Pre-operative rehabilitation in lower-limb amputation patients and its effect on post-operative outcomes

Major lower-limb amputation (LLA) is a life-changing event associated with poor post-operative physical and psychological functioning and decreased quality of life. The general physical condition of most LLA patients prior to surgery is already significantly deteriorated due to chronic peripheral vascular disease often in combination with diabetes. Pre-operative rehabilitation (also called 'pre-rehabilitation') is an increasingly common strategy used in multiple patient populations to improve patients' physical and mental condition prior to surgery, thus aiming at improving the post-operative patient outcomes. Given the positive effects of post-surgical outcomes in many patient populations, we hypothesize that pre-operative rehabilitation will improve post-operative outcomes after LLA. To test this hypothesis, a literature search of PubMed, EMBASE, EBSCOhost, Web of Science and ScienceDirect was performed to identify studies that investigated the impact of a pre-operative rehabilitation therapy on post-operative outcomes such as length of hospital stay, mobility, physical functioning, and health related quality of life. No time restrictions were applied to the search. Only articles published in English were included in the selection. Two studies satisfied the eligibility criteria for inclusion in the review, one qualitative and one quantitative study. The quantitative study reported a beneficial effect of pre-rehabilitation, resulting in post-operative mobility (at least indoor ambulation) in 63% of the included LLA patients. There is a need for prospective clinical studies examining the effect of pre-rehabilitation on post-operative outcomes to be able to confirm or reject our hypothesis. Although the hypothesis seems plausible, evidence is lacking to support our hypothesis that pre-operative rehabilitation will improve post-operative outcomes in patients with LLA. The qualitative study indicated that integrating pre-rehabilitation in the care for LLA patients seems to be limited to a selected group of dysvascular patients, but at this stage cannot be advised based on current evidence even in this subgroup. Further research is needed to clarify whether such an intervention prior to amputation would be a useful and effective tool for optimizing post-operative outcomes in LLA patients.