Acute Care

Pre-Operative Physiotherapy

In an ideal world all patients facing amputation surgery would have a full multidisciplinary assessment pre-operatively. In reality this is not always possible for a number of reasons, including the urgency of the surgery, patient level of consciousness, or even poor planning and communication.

Subjective Assessment

A Physiotherapy pre-operative assessment would ideally include:

  • The date of the amputation, if known
  • The level and side of the amputation, if known
  • The cause of the amputation surgery, including the progression / current history of the disease, illness, or injury if applicable
  • Details of the surgical team, for use in ongoing referrals and communication
  • Past medical history. Particularly search for comorbidities that may have an impact on the post-operative course or rehabilitation, including an ability to follow instructions, learn new skills, or exercise safely and effectively. Examples of such comorbidities include diabetes, vascular disease, hypertension, cardiac history, respiratory illnesses, stroke, orthopaedic comorbidities (arthritic conditions, fractures, contractures, etc), smoking, alcohol and drug consumption, diseases affecting cognition and learning, previous surgery including other amputations
  • The condition of the remaining limb and upper limbs. If the patient has a contralateral amputation, gather information on their function with a prosthesis, if they use one. This includes fit & comfort, ability to don / doff the prosthesis correctly, and prosthetic mobility level
  • A list of current medications. Gathering this list can also highlight conditions the patient may have forgotten to mention or did not realise they had
  • Social history. This will include, but not limited to:
    • Who lives with the patient. Add to this the proximity of any carers who do not live at the same address, and the ability of all family / carers to assist in rehabilitation or functional activities of daily living
    • List of any existing community services
    • The type of residence, including access (stairs, ramps, rails) and the previous ability of the patient to manage this access. Also consider the location and accessibility to bathrooms / toilets
    • Lifestyle and vocation - the type of work, education, hobbies, social or sporting activities usually engaged in
  • Pre-existing mobility levels:
    • Independence in transfers, bed mobility, and standing up
    • Use of walking aids / wheelchairs
    • Endurance / distance
    • Limiting factors in mobility
    • Ability to traverse outdoor environments - stairs, slopes, grass, curbs, obstacles, crowds
  • Current pain levels, using VAS if possible.

It is also important to discuss the patient's short term and long term goals, and gain information regarding their expectations for after the surgery, as well as their feelings towards the surgery and their ability to recover.

Objective Examination

The pre-operative physical examination would include:

  • Chest & respiratory assessment as appropriate
  • Visible inspection of the condition of the limbs, looking for wounds, contractures or deformities, areas of pain, signs of vascular insufficency / PVD. This will include examining the remaining limb and upper limbs (including hand dexterity), for a lower limb amputee
  • Measures of joint range / muscle length
  • Measures of muscle strength. Functional tests are preferred over manual muscle testing, if possible
  • Patient weight
  • Functional mobility:
    • Bed mobility
    • Transfers - bed to chair, bed to wheelchair, etc. Standing / pivot / sliding as appropriate
    • Sit to stand
    • Standing balance and postural adjustments
    • Gait. This may also include an assessment on the ability to use crutches or frames, for the post-operative period
    • Ability to manage stair, again with crutches as appropriate. It is sometimes best to practice these skills pre-operatively, when the patient is less concerned with pain or falls, but consider their physical and emotional status
  • Cognitive assessment. Includes ability to follow instructions, learn new skills, and memory

The tools used to gather objective assessment information are up to the individual physiotherapist, but may depend on the time available, ability of the patient to co-operate, the level of detail required, tools available, requirements for quality or research / outcome projects, information required for post-operative comparison and goal-setting. Typically, information to be used as for post-operative comparison or to show progress over time would use more detailed, empirical data.


Once the assessment is completed, treatment / rehabilitation can often begin in the pre-operative phase, depending on the amount of time before the surgery. This can take the form of:

  • Education:
    • Post-operative wound dressing types, exercises, pain management techniques
    • Discussion of phantom pain
    • Stump care and oedema management in the early phases
    • Prevention of contractures
    • Course of rehabilitation, including types of prostheses and their capabilities
    • Expected progress towards long term goals
  • Instruction on post-operative chest physiotherapy
  • Instruction on post-operative bed exercises for maintenance of strength and range of motion - residual limb, intact limb, and upper limbs. Includes positioning programmes
  • Practice with mobility aids, including slideboards, wheelchairs, crutches or frames, as appropriate

If time permits, in the case of elective amputations, there may even be opportunity for more intensive strengthening, stretching, mobility, or cardiovascular training programmes.