VA/DoD CLINICAL PRACTICEGUIDELINE FOR THE MANAGEMENT OF UPPER
LIMB AMPUTATION REHABILITATION
Department of Veterans Affairs
Department of Defense
QUALIFYING STATEMENTS
The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best
information available at the time of publication. They are designed to provide information and assist
decision making. They are not intended to define a standard of care and should not be construed as one.
Neither should they be interpreted as prescribing an exclusive course of management.
This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiologicalevidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logicalrelationships between various care options and health outcomes while rating both the quality of theevidence and the strength of the recommendation.
Variations in practice will inevitably and appropriately occur when clinicians take into account the needsof individual patients, available resources, and limitations unique to an institution or type of practice.
Every healthcare professional making use of these guidelines is responsible for evaluating theappropriateness of applying them in the setting of any particular clinical situation with a patientcentered approach.
These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy.
Further, inclusion of recommendations for specific testing and/or therapeutic interventions within theseguidelines does not guarantee coverage of civilian sector care. Additional information on current
TRICARE benefits may be found at www.tricare.mil by contacting your regional TRICARE Managed Care
Support Contractor.
Version 2.0 – 2022

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Prepared by:

The Management of Upper Limb Amputation Rehabilitation Work Group
With support from:

Office of Quality and Patient Safety, Veterans Health Administration&
Clinical Quality Improvement Program, Defense Health Agency

Version 2.0 – 2022a
Based on evidence reviewed through April 2021

a

VA/DoD Clinical Practice Guideline. (2022). The Management of Upper Limb Amputation Rehabilitation. Washington, DC:
U.S. Government Printing Office.

March 2022

Page 2 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Table of Contents
I.

Introduction ................................................................................................................................. 6

II.

Background .................................................................................................................................. 6
A.

Amputation Level Classification .................................................................................................... 6

B.

Epidemiology ................................................................................................................................. 7

III. Scope of this Guideline ................................................................................................................. 8
A.

Guideline Audience ....................................................................................................................... 8

B.

Guideline Population ..................................................................................................................... 8

IV. Highlighted Features of this Guideline .......................................................................................... 8V.

A.

Highlights in this Guideline Update ............................................................................................... 8

B.

Components of the Guideline ....................................................................................................... 9

Guideline Development Team ...................................................................................................... 9

VI. Summary of Guideline Development Methodology .................................................................... 11
A.

Evidence Quality and Recommendation Strength ...................................................................... 11

B.

Categorization of 2014 Clinical Practice Guideline Recommendations ...................................... 13C.

Management of Potential or Actual Conflicts of Interest ........................................................... 14

D.

Patient Perspective ..................................................................................................................... 15E.

External Peer Review................................................................................................................... 15

F.

Implementation ........................................................................................................................... 15VII. Approach to Care in Department of Veterans Affairs and Department of Defense ...................... 16
A.

Patient-centered Care ................................................................................................................. 16

B.

Shared Decision Making .............................................................................................................. 16

C.

Patients with Co-occurring Conditions ........................................................................................ 16

D.

Phases of Rehabilitation Care ..................................................................................................... 17

VIII. Algorithm .................................................................................................................................. 19A.

Module A: Upper Limb Amputation Management ..................................................................... 20

B.

Module B: Upper Limb Amputation Management for Primary Care .......................................... 22

IX. Recommendations...................................................................................................................... 23
A.

Surgery/Pre-prosthetic ................................................................................................................ 24

B.

Rehabilitation .............................................................................................................................. 28

C.

Prosthetic Restoration................................................................................................................. 31

March 2022

Page 3 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

X.

D.

Medical ........................................................................................................................................ 33

E.

Outcomes .................................................................................................................................... 36

F.

Psychosocial Considerations ....................................................................................................... 38

Research Priorities...................................................................................................................... 40
A.

Prevention and Treatment of Phantom and Residual Limb Pain ................................................ 41

B.

Clinical Assessments and Outcomes Tools .................................................................................. 41

C.

Psychosocial Interventions .......................................................................................................... 42

D.

Surgical Procedures and Medical Interventions.......................................................................... 42E.

Rehabilitation and Prosthetic Outcomes .................................................................................... 43a.

Epidemiologic Studies .......................................................................................................... 43b.

Efficacy and Effectiveness Studies ....................................................................................... 44

Appendix A: Guideline Development Methodology ......................................................................... 45
A.

Developing Key Questions to Guide the Systematic Evidence Review ....................................... 45

B.

Conducting the Systematic Review ............................................................................................. 50

C.

Developing Evidence-based Recommendations ......................................................................... 55

D.

Drafting and Finalizing the Guideline .......................................................................................... 58

Appendix B: Summary of Assessments and Interventions in Rehabilitation Phases .......................... 59
Appendix C: Outcome Measures...................................................................................................... 66
A.

Inclusion Criteria ......................................................................................................................... 66

B.

Exclusion Criteria ......................................................................................................................... 66

Appendix D: Essential Elements of the Annual Contact .................................................................... 73
A.

Medical Considerations ............................................................................................................... 73

B.

Functional Status ......................................................................................................................... 73

C.

Prosthesis-related Considerations .............................................................................................. 73

D.

Pain and Residual Limb Considerations ...................................................................................... 73

E.

Psychosocial Considerations ....................................................................................................... 73

F.

Secondary Amputation Prevention ............................................................................................. 74

Appendix E: Advantages and Disadvantages of Prostheses .............................................................. 75
Appendix F: Surgical Considerations ................................................................................................ 76
A.

Surgical Considerations ............................................................................................................... 76

B.

Emerging Surgical Techniques ..................................................................................................... 79

March 2022

Page 4 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix G: Control Strategies for Body-Powered and Externally Powered Prostheses ................... 81
A.

Control of a Body-Powered Prosthesis ....................................................................................... 81

B.

Control of an Externally Powered Prosthesis .............................................................................. 81

Appendix H: Training for Body-Powered and Externally Powered Prostheses ................................... 83
A.

Overview of Training ................................................................................................................... 83

B.

Residual Limb Management ........................................................................................................ 83

C.

