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Active Hospitals

Prosthetics Pathway

The Oxford Centre for Enablement is a Tertiary referral centre with on-site physiotherapy gym and prosthetics workshop. Within the prosthetics department multi-disciplinary clinical teams work together to help people who need a prosthetic limb, providing out-patient rehabilitation both at outset and for the rest of that person’s life.

Prosthetics Pathway video

Prosthetics Pathway Overview

Outpatient appointment
Physio assessment
Exercise Class

12 week group exercise class

Peer support

Home Exercise Booklet

Community Navigator

Physical Activity Calculator

Home exercise videos


Training – Active Conversations

Governance Framework

Environment changes

Culture change


A thorough COM-B analysis was undertaken to ensure that all aspects of behaviour change were considered and to enable specific interventions to be targeted to these using the Behaviour Change Wheel.

The behaviours that we identified as targets to change were health related physical activity of amputees within the rehabilitation pathway, peer to peer support and healthcare professionals talking to patients about physical activity during routine care.

The broad interventions used to achieve these were the development of a physical activity class for amputees, the development of peer to peer support strategies and supporting staff to develop knowledge regarding the importance of physical activity and enabling them to integrate this into their routine practice.

Click on the boxes below to find out more information about the interventions used in this pathway.

Physical Activity Champion

Our Physical Activity Champion was employed for one day per week to work on the maternity pathway. The clinical champion was critical to the success of the project, and when recruiting we were looking for an enthusiastic, innovative and experienced professional with outstanding leadership and interpersonal skills.

The role included opportunities to develop clinical skills in behavioural change counselling and exercise medicine as well as develop managerial skills such as education, systems review and leadership.

As well as Trust induction, our Physical Activity Champion was given an induction to the Active Hospital project. – we developed an Active Hospitals Staff Induction document to help them with the induction process.  They received training in motivational interview techniques from the central active hospital team, as well as completing the online Active Conversations course to consolidate learning further.

All Physical Activity Champions were supported through regular appraisal, using our Clinical Supervisor Meeting template and Personal Development Plan template.


An audit was conducted to determine current practice around offering physical activity advice and goal setting during the Combined Prosthetic Assessment clinic (this was the first contact patients had with the prosthetics service).

This was important to understand the current culture within the department and to determine where interventions could be targeted. The results revealed that no documented physical activity advice was being given to any patients that attended the clinic.

Goal-setting was discussed with all patients in the form of aspirations, as these questions were included in the standard proforma used during the clinic and they are used to enable healthcare professionals to determine the most appropriate prosthesis.

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Staff education

Education on the benefits of physical activity during undergraduate and postgraduate training of healthcare professionals in the UK is inconsistent, and our local audit highlighted that conversations with patients about physical activity were not part of regular clinical practice.

It was felt that it is difficult for staff to utilise physical activity as a treatment strategy if they are unaware of the reasons why it is important and how best to approach the subject.

Education was delivered via a Grand Round presentation to the department on the benefits of physical activity, in both the general population and specific to amputees, common motivators and barriers to physical activity in this population, the mechanisms through which it is thought to work, current physical activity guidelines and how to incorporate this into everyday practice. Delivering this training during protected working hours was identified as being essential in ensuring attendance.

In addition, the appointed Physical Activity Champion and SEM doctor working with the pathway undertook training in Motivational Interviewing via a two-day classroom-based course. Motivational interviewing was seen as a key intervention of this pathway.

Other staff within the department were offered the opportunity to train in motivational interviewing via the Active Conversations online course.

Physical Activity Calculator

The Physical Activity Calculator is a modified version of the exercise vital sign (1, 2, 3) that was designed and incorporated into the Trust’s electronic record system. This validated self-reported tool was chosen it was felt practical and realistic for staff to deliver.

Physical activity levels are assessed and coded into three categories with a very brief advice prompt given depending on patient’s physical activity levels. The three categories are:

(1) Green (more than 150 minutes/week)

(2) Amber (30-150 minutes/week)

(3) Red (less than 30 minutes/week).

Brief advice, in the form of a 1 minute conversation, is given depending on physical activity levels.



  1. Sallis R, Franklin B, Joy L, et al. Strategies for promoting physical activity in clinical practice. Prog Cardiovasc Dis 2015;57:375–86.
  2. Coleman, K.J., et al., Initial validation of an exercise “vital sign” in electronic medical records. Med Sci Sports Exerc, 2012. 44(11): p. 2071-6
  3. Department of Health and Social Care: UK CMO Physical Activity guidelines for older adults. Accessible from
Patient information leaflet

A Patient Information Leaflet was developed for amputees and offered as a brief intervention at the beginning of the pathway. This contained information about the benefits of physical activity for them, some Frequently Asked Questions (FAQs) and details of the community and charitable organisations with whom we’d collaborated, including information about what they offer.

