthotics (ISPO), Netherlands

Despite the strong evidence for the benefits of exercise, a gap in healthcare service persisted and there were no regional, community-based exercise programmes to address the specific needs of people living with limb loss, so a pilot study was launched whereby the University provided people with a LLA the opportunity to engage in personalised exercise within a community setting. The participants’ feedback highlighted the "life-changing" experience of exercising within the community (“The gym has changed how I look at life because it’s given me confidence”), and this pilot study provided the rationale for establishing the KEEP MOVING programme. Clinicians can now refer patients with a LLA onto the KEEP MOVING programme. It is delivered face-to-face within the local community in Hull and virtually to people across the UK thanks to the Limbless Association’s Virtually Speaking platform. KEEP MOVING was also shortlisted as one of three for the British Universities and College Sport (BUCS) Diversity and Inclusion Award 2020.

The KEEP MOVING programme fulfils many of this charity’s aims such as reducing the feeling of isolation that many amputees experience by enabling people to meet virtually, teaching amputees to do exercises at home safely and comfortably and helping to improve their health and wellbeing. The KEEP MOVING programme is unique in the UK, where there is an obvious gap in programmes that design and deliver exercise especially for people with limb loss, and it is really valuable to be able to signpost members to it

The Limbless Association’s Midlands Hub Co-Ordinator, Trevor Gallivan

From a clinical point of view, the benefits for the amputees have included fewer falls, longer walking distances, improved strength and balance. It is clear that KEEP MOVING has had a really meaningful impact for the participants and is capable of being offered at a relatively low cost... It should be offered as an integral part of the package of support for all individuals with limb loss to help them regain or maintain their functionality and improve quality of life

NHS Consultant Dr Abayomi Salawu

Prosthetics therapies within the NHS are another under-researched area, especially concerning prosthetics provision for older patients with LLA. University researchers worked with healthcare professionals (consultants, prosthetists, physiotherapists) to launch the STEPFORWARD trial. STEPFORWARD was a national randomised controlled trial investigating the feasibility of a full-scale trial of the effectiveness for patients (and cost-effectiveness for the NHS) of a self-aligning prosthetic ankle-foot compared to a standard ankle-foot. The trial demonstrated high retention and treatment completion rates, as well as a signal of efficacy for improved walking ability and quality of life for participants with the self-aligning prosthesis.

A self aligning ankle foot prsthesis adjusts comfortably to sloped surfaces.

The Impact

This research has informed British and Dutch national clinical guidelines on the rehabilitation of patients following lower limb amputation (LLA), used by 1550 healthcare practitioners. Through STEPFORWARD, the research has demonstrated the benefits of a functional ankle-foot prothesis, improving patients’ daily function and quality of life in meaningful ways, including reduced pain and enhanced mobility.

The research has also led to the establishment of KEEP MOVING, an innovative community-based exercise programme for patients in and around East Yorkshire and North Lincolnshire and accessible nationally online via the Limbless Association. KEEP MOVING has benefitted the physical and mental health of those with a LLA, positively reducing falls, improving their general fitness, and facilitating a social support group that had been missing locally.

Amputee collage

Participants have talked about how the research has helped improve their lives:

“the big thing is it’s a social group of similar people that have got similar sorts of of the things you find when this happens [amputation] is you can become a bit cut off and isolated...I was depressed... So, I’ve now got a social group that I mix with...I’ve rediscovered some muscles I didn’t think I had before...So I think my all-round level of fitness has improved”

“Well, the best thing about it was I could get up and walk about without being in a lot of pain in the foot... you felt the difference as soon as they put the [self-aligning ankle-] foot on and I stood up and walked. There was just no pressure in the knee, none in the hip and no pain at was a lot better walking. It’s more comfortable. It’s the best thing that could have happened”


Vanicek N, Strike S, McNaughton L, Polman R. Postural responses to dynamic perturbations in amputee fallers vs. non-fallers: a comparative study with able-bodied subjects. Arch Phys Med Rehabil 2009b; 90: 1018-1025.

Vanicek N, Strike S, McNaughton L, Polman R. Gait patterns in transtibial amputee fallers vs. non-fallers: biomechanical differences during level walking. Gait Posture2009a; 29: 415-420. 10.1016/j.gaitpost.2008.10.062

Schafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait Posture 2018; 63: 282-289.

Vanicek N. Specialised exercise for individuals with lower limb loss: Reflections from Hull. In International Society for Prosthetics and Orthotics (ISPO UK MS) Annual Scientific Meeting, Southampton, 2018

Mitchell N, Coleman E, Watson J, Bell K, McDaid C, Barnett C, Twiste M, Jepson F, Salawu A, Harrison D, Vanicek N. Self-aligning prosthetic device for older patients with vascular-related amputation: protocol for a randomised feasibility study (the STEPFORWARD study). BMJ Open 2019; 9:e032924

Vanicek N, Coleman E, Watson J, Bell K, McDaid C, Barnett C, Twiste M, Jepson F, Salawu A, Harrison D, Mitchell N. STEPFORWARD study: a randomised controlled feasibility trial of a self-aligning prosthetic ankle-foot for older patients with vascular-related amputations. BMJ Open 2021;

Schafer ZA, Vanicek N. A block randomised controlled trial investigating changes in postural control following a personalised 12-week exercise programme for individuals with lower limb amputation. Gait Posture 2021; 84: 198-204