1. www.COT.org.uk Occupational therapy with people who have had lower limb amputations Evidence-based guidelines College of Occupational Therapists Specialist Section – Trauma and Orthopaedics COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists. This PowerPoint may be copied and adapted for non-commercial use

2. www.COT.org.uk Key aims Provide an evidence-based resource for occupational therapists working with adults with acquired unilateral or bilateral lower limb amputation To facilitate evidence-based practice To support occupational therapy and service managers in service provision and planning The guidelines are applicable to any setting 2 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

3. www.COT.org.uk Areas covered Functional rehabilitation Environment Psychology Prosthetic use Assessment tools and outcome measures Cognition Work Leisure and recreation 3 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

4. www.COT.org.uk Methodology 4 Guideline development group established Guideline topic and scope established Critical appraisal of articles Development of evidence- based guidelines Literature searchReview of findings Peer review and stakeholder consultation Final draft approved by COT Practice Publications Group Published COT 2011 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists.

5. www.COT.org.uk Evidence-based recommendations Recommendations are based on the evidence available within 29 critically appraised papers Each article is assigned: An evidence score V–I (Low–High) A quality score 0–10 (Low–High) 5 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

6. www.COT.org.uk Recommendations – Functional Rehabilitation Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/31.Occupational therapists need to adhere to key milestones with respect to bed mobility and upper and lower body dressing (Ham et al 1994) V/42.It is recommended that stump boards are provided for people with transtibial amputations (White 1992) III – 2/5 3.Indoor electric wheelchairs should be provided for personal independence for patients with rheumatoid arthritis (Lachman 1993) V/4, V/6, III – 3/4, V/8, V/6, IV/3 4.Occupational therapists need to identify falls risk factors and provide appropriate individual interventions in collaboration with the multidisciplinary team (Kulkarni et al 1996, Miller et al 2001, Gooday and Hunter 2004, Miller and Deathe 2004, Pauley et al 2006, Dyer et al 2008) V/75.Frequency of occupational therapy sessions along with the service user’s physical independence, better cognition, younger age and satisfaction with the prosthesis is significantly related to prosthetic use (Bilodeau et al 2000) 6 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

7. www.COT.org.uk Recommendations – Environment Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/21.Occupational therapy with older adults who have had an amputation due to peripheral vascular disease or diabetes mellitus should enhance function through environmental modification appropriate for wheelchair use (Collin et al 1992) 7 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

8. www.COT.org.uk Recommendations – Psychology Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/6, V/41.Occupational therapists need to monitor distress for longer than the initial postoperative phase (Atherton and Robertson 2006, Hawamdeh et al 2008) IV/4, V/4, V/62.Occupational therapists need to assess for anxiety throughout all episodes of care: preoperatively (Singh et al 2007), Hawamdeh et al 2008) and in the prosthetic phase (Atherton and Robertson 2006, Singh et al 2007) V/53.Where appropriate, referrals should be made for psychological support for adults with lower limb amputations (Price and Fisher 2002) V/3, V/3, V/54.Occupational therapists should consider the importance of body image during the rehabilitation process (Beekman and Axtell 1987, Breakey 1997, Price and Fisher 2002) 8 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

9. www.COT.org.uk Recommendations – Prosthetic use Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/51.Occupational therapists need to be aware of impaired hand function before prescription of liners used with lower limb prostheses (Baars et al 2008) V/32.Occupational therapists need to ascertain reasons for non-prosthetic use and refer to the multidisciplinary team as appropriate (Beekman and Axtell 1987) V/33.Older adults with above-knee or though-knee amputations should be provided with a wheelchair at the prosthetic and post-prosthetic stage of rehabilitation (Beekman and Axtell 1987) 9 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

10. www.COT.org.uk Recommendations – Assessment tools and outcome measures Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/61.Occupational therapists should use the Amputee Activity Score (AAS) with lower limb prosthetic users to assess the level of activity a person achieves at discharge from prosthetic rehabilitation to review (Panesar et al 2001) V/62.Occupational therapists should use the Frenchay Activities Index (FAI) to determine the level of participation in extended activities of daily living following the rehabilitation and the prosthetic phase (Miller et al 2004) V/73.Occupational therapists should use the Patient Generated Index (PGI) measure to assess quality of life (QOL) outcomes in face-to-face assessment (Gallaghan and Condie 2003) V/74.Occupational therapists should use the Trinity Amputation and Prosthesis Experience Amputation Scales (TAPES) to assess adjustment to lower limb prostheses (Gallagher and MacLachlan 2000) 10 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

11. www.COT.org.uk Continued Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/65.Occupational therapists should use TAPES to evaluate changes in QOL during the rehabilitation process and provide a more holistic assessment (Gallagher and MacLachlan 2004) V/86.Occupational therapists should use the Amputee Body Image Scale (ABIS) to determine the level of body image disturbance and consider how this may affect rehabilitation (Gallagher et al 2007) V/67.Occupational therapists should use the Office of Population Consensus and Surveys Scale (OPCS) with lower limb prosthetic users to assess functional capacity in the community at the inpatient stage (Panesar et al 2001) V/6, V/48.Occupational therapists should use the Clifton Assessment Procedures for the Elderly (CAPE) to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997) V/49.Occupational therapists should use the Kendrick Object Learning Test (KOLT) to facilitate decision-making in prosthetic use (Larner et al 2003) 11 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

12. www.COT.org.uk Recommendations – Cognition Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/6, V/41.Occupational therapists should use CAPE to predict mobility using a prosthesis (Hanspal and Fisher 1991, 1997) V/42.Occupational therapists should use KOLT to facilitate decision-making in prosthetic use (Larner et al 2003) 12 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

13. www.COT.org.uk 13 Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/51.Support should be provided from the multidisciplinary team regarding successful work reintegration and maintenance of the work-role (Bruins et al 2003) Recommendations – Work Recommendations – Leisure and recreation Evidence level/ quality score Evidence-based recommendation for occupational therapy with people who have had lower limb amputation V/41.Occupational therapists need to assess and review participation in recreational activities (Legro et al 2001) COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

14. www.COT.org.uk Impact of evidence-based guidelines for you Challenges / affirms your current practice Informs your practice Provides evidence to support your practice (completion of Audit Form) Provides a vehicle for you to justify your practice 14 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

15. www.COT.org.uk Impact of evidence-based guidelines for managers Provides evidence of the need for occupational therapy input into services for people who have had lower limb amputation Provides a structure to audit the work of occupational therapists within the service to improve service quality Provides a vehicle for justifying service provision 15 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

16. www.COT.org.uk Impact of evidence-based guidelines for service users In being adopted by services and occupational therapists, the guidelines should improve the consistency and quality of intervention for users of services Gives assurance that practitioners use the available evidence to support interventions 16 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

17. www.COT.org.uk Impact for evidence-based guidelines for commissioners Articulates the need for occupational therapy interventions within services for people with lower limb amputation May help educate commissioners to identify learning needs for the workforce Associated audit form provides a mechanism to review service delivery in accordance with the evidence 17 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists

18. www.COT.org.uk Help from COT/BAOT Link up with your BAOT networks to gain advice and support. Find out through your BAOT regional group or the COT Specialist Section you belong to whether they have resources that can help you. iLOD is designed to be a one-stop shop for all your CPD needs and it was developed to make it simple for BAOT members to meet the HPC’s baseline standards for CPD. If you are having difficulties or need support contact professional.enquiries@cot.co.uk 18 COT Implementation toolkit/CPD Session © 2012 College of Occupational Therapists