This was developed because having a lower limb amputation is a major life event and experience told us that many patients are afraid and unsure of how they can remain active. The FAQs enabled identified barriers to be directly addressed.

A Prosthetics-Exercise-Booklet containing all of the exercises that are used within the physical activity class and information regarding how to set up an exercise circuit at home was given to all patients, prior to them starting the class.

The booklet contained instructions of how to perform the activity, ideas for adaptation at home, information on why it is important and pictures to demonstrate correct technique. This was developed to help enable patients to undertake these activities at home and to demonstrate that you do not need expensive equipment or a gym to be active.

The exercise class program was made into a series of videos accessible for patients attending the class. This enables them to continue to engage with the exercise at home.

Contraindications checklist

A contraindications checklist was developed to ensure that it was safe for a patient to undertake physical activity within the class.

This was created because this population is a particularly high-risk group, with mortality rates of 30-50% at 1 year and 60-77% at 5 years, and an even greater risk in people with diabetes (Jones, 2013; Shah, 2013; Singh, 2016; Fortington, 2013; Kim, 2018).

Our audit data revealed that 47% of the patients seen in our Combined Prosthetic Assessment Clinic were had Diabetes, 60% had hypertension, 63% were smokers and 17% had established Ischaemic Heart Disease, illustrating the multi-morbidity present in our population.


Jones WS, Patel MR, Dai D, et al. High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease. American Heart Journal 2013;165(5):809-+. doi: 10.1016/j.ahj.2012.12.002

Shah SK, Bena JF, Allemang MT, et al. Lower Extremity Amputations: Factors Associated With Mortality or Contralateral Amputation. Vascular and Endovascular Surgery 2013;47(8):608-13. doi: 10.1177/1538574413503715

Fortington LV, Geertzen JHB, van Netten JJ, et al. Short and Long Term Mortality Rates after a Lower Limb Amputation. European Journal of Vascular and Endovascular Surgery 2013;46(1):124-31. doi: 10.1016/j.ejvs.2013.03.024

Kim YK, Lee HS, Ryu JJ, et al. Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot. Journal of Foot and Ankle Research 2018;11 doi: 10.1186/s13047-018-0274-1

Singh RK, Prasad G. Long-term mortality after lower-limb amputation. Prosthetics and Orthotics International 2016;40(5):545-51. doi: 10.1177/0309364615596067

Motivational Interview (More minutes conversation)

Our Physical Activity Champion conducted motivational interviews (that followed the structure of a More minutes conversation) with patients at the beginning of their exercise program and again at week 8 of the program.

Our Physical Activity Champion was trained in motivational interview techniques by the central Active Hospital team, as well as completing the online Active Conversations course to consolidate learning further.

A Goal setting workbook was used during conversations to give consistent structure to the conversation, help patients set their ambitions and plan how to achieve their goals.

All Active Conversations were documented in the patient’s Electronic Patient Record.

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Physical Activity Class

A 12-week circuit class programme was developed to augment usual care in those rehabilitating following a lower limb amputation. Each weekly class contained a range of strengthening, flexibility, balance and cardiovascular exercises and exercises were designed to be adapted and performed at home using simple equipment, such as chairs, beds and resistance bands.

The class was based on models used by prosthetic rehabilitation centres elsewhere and was developed because experience has shown that patients are often unsure of what they can do following an amputation, they lose confidence and have difficulty learning to use their prosthesis.

In addition, programmes incorporating similar exercises in this population have been shown to improve physical function, improve lower limb strength, improve balance and reduce falls (Miller, 2017; Schafer, 2018).

Completing these exercises in a class-based format enables them to be done in a safe, controlled environment where the exercises can be demonstrated and taught. In addition, it enables the use of peer support and positive imagery.

The exercise class program was made into a series of videos accessible for patients attending the class. This enables them to continue to engage with the exercise at home.


Miller CA, Williams JE, Durham KL, et al. The effect of a supervised community-based exercise program on balance, balance confidence, and gait in individuals with lower limb amputation. Prosthetics and Orthotics International 2017;41(5):446-54. doi: 10.1177/0309364616683818

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;63:282-89. doi: 10.1016/j.gaitpost.2018.04.030

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Peer support

Peer support is known to be a facilitator to physical activity in this population, enabling people to discuss their thoughts, feelings and dilemmas with others who have similar problems (Littman, 2014; Littman, 2017; Miller, 2018). Evidence from the amputee population has shown that physical activity should be encouraged within a supportive social environment (Deans, 2008).