Prosthesis Training Concepts ...................................................................................................... 84

D.

Education Topics ......................................................................................................................... 89

Appendix I:

Patient Focus Group Methods and Findings ................................................................. 91

A.

Methods ...................................................................................................................................... 91

B.

Patient Focus Group Findings...................................................................................................... 91

Appendix J:

Evidence Table ............................................................................................................. 93

Appendix K: 2014 Recommendation Categorization Table ............................................................... 95
Appendix L:

Participant List ............................................................................................................. 98

Appendix M: Literature Review Search Terms and Strategy ............................................................ 100
A.

EMBASE and MEDLINE with EMBASE.com syntax (all questions) ............................................. 100

B.

CINAHL in EBSCO Syntax (KQs 2, 3, 7, 8, 9, 12) ......................................................................... 123

C.

PsycINFO with OVID syntax (KQs 2, 4, 5, 7, 8, 9, 12) ................................................................. 129

Appendix N: Alternative Text Descriptions of Algorithm ................................................................ 131
Module A: Upper Limb Amputation Management ........................................................................... 131
Module B: Upper Limb Amputation Management for Primary Care ................................................ 132
Appendix O: Abbreviations ............................................................................................................ 134
References ....................................................................................................................................... 136

March 2022

Page 5 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

I.

Introduction

The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based PracticeWork Group (EBPWG) was established and first chartered in 2004, with a mission to advise the Health
Executive Committee (HEC) “… on the use of clinical and epidemiological evidence to improve the healthof the population …” across the Veterans Health Administration (VHA) and Military Health System(MHS), by facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD
populations.(1) Development and update of VA/DoD CPGs is funded by VA Evidence Based Practice,
Office of Quality and Patient Safety. The system-wide goal of evidence-based CPGs is to improve patient
health and well-being.
In 2014, the VA and DoD published a CPG for the Management of Upper Extremity Amputation
Rehabilitation (2014 VA/DoD UEAR CPG), which was based on evidence reviewed through June 2013.
Since the release of that CPG, a growing body of research has expanded the evidence base andunderstanding of upper limb amputation (ULA) rehabilitation. Consequently, the VA/DoD EBPWG
initiated the update of the 2014 VA/DoD UEAR CPG in 2020. This updated CPG’s use of GRADE reflects amore rigorous application of the methodology than previous iterations. Consequently, the strength ofsome recommendations may have been modified due to the confidence in the quality of the supporting
evidence (see Evidence Quality and Recommendation Strength).
The updated CPG includes recent objective, evidence-based information on the care and rehabilitationof persons with ULA. It is intended to provide guidance to assist healthcare providers in perioperative,
pre-prosthetic training, prosthetic training, and life-long phases of patient care. The system-wide goal ofthis evidence-based guideline is to improve the patient’s health and well-being. It guides healthcare
providers along evidence supported management pathways to assist patients in rehabilitation following
ULA. The expected outcome of successful implementation of this guideline is to:·Assess the patient’s condition and collaborate with the patient, family, and caregivers todetermine optimal management of patient care·

Emphasize the use of patient-centered care and shared decision making·

Minimize preventable complications and morbidity·

Optimize individual health outcomes and quality of life (QoL)

II.

BackgroundA.

Amputation Level Classification

Various taxonomies are used to describe the different levels of ULA.(2) Table 1 correlates theInternational Standards amputation terminology with the common terminology used to describe theamputation level in both the clinical setting and research publications. The VA and DoD recommend that
the International Standards terminology be used to describe ULA. In addition, ULA can be classified aseither major or minor. As shown in Table 1, this taxonomy classifies amputations at the wrist
disarticulation level and more proximal as major amputations, and those involving the hand or digits as
minor amputations. While this taxonomy is widely used in both the clinical and research settings, the VA
and DoD do not specifically endorse use of this terminology because amputation levels classified as

March 2022

Page 6 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

minor can still result in significant functional impairment. Despite most of the rehabilitation andprosthesis fitting research literature focusing on major ULA, this CPG’s literature review search strategy
included all levels of ULA. Where guideline recommendations pertain to a certain subgroup of persons
with ULA, this information is specified in the recommendation language.
Table 1. Upper Limb Amputation Level Terminology
International Standards Terminology

Common Terminology

Major or Minor Amputation

Forequarter

Forequarter

Major

Shoulder disarticulation

Through shoulder

Major

Transhumeral

Above elbow

Major

Elbow disarticulation

Through elbow

Major

Transradial

Below elbow

Major

B.

Wrist disarticulation

Through wrist

Major

Partial hand

Through hand, ray

Minor

Thumb

Thumb

Minor

Digits (upper extremity)

Fingers

Minor

Epidemiology

In the United States (U.S.), approximately two million individuals are living with limb loss. Most arelower limb loss with ULA affecting only about 3% of the U.S. limb loss population.(3) The etiologies forlimb loss differ with the primary reason for lower limb loss being disease processes, while trauma is theprimary reason for loss of the upper limb. Loss of a limb is a life-altering occurrence for an individual andtheir family. This is especially true in traumatic injuries where individuals are primarily younger, causing
significant vocational, functional, and financial consequences.
Traumatic injuries account for nearly 70% of ULA in the U.S. and are also the most common cause of ULA
within DoD and VA.(4) Extremity injuries occur from military combat (e.g., blast, shrapnel, and gunshot),motor vehicle accidents, and other training and industrial accidents. While improvements in immediate
trauma care, advanced reconstructive surgical techniques, and rehabilitation have reduced the need forsome amputations, Veterans and Service Members continue to be at significant risk. Of the total
amputation population, including all levels of limb amputation, cared for within DoD and VA healthcare
since 2001, approximately 51.2% in DoD and 19% in VA involve one or both upper limbs.(5, 6) Looking
more specifically at those with major limb amputation receiving care in the VA, only 7.6% of these
individuals have involvement of one or both upper limbs. In the DoD, only 9.5% of the amputation
population over age 18 have major limb amputation involving one or both upper limbs. This is secondary
to the relatively high number of Veterans with digit amputations involving the upper limb.
While the pathophysiology of traumatic amputations may differ from non-traumatic amputations,rehabilitation strategies and prosthetic prescriptions for both should be centered on realistic patient
goals with concentrated efforts directed to maximize function. Level of amputation, cognitive
impairment, physical conditioning, nutritional status, social support, psychological factors, andmotivation are some challenges that influence the rehabilitation of patients with ULA. To maximize
successful outcomes and return Veterans or Service Members with an ULA to independent living inMarch 2022

