Limb amputation
Case study

Rehabilitation for Amputees

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.

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.

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.

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.

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.

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.

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 problems...one 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 all...it was a lot better walking. It’s more comfortable. It’s the best thing that could have happened”