Peer support is encouraged following each class and is facilitated by the Physical Activity Champion leading the session and offering refreshments.

Other groups, including the existing peer support group, charitable organisations and behaviour change teams within the hospital Trust, have attended to provide an educational component to the course, and the aim is for these groups to attend once every 12-week cycle.


Littman AJ, Boyko EJ, Thompson ML, et al. Physical activity barriers and enablers in older Veterans with lower-limb amputation. Journal of Rehabilitation Research and Development 2014;51(6):895-906. doi: 10.1682/jrrd.2013.06.0152

Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disability and Health Journal 2017;10(4):600-06. doi: 10.1016/j.dhjo.2017.03.004

Miller MJ, Jones J, Anderson CB, et al. Factors influencing participation in physical activity after dysvascular amputation: a qualitative meta-synthesis. Disability and rehabilitation 2018:1-10. doi: 10.1080/09638288.2018.1492031

Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: A study of a lower-limb amputee population. Prosthetics and Orthotics International 2008;32(2):186-200. doi: 10.1080/03093640802016514

MM-Icons-Home Exercise Videos
Home exercise videos

We worked with the Trust’s medical illustration team to produce exercise videos of the class. These were designed to be both informative and help patients to continue to engage with class exercises at home.



Community Navigator

Feedback from staff before training highlighted that one of the barriers to supporting and advising physical activity to patients was a lack of knowledge of what was available locally to which they could refer.  A community navigator role was developed for the Active Hospital pilot across all our clinical pathways, providing one-to-one consultations with patients as well as providing advice and guidance to staff on where to find support for patients in the community. Their role was critical to ensure continuity of care through hospital admission to discharge to community environment.

An online map was developed to allow all staff and patients access to the wide range of community based classes and support throughout the region.


In this section you will find some of the outcomes from the pathway.

Qualitative Outcomes

Qualitative data was collected from this pathway, including patient feedback and quotes;

“It has been really good before getting my prosthesis to have the constant interaction with Physios to check my wound and give me advice”“I feel much fitter since the class and I’m doing more than I was when I started”

“It is something positive to look forward to each week that is away from my other troubles”

“Do you know the whole thing is of a value as far as I would say. It’s not just one aspect of it. It’s the whole group working together and the encouragement of everybody that’s there, not just the physios and the doctor. It’s everybody else, as patients, helping each other out. And I think it’s good we can talk about what happened to us because it is massively life changing”

“And if we can help each other out then that’s why we’re there”

“It is beneficial to no end….I want to continue after the 12 weeks because it is a really good motivator because I can’t go back to sport yet because of other personal reasons, but the class motivates me, and I am starting to do more exercise at home using the thera-bands from what I have learned in the class”

Prosthetics pathway patient feedback

Improving the Physical Activity of Lower Limb Amputees in Oxford


  • 28 patients enrolled
  • 10 completed full programme
  • 6 on-going

Reasons for non-completion; Medically unfit, Returned to high functioning level early, Attendance whilst inpatient only, Social circumstances

  • Activity levels increased following the class
    • Average 2.5x higher than baseline
    • 80% more active


Click on the numbers below for some tips from our Active Hospital team

Changes take time

Physical activity pathways may take time to fully embed within a service, especially if you’re new to the team and the pathway is changing the current culture within the department. Be prepared to allow time for changes to be made, ensuring that key staff members responsible for delivering the changes are happy with the plans and agreeable to change.

Seek input from experienced members of team

Be prepared to try different things and propose changes, but listen to feedback from those experienced team members working within the system and those delivering the pathway and ensure that feedback is considered before solutions are identified.

You will face unanticipated challenges

We encountered a number of challenges that were not anticipated at the beginning of the process such as unpredictable patient transport, the lack of a counsellor to assist with mental health problems in the cohort we were working with and apprehension from some members of staff regarding the changes that were being made. Meeting with staff early on to discuss potential challenges and consider strategies that may help to combat this. You will need to consider how to tackle unforeseen issues as a team.

Appreciate the risk

A robust governance structure, good planning and inbuilt safety mechanisms are essential. Physical activity has been shown to be of benefit in this population, but many of the patients remain at a high risk of additional medical problems.

Try to minimise the complications by checking for contraindications to physical activity and adopting other strategies, such as checking blood pressure in those at risk of significant hypertension, or checking pre- and post- blood sugar levels in patient with insulin dependent diabetes.


Personal Development Plan template
Clinical Supervisor Meeting template
Contraindications checklist
Goal setting Booklet
Prothetics Home Exercise Booklet
Physical Activity Following an Amputation

Patient Information Leaflet