Page 7 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

home, work, and community environments, providers must consider these factors in the developmentof a rehabilitation program and care plan. The rehabilitation treatment plan should also take into
consideration that some individuals may choose to not use a prosthesis. For those patients, care teams
need to consider other approaches to maximize functional independence.
Because of the complex rehabilitative needs of persons with ULA, a rehabilitation setting with vocational
and psychological counselors, therapists, physicians, and prosthetists with specialized expertise andexperience is vital to successful outcomes. The overall goal of amputation rehabilitation is to optimize
the patient’s health status, function, independence, and QoL. To achieve these desired outcomes,
patients should participate in ongoing medical assessments and therapy interventions throughout thelife-long continuum of care to address psychosocial, physical, and functional limitations.

III. Scope of this Guideline
This CPG is based on published clinical evidence and related information available through April 30,
2021. It is intended to provide general guidance on best evidence-based practices (see Appendix A for
additional information on the evidence review methodology). This CPG is not intended to serve as astandard of care.

A.

Guideline Audience

This CPG is intended for use by all healthcare providers caring for patients with ULA. This version of the
CPG was specifically tailored to be of greatest value to rehabilitation care providers, including
physicians, therapists, and prosthetists, involved in the management of persons with ULA.

B.

Guideline Population

The patient population of interest for this CPG is adults (≥18 years) with ULA, including Veterans as wellas Service Members, military retirees, and beneficiaries.

IV. Highlighted Features of this Guideline
A.

Highlights in this Guideline Update

The current document is an update to the 2014 VA/DoD UEAR CPG. The 2022 VA/DoD ULA
Rehabilitation edition is the first update to this CPG and includes recent objective, evidence-based
information on the care and rehabilitation of persons with ULA. It is intended to provide guidance toassist healthcare providers in managing the care of persons with ULA across the entire care continuum.
The 2022 VA/DoD ULA CPG developed recommendations using the GRADE methodology. Thismethodology does not allow for recommendations based on expert opinion alone. This contrasts withthe 2014 CPG methodology, which resulted in 26 out of 27 recommendations being based solely on
expert opinion. In addition to a more stringent development methodology, the 2022 CPG wasstrengthened by the utilization of gender-specific patient focus groups to identify priority clinical issues
and gender-specific management considerations. Another new aspect of the 2022 VA/DoD ULA CPG isthat a different structure was used both for the development of the key questions and for theorganization of the guideline recommendations.

March 2022

Page 8 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Consistent with the 2014 UEAR CPG, this CPG is tailored to be of greatest value to rehabilitation careproviders, including physicians, therapists, and prosthetists involved in the management of persons with
ULA. However, the 2022 update includes an additional treatment algorithm that is designed specificallyfor primary care providers to assist in their care of persons with ULA. The treatment algorithm primarily
designed for rehabilitation providers remains a strength of this CPG. This algorithm has been updated
and continues to address key milestones and decision points across all four phases of rehabilitation care(see Algorithm).
Rather than focus on a narrow aspect of care, the 2022 CPG remains comprehensive in scope. Although
this CPG includes only 14 recommendations (13 less than the 2014 CPG), it still provides management
recommendations across the life span of the person with ULA and across the spectrum of clinicalconditions and management challenges faced following ULA. Although improved in comparison to the2014 CPG, the quality and quantity of research evidence identified for inclusion in the updated 2021
literature review was still limited, which resulted in no Strong for recommendations, four Weak forrecommendations, and 10 Neither for nor against recommendations (see Recommendations). Thus, the2022 CPG highlights the ongoing need for further high quality research in all fields of ULA rehabilitationand includes a section focused on Research Priorities.
To accompany this CPG, the Work Group also developed toolkit materials for providers and patients,
including a provider summary, patient summary, and pocket card. These can be found athttps://www.healthquality.va.gov/index.asp.
The 2022 VA/DoD ULA CPG used a more rigorous application of the methodology than previous
iterations. For additional information on GRADE or CPG methodology, see Appendix A.

B.

Components of the Guideline

The 2022 VA/DoD ULA CPG is the first update to this CPG. It provides clinical practice recommendations
for the care of patients with ULA (see Recommendations). In addition, the Algorithm incorporates therecommendations in the context of the flow of patient care. This CPG also includes Research Priorities,
which list areas the Work Group identified as needing additional research.
To accompany this CPG, the Work Group also developed toolkit materials for providers and patients,
including a provider summary, patient summary, and pocket card. These can be found athttps://www.healthquality.va.gov/index.asp.

V.

Guideline Development TeamThe VA Evidence Based Practice, Office of Quality and Patient Safety, in collaboration with the Clinical
Quality Improvement Program, Defense Health Agency (DHA), identified the following four clinicians toserve as Champions (i.e., leaders) of this CPG’s Work Group: Billie Randolph, PT, PhD and Joseph Webster,MD from the VA and Andrea Crunkhorn, PT, DPT and MAJ Megan Loftsgaarden, DO from the DoD.
The Work Group comprised individuals with the following areas of expertise: internal medicine,
occupational therapy, pain management, pharmacology, physical medicine and rehabilitation

March 2022

Page 9 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

physicians, physical therapy, plastic surgery, polytrauma nursing, prosthetics, and rehabilitation
psychology. See Table 2 for a list of Work Group members.
This CPG Work Group, led by the Champions, was tasked with:·

Determining the scope of the CPG·

Crafting clinically relevant key questions (KQs) to guide the systematic evidence review·

Identifying discussion topics for the patient focus group and considering the patient perspective·

Providing direction on inclusion and exclusion criteria for the systematic evidence review andthe assessment of the level and quality of evidence·

Developing evidence-based clinical practice recommendations, including determining thestrength and category of each recommendation

The Lewin Team, including The Lewin Group, ECRI, Sigma Health Consulting, and Duty First Consulting,
was contracted by the VA to help develop this CPG.
Table 2. Guideline Work Group and Guideline Development Team
Organization

Department of Veterans Affairs

Department of Defense

Office of Quality and Patient Safety
Veterans Health Administration

March 2022

Names*
Billie Randolph, PT, PhD (Champion)
Joseph Webster, MD (Champion)
Irina Agranova-Breyter, MPT
Erin Andrews, PsyD, ABPP
Roxanne Disla, OTD, OTR/L
Selina Doncevic, MSN, RN, CRRN
Christopher Fantini, MSPT, CP, BOCO
M. Jason Highsmith, PhD, DPT, CP, FAAOP
Denise Lester, MD
William C. Mayes, MSPO, CPO
Linda Resnik, PT, PhD, FAPTA
Bradley Tucker, MD
Andrea Crunkhorn, PT, DPT (Champion)
Maj Megan Loftsgaarden, DO (Champion)
Shannon Barnicott, MOT, OTR/L
Josef Butkus, MS, OTR/L
Rachael Coller, PharmD, BCPS, BCPP
LCDR Joseph Happel, MD
Louise Hassinger, CP
Michelle Nordstrom, MS, OTR/L
Annemarie Orr, OTD, OTR/L
Maj Casey Sabbag, MD
M. Eric Rodgers, PhD, FNP-BC
James Sall, PhD, FNP-BC
Rene Sutton, BS, HCA

Page 10 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Organization

Names*

Clinical Quality Improvement Program
Defense Health Agency

Lisa D. Jones, BSN, RN, MHA, CPHQElaine Stuffel, MHA, BSN, RN
Clifford Goodman, PhD
Erika Beam, MS
Ben Agatston, JD, MPH
Shaina Haque, MPH
Amanda Huben, BA
Ryan Wilson, BA
Kris D’Anci, PhD
Stacey Uhl, MS
Aaron Bloschichak, MPH
Amber Moran, MA
Emilio Berdiel, MPH
Jessica T. Gontarek, MSLIS
Michele Datko, MLS
Frances Murphy, MD, MPHJames Smirniotopoulos, MD
Rachel Piccolino, BA
Mary Kate Curley, BA
Richa Ruwala, BS
Anita Ramanathan, BA

The Lewin GroupECRISigma Health Consulting

Duty First Consulting*Additional contributor contact information is available in Appendix L.

VI. Summary of Guideline Development Methodology
The methodology used in developing this CPG follows the Guideline for Guidelines, an internal documentof the VA/DoD EBPWG updated in January 2019 that outlines procedures for developing and submitting
VA/DoD CPGs.(7) The Guideline for Guidelines is available at
http://www.healthquality.va.gov/policy/index.asp. This CPG also aligns with the National Academy ofMedicine’s (NAM) principles of trustworthy CPGs (e.g., explanation of evidence quality and strength, themanagement of potential conflicts of interest [COI], interdisciplinary stakeholder involvement, use of
systematic review, and external review).(8) Appendix A provides a detailed description of the CPG
development methodology.

A.

Evidence Quality and Recommendation Strength

The Work Group used the Grading of Recommendations Assessment, Development and Evaluation(GRADE) approach to craft each recommendation and determine its strength. Per GRADE approach,recommendations must be evidence-based and cannot be made based on expert opinion alone. The
GRADE approach uses the following four domains to inform the strength of each recommendation (seeDetermining Recommendation Strength and Direction):(9)·Confidence in the quality of the evidence·

Balance of desirable and undesirable outcomes

March 2022

Page 11 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

Patient values and preferences·

Other considerations, as appropriate, e.g.:¨Resource use¨

Equity¨

Acceptability¨

Feasibility¨

Subgroup considerations

Using these four domains, the Work Group determined the relative strength of each recommendation(Strong or Weak). The strength of a recommendation is defined as the extent to which one can be
confident that the desirable effects of an intervention outweigh its undesirable effects and is based on
the framework above, which incorporates the four domains.(10) A Strong recommendation generallyindicates High or Moderate confidence in the quality of the available evidence, a clear difference inmagnitude between the benefits and harms of an intervention, similar patient values and preferences,and understood influence of other implications (e.g., resource use, feasibility).
In some instances, there is insufficient evidence on which to base a recommendation for or against aparticular therapy, preventive measure, or other intervention. For example, the systematic evidence
review may have found little or no relevant evidence, inconclusive evidence, or conflicting evidence forthe intervention. The manner in which this is expressed in the CPG may vary. In such instances, theWork Group may include among its set of recommendations a statement of insufficient evidence for anintervention that may be in common practice even though it is not supported by clinical evidence, andparticularly if there may be other risks of continuing its use (e.g., high opportunity cost, misallocation of
resources). In other cases, the Work Group may decide to not include this type of statement about anintervention. For example, the Work Group may remain silent where there is an absence of evidence fora rarely used intervention. In other cases, an intervention may have a favorable balance of benefits andharms but may be a standard of care for which no recent evidence has been generated.
Using these elements, the Work Group determines the strength and direction of each recommendationand formulates the recommendation with the general corresponding text (see Table 3).
Table 3. Strength and Direction of Recommendations and General Corresponding Text
Recommendation Strength and Direction

General Corresponding Text

Strong for

We recommend …

Weak forWe suggest …

Neither for nor against

There is insufficient evidence to recommend for or against …

Weak against

We suggest against …

Strong against

We recommend against …

It is important to note that a recommendation’s strength (i.e., Strong versus Weak) is distinct from its
clinical importance (e.g., a Weak recommendation is evidence-based and still important to clinical care).
The strength of each recommendation is shown in the Recommendations section.

March 2022

Page 12 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

This CPG’s use of GRADE reflects a more rigorous application of the methodology than previous
iterations. For instance, the determination of the strength of the recommendation is more directly
linked to the confidence in the quality of the evidence on outcomes that are critical to clinical decisionmaking. The confidence in the quality of the evidence is assessed using an objective, systematic
approach that is independent of the clinical topic of interest. Therefore, recommendations on topics forwhich it may be inherently more difficult to design and conduct rigorous studies (e.g., randomized
controlled trials [RCTs]) are typically supported by lower quality evidence and, in turn, Weakrecommendations. Recommendations on topics for which rigorous studies can be designed andconducted may more often be Strong recommendations. Per GRADE, if the quality of evidence differs
across the relevant critical outcomes, the lowest quality of evidence for any of the critical outcomes
determines the overall quality of the evidence for a recommendation.(11, 12) This stricter standard
provides a consistent approach to determining recommendation strengths. For additional information
on GRADE or CPG methodology, see Appendix A.

B.

Categorization of 2014 Clinical Practice Guideline Recommendations

Evidence-based CPGs should be current. Except for an original version of a new CPG, this typicallyrequires revision of a CPG’s previous versions based on new evidence or as scheduled subject to timebased expirations.(13) For example, the U.S. Preventive Services Task Force (USPSTF) has a process formonitoring the emergence of new evidence that could prompt an update of its recommendations, and itaims to review each topic at least every five years for either an update or reaffirmation.(14)Recommendation categories were used to track how the previous CPG’s recommendations could bereconciled. These categories and their corresponding definitions are similar to those used by the
National Institute for Health and Care Excellence (NICE, England).(15, 16) Table 4 lists these categories,
which are based on whether the evidence supporting a recommendation was systematically reviewed,
the degree to which the previous CPG’s recommendation was modified, and whether a previous CPG’s
recommendation is relevant in the updated CPG.
Additional information regarding these categories and their definitions can be found in
Recommendation Categorization. The 2022 CPG recommendation categories can be found in
Recommendations. Appendix K outlines the 2014 VA/DoD UEAR CPG’s recommendation categories.

March 2022

Page 13 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Table 4. Recommendation Categories and Definitionsa
Evidence
Reviewed

Reviewedb

Notreviewedc

Recommendation
Category

Definition

New-added

New recommendation

New-replaced

Recommendation from previous CPG was carried forward and revised

Not changed

Recommendation from previous CPG was carried forward but not changed

AmendedRecommendation from previous CPG was carried forward with a nominalchangeDeletedRecommendation from previous CPG was deleted

Not changed

Recommendation from previous CPG was carried forward but not changed

AmendedRecommendation from previous CPG was carried forward with a nominalchangeDeletedRecommendation from previous CPG was deletedaAdapted from the NICE guideline manual (2012) (15) and Garcia et al. (2014) (16)b

The topic of this recommendation was covered in the evidence review carried out as part of the development of the current CPG.

c

The topic of this recommendation was not covered in the evidence review carried out as part of the development of thecurrent CPG.

Abbreviation: CPG: clinical practice guideline

C.

Management of Potential or Actual Conflicts of Interest

Management of COIs for the CPGs is conducted as described in the Guideline for Guidelines.(7) Further,
the Guideline for Guidelines refers to details in the VHA Handbook 1004.07 Financial Relationships
between VHA Health Care Professionals and Industry (November 2014, issued by the VHA National
Center for Ethics in Health Care),(17) as well as to disclosure statements (i.e., the standard disclosure
form that is completed at least twice by CPG Work Group members and the guideline developmentteam).(7) The disclosure form inquires regarding any relevant financial and intellectual interests or otherrelationships with, e.g., manufacturers of commercial products, providers of commercial services, orother commercial interests. The disclosure form also inquires regarding any other relationships oractivities that could be perceived to have influenced, or that give the appearance of potentiallyinfluencing, a respondent’s contributions to the CPG. In addition, instances of potential or actual COIs
among the CPG Work Group and the guideline development team were also subject to random webbased identification via standard electronic means (e.g., Centers for Medicare & Medicaid Services[CMS] Open Payments and/or ProPublica).
No COIs were identified among the CPG Work Group or the guideline development team. If an instanceof potential or actual COI had been reported, it would have been referred to the VA and DoD program
offices and reviewed with the CPG Work Group Champions. The VA and DoD program offices and the
CPG Work Group Champions would have determined whether, and if so, what, further action wasappropriate (e.g., excusing Work Group members from selected relevant deliberations or removal fromthe Work Group). Disclosure forms are on file with the VA Office of Quality and Patient Safety and areavailable upon request.

March 2022

Page 14 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

D.

Patient Perspective

When developing a CPG, consideration should be given to patient perspectives and experiences, which
often vary from those of providers.(11, 18) Focus groups can be used to help collect qualitative data on
patient perspectives and experiences. VA and DoD Leadership arranged two virtual patient focus groups,
one comprised of all men and the other all women, on March 19, 2021. The focus groups exploredpatients’ perspectives on topics related to the management of ULA in the VA and DoD healthcare
systems, including information about their history of treatment, experiences with care delivery invarious settings, treatments including occupational and physical therapy, prostheses, self-management,
and the impact of their ULA and related therapies on their lives.
The patient focus groups comprised a convenience sample of nine people. Six participants were
Veterans who received care from the VA health system, and four participants were Service Members
who received care from the DoD health system. Two participants indicated receiving care at the Centerfor the Intrepid, and two participants reported receiving initial rehabilitation care outside of the VA andDoD health systems. The Work Group acknowledges this convenience sample is not representative of all
patients with ULA within the VA and DoD healthcare systems and, thus, findings are not generalizableand do not comprise evidence. For more information on the patient focus group methods and findings,
see Appendix I. Patient focus group participants were provided the opportunity to review the final draftof the focus group report and provide additional feedback.

E.

External Peer Review

The Work Group drafted, reviewed, and edited this CPG using an iterative process. For more
information, see Drafting and Finalizing the Guideline. Once the Work Group completed a near-final
draft, they identified experts from the VA and DoD healthcare systems and outside organizations
generally viewed as experts in the respective field to review that draft. The draft was sent to thoseexperts for a 14-business-day review and comment period. The Work Group considered all feedback
from the peer reviewers and modified the CPG where justified, in accordance with the evidence.
Detailed information on the external peer review can be provided by the VA Office of Quality andPatient Safety.

F.

Implementation

This CPG and algorithm are designed for adaptation by individual healthcare providers with considerationof unique patient considerations and preferences, local needs, and resources. The algorithm serves as atool to prompt providers to consider key decision points in the care for a patient with ULA. The WorkGroup submits suggested performance metrics for the VA and DoD to use when assessing theimplementation of this CPG. Robust implementation is identified in VA and DoD internal implementationplans and policies. Additionally, implementation would entail wide dissemination through publication in
the medical literature, online access, educational programs, and, ideally, electronic medical record (EMR)
programming in the form of clinical decision support tools at the point of care.

March 2022

Page 15 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

VII. Approach to Care in Department of Veterans Affairs andDepartment of Defense
A.

Patient-centered Care

Guideline recommendations are intended to consider patient needs and preferences. Guideline
recommendations represent a whole/holistic health approach to care that is patient-centered, culturally
appropriate, and available to people with limited literacy skills and physical, sensory, or learning
disabilities. VA/DoD CPGs encourage providers to use a patient-centered, whole/holistic healthapproach (i.e., individualized treatment based on patient needs, characteristics, and preferences). Thisapproach aims to treat the particular condition while also optimizing the individual’s overall health andwell-being.
Regardless of the care setting, all patients should have access to individualized evidence-based care.
Patient-centered care can decrease patient anxiety, increase trust in clinicians, and improve treatment
adherence.(19, 20) A whole/holistic health approach (https://www.va.gov/wholehealth/) empowers andequips individuals to meet their personal health and well-being goals. Good communication is essential
and should be supported by evidence-based information tailored to each patient’s needs. An
empathetic and non-judgmental approach facilitates discussions sensitive to gender, culture, ethnicity,and other differences.

B.

Shared Decision Making

This CPG encourages providers to practice shared decision making, which is a process in which providers
and patients consider clinical evidence of benefits and risks as well as patient values and preferences tomake decisions regarding the patient’s treatment.(21) Shared decision making was emphasized in
Crossing the Quality Chasm, an Institute of Medicine (IOM) (now NAM) report, in 2001 (22) and isinherent within the whole/holistic health approach. Providers must be adept at presenting information
to their patients regarding individual treatments, expected risks, expected outcomes, and levels and/or
settings of care, especially where there may be patient heterogeneity in risks and benefits. The VHA andMHS have embraced shared decision making. Providers are encouraged to use shared decision making
to individualize treatment goals and plans based on patient capabilities, needs, and preferences.

C.

Patients with Co-occurring Conditions

Co-occurring conditions can modify the degree of risk, impact diagnosis, influence patient and provider
treatment priorities and clinical decisions, and affect the overall approach to the management of ULA
rehabilitation. Many Veterans, Service Members, and their families have one or more co-occurring
conditions. Because ULA is sometimes accompanied by co-occurring conditions, it is often best to
manage ULA collaboratively with other care providers. Some co-occurring conditions may require earlyspecialist consultation to determine any necessary changes in treatment or to establish a common
understanding of how care will be coordinated. This may entail reference to other VA/DoD CPGs (e.g.,
for posttraumatic stress disorder [PTSD], substance use disorders [SUD], suicide risk, major depressive
disorder [MDD], and opioid therapy for chronic pain).b

b The VA/DoD CPGs are available at: https://www.healthquality.va.gov/index.asp

March 2022

Page 16 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

D.

Phases of Rehabilitation Care

The VA and DoD have previously described four phases of care which create a framework forrehabilitation and long-term management of patients with an ULA. The phases are not defined by fixed
points in time. Rather, they often overlap to accommodate for the patient’s recovery process based on
an appreciation of the patient’s needs, severity of injury, wound healing, pain tolerance, andpsychological readiness. Additionally, progression through the phases of care does not necessarily occur
sequentially in a linear direction. Phases are repeated as appropriate based on the needs of the patient.
The four phases are:·Phase 1: Perioperative·

Phase 2: Pre-prosthetic·

Phase 3: Prosthetic training·

Phase 4: Lifelong care

The perioperative phase of rehabilitation commences when a patient has been initially evaluated in theclinical setting and has either undergone an ULA or the decision has been made that amputation isnecessary. In most cases, the underlying cause resulting in the need for an ULA involves a traumatic
injury. Complete interdisciplinary assessments of the patient’s medical, functional, and psychologicalstatus should be performed as soon as it is clinically appropriate to establish a baseline level of function
and prepare the patient for the ensuing rehabilitation plan and, ultimately, lifelong care. The continuumof this phase is to: ensure communication and coordination of care; provide proper medical, surgical,
and psychological management; initiate rehabilitation; and facilitate protective healing of the residuallimb. The end of the perioperative phase occurs when residual limb incisions are closed and free of
infection, sutures are removed, self-care activities of daily living (ADL) using one-handed strategies andadaptive or durable medical equipment are progressing, and the patient has been medically cleared forfurther rehabilitation.
The goal of the pre-prosthetic phase is to prepare the patient and his or her residual limb for initial
prosthetic fitting. In this phase, the care team determines if the patient is a candidate for a prosthesis
and aids the patient in determining which type of prosthesis(es) will be most beneficial. During thisphase, wound closure and pain control continue to be monitored, ongoing rehabilitation interventions
are performed, and continued psychosocial support is provided. The patient must be medically,
surgically, and cognitively cleared by the care team for a diagnostic socket fitting to occur. The initial
prosthesis prescription should be developed with input from all members of the care team andindividualized for the patient based on the patient’s specific needs and goals related to prosthesis use.
Table 5 provides the care team with the essential elements that should be included in an upper limb
prosthesis prescription. The pre-prosthetic phase ends with the fitting of the initial prosthesis. This
phase typically occurs in an outpatient or rehabilitation setting.

March 2022

Page 17 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Table 5. Components of the Upper Limb Prosthesis Prescription
Comprehensive prescription for an upper limb prosthesis should include:
·
·
·
·
·
·
·
·
·
·

Design (e.g., preparatory versus definitive)
Control strategy (e.g., passive, externally powered, body powered, task specific)
The anatomical side and amputation level of the prosthesis
Type of socket interface (e.g., soft insert, elastomer liner, flexible thermoplastic)
Type of socket frame (e.g., thermoplastic or laminated)
Suspension mechanism (e.g., harness, suction, anatomical)
Terminal device (TD)Wrist unit (if applicable)
Elbow unit (if applicable)
Shoulder unit (if applicable)

The prosthetic training phase marks a turning point in the rehabilitation of the patient who isdetermined to be an appropriate candidate to proceed to prosthesis fitting. Phases one and two provide
a foundation for success in phase three. This phase commences upon delivery of an initial prosthesis andcontinues until the patient demonstrates desired functional outcomes with proper prosthetic use during
desired functional activities. This phase involves continued physical rehabilitation interventions as
appropriate, functional prosthetic training, return to vocational and avocational activities, andcontinued psychological support. Patients may ebb and flow through this phase after receiving each new
or different type of prosthesis. During this phase of care, the members of the care team must monitor
the patient for potential complications that can occur during prosthesis use. Table 6 provides the careteam with some common signs and symptoms that the prosthesis may need to be modified. This phase
may also begin because a patient receives a new prosthetic component or a novel control scheme.
Table 6. Signs and Symptoms the Prosthesis May Need to Be Modified
Patients who use a prosthesis should be advised to report any of the following symptoms:· Ongoing pain in the residual limb or associated with a prosthetic harness· Skin breakdown· Change in the ability to don and doff the prosthesis· Change in limb volume (weight gain or loss)· Change in pattern of usage
The last phase of ULA rehabilitation is lifelong care. This phase begins upon completion of the prosthetic
training phase and continues throughout the remainder of the patient’s life. The importance of thisphase cannot be understated. During this phase, the patient should return for annual routine follow-up
assessments and review of the patient’s functional goals with the amputation care team. A
comprehensive, interdisciplinary approach is used at each follow-up regardless of prosthetic use. Eachroutine follow-up assessment should focus on maximizing the patient’s functional independence using
available rehabilitation services and emerging technologies in ULA rehabilitation.
The Algorithm summarizes the activities and milestones achieved in each phase of care.

March 2022

Page 18 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

VIII. Algorithm
This CPG’s algorithm is designed to facilitate understanding of the clinical pathway and decision making
process used in managing patients with ULA. This algorithm format represents a simplified flow of the
management of patients with ULA and helps foster efficient decision making by providers. It includes:·

An ordered sequence of steps of care·

Decisions to be considered·

Recommended decision criteria·

Actions to be taken

The algorithm is a step-by-step decision tree. Standardized symbols are used to display each step, andarrows connect the numbered boxes indicating the order in which the steps should be followed.(23)
Sidebars provide more detailed information to assist in defining and interpreting elements in the boxes.
Shape

Description
Rounded rectangles represent a clinical state or condition
Hexagons represent a decision point in the process of care, formulated as a questionthat can be answered “Yes” or “No”
Rectangles represent an action in the process of care
Ovals represent a link to another section within the algorithm

Appendix N contains alternative text descriptions of the algorithm.

March 2022

Page 19 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation RehabilitationA.

Module A: Upper Limb Amputation Management*Peer support includes both peer visitors right after surgery and peer support in an outpatient setting**May involve trials of various device components as appropriate and feasible
Abbreviations: ULA: upper limb amputation

March 2022

Page 20 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Sidebar 1: Components of the Comprehensive Assessment
·
·
·
·
·
·
·
·
·
·
·

Present health status
Level of function
Modifiable/controllable health risk factors
Pain assessment
Cognition and behavioral health
Personal, family, social, and cultural context
Learning assessment
Residual limb assessment
Non-amputated limb and trunk assessment
Prosthetic assessment (if applicable)
Vocational assessment

Sidebar 2: The Patient-centered Rehabilitation Plan
· Evaluations from all members of the care team
· Input from the patient and family/caregiver(s)· Treatment plan, which must address all identified realistic patient-centered treatment goals, rehabilitation,
medical, psychological, and surgical problems· Indication of the next anticipated phase of rehabilitation care based on discharge criteria

Sidebar 3: Physical and Functional Rehabilitation Interventions· ADL retraining and consideration of adaptive equipment, modified or altered strategies, and one-handed
·
·
·
·
·
·

techniques
Residual limb management (e.g., volume, pain, sensitivity, skin integrity, and care)
Progressive ROM exercises
Postural exercises and progressive strengthening
Cardiovascular endurance
IADL interventions, home and driving modifications, assistive technologies, and community integration
Adaptive sports or leisure activities

Abbreviations: ADL: activities of daily living; IADL: instrumental activities of daily living; ROM: range of motion

March 2022

Page 21 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

B.

Module B: Upper Limb Amputation Management for Primary Care

Abbreviations: OT: occupational therapy; PM&R: physical medicine and rehabilitation; ULA: upper limb amputation

March 2022

Page 22 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Sidebar 4: Amputation Care TeamThe amputation care team is an interdisciplinary team consisting of, at a minimum, a physiatrist (or prescribing
clinician), occupational and physical therapists, and prosthetist, that provides assessment and treatment for
amputation-related needs. Other providers who may be included are mental health, rehabilitation psychology (ifavailable), social work, nursing, wound care, surgery, vocational planning. Members of the team may participate
face to face or via telehealth as appropriate.

IX.

Recommendations

The following evidence-based clinical practice recommendations were made using a systematic
approach considering four domains as per the GRADE approach (see Summary of Guideline
Development Methodology). These domains include: confidence in the quality of the evidence, balanceof desirable and undesirable outcomes (i.e., benefits and harms), patient values and preferences, andother implications (e.g., resource use, equity, acceptability).
Recommendation

Strengtha

Categoryb

There is insufficient evidence to assess the impact of the level ofamputation or amputation surgical procedure type on functional
status and prosthesis-related outcomes.

Neither for
nor against

Reviewed,
New-added2.

For patients undergoing upper limb amputation surgery, there isinsufficient evidence to recommend the use of any particular factors
to predict the speed and quality of wound healing, successful
prosthesis fitting, or need for revision surgery.

Neither for
nor against

Reviewed,
New-added

3.

There is insufficient evidence to recommend for or against the use ofany particular recent treatment advances including hardware,
software, surgical, technology, or supplemental surgicalinterventions, such as:· targeted muscle reinnervation (TMR)
Neither for· regenerative peripheral nerve interfaces (RPNI)
nor against· vascularized composite allotransplantation (VCA)· agonist-antagonist myoneural interface (AMI)· implantable myoelectric sensor system (IMES)· osseointegration (OI)

Reviewed,
New-added

4.

There is insufficient evidence to recommend for or against any
particular training protocol to improve function and outcomes.

Neither for
nor against

Reviewed,
New-added

5.

We suggest the use of mirror therapy for the short-term reduction ofphantom limb pain.

Weak for

Reviewed,
New-replaced

6.

There is insufficient evidence to recommend for or against any
particular treatment setting, intensity, or service delivery model.

Neither for
Reviewed,
nor against New-replaced

7.

For patients with major unilateral upper limb amputation (i.e.,through or proximal to the wrist), we suggest use of a body-poweredor externally powered prosthesis to improve independence andreduce disability.

Weak for

Reviewed,
New-added

8.

There is insufficient evidence to recommend for or against any
specific control strategy, socket design, suspension method, orcomponent.

Neither for
nor against

Reviewed,
New-added

Prosthetic
Restoration

1.

Surgery/Pre-prosthetic#

Rehabilitation

Topic

March 2022

Page 23 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Topic

#

Medical
Psychosocial
Outcomes
ConsiderationsbStrengtha

Categoryb

There is insufficient evidence to recommend for or against aparticular intervention for the prevention of phantom and/or
residual limb pain.

Neither for
Reviewed,
nor against New-replaced

There is insufficient evidence to recommend for or against any
10. particular pharmacologic intervention for the management ofphantom and/or residual limb pain.

Neither for
Reviewed,
nor against New-replaced

9.

aRecommendation

There is insufficient evidence to recommend for or against the use of
Neither for
11. non-invasive brain stimulation for the management of phantom limb
nor against
pain.

Reviewed,
New-added

There is insufficient evidence to recommend for or against the use of
Neither forany specific assessment tool to guide the determination of
12.
prosthetic candidacy, the need for therapy, or for identifying
nor against
improvement or worsening of function and quality of life.

Reviewed,
New-added

We suggest screening patients for cognition, mental health
13. conditions such as posttraumatic stress disorder and depression, andpain during the initial evaluation and across the continuum of care.

Weak for

Reviewed,
New-added

14. We suggest offering peer support services.

Weak for

Reviewed,
New-replaced

For additional information, see Determining Recommendation Strength and Direction.
For additional information, see Recommendation Categorization and Appendix K.

A.

Surgery/Pre-prosthetic

Recommendation
1. There is insufficient evidence to assess the impact of the level of amputation or amputation
surgical procedure type on functional status and prosthesis-related outcomes.
(Neither for nor against | Reviewed, New-added)

Discussion
The effect of surgical technique and level of amputation on functional status in persons with ULA has
not been fully determined as there is limited evidence. This CPG’s systematic evidence review identified
two systematic reviews (SR) and three observational studies; however, the Work Group determinedthese studies contained evidence that is either inconclusive or limited by indirectness and/or study
design.
Yuan et al. (2015) conducted an SR that reviewed 43 studies (63% prospective studies) that focused ontraumatic finger amputations, revision surgeries, and functional outcomes.(24) They found that revisionamputation promoted improved static two-point discrimination in comparison to traumatic finger
amputation without revision. However, they reported no difference in function as it relates toconservative treatment versus revision surgery. Data from this study pertains to finger amputations only
and cannot be extrapolated to other amputation levels.(24) This CPG’s systematic evidence review
identified no other studies addressing the impact of surgical procedure type on functional status andprosthesis-related outcomes.
This CPG’s systematic evidence review identified three observational studies and one SR related to
amputation levels and functional status.(25-28) None of the studies showed any difference in function

March 2022

Page 24 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationor pain with the exclusion of Resnik & Borgia (2015), which documented that persons with transradial(TR) amputation reported less disability compared to more proximal amputations utilizing the
QuickDASH assessment tool.(28) However, the Work Group was unable to draw any objective
conclusions from Resnik & Borgia (2015) as the quality of evidence was poor due to selection bias, nodescription of response rate or responder versus non-responder characteristics, and controlling only forlevel of amputation.(28)
Otto et al. (2015) analyzed seven observational studies that evaluated functional outcomes in
replantation patients (n=301) and prosthetic users (n=172).(27) They reported that persons with below
elbow amputations have better functional outcomes in both prosthetic users and replantationcompared to persons with above elbow amputations. Although the data suggested that distal
amputations fare better functionally than more proximal amputations, all the data was descriptive andthe authors noted that the data on the level of amputations was incomplete.(27)The Work Group also reviewed another study that investigated levels of amputation and functional
outcomes that were not included in this CPG’s systematic evidence review.(29) Resnik et al. (2020)
found that dexterity is best at the TR level followed by transhumeral (TH) amputation and glenohumeral
disarticulation/shoulder amputation level.(29) This study was not included in the recommendation
because of potential selection bias as patients were selected into studies based primarily on
convenience, minimal control for potential confounders, and lack of blinding of outcomes assessors.
The patient focus group indicated a preference for consultation with their surgeons and prosthetists
before and after surgery since it may improve outcomes. Furthermore, participants also reported being
concerned about the lack of gender-specific customization in prosthetics as they stated that prostheses
are not designed for female fit (e.g., too large/heavy, sized for men). In addition, since two of the studies
reviewed focused on the DEKA arm, it should be noted that not all patients prefer or are comfortablewith the weight of the DEKA arm and the necessity of wearing extra batteries. Advanced prostheses,such as the DEKA arm, are high-cost units that require prosthetist and therapist expertise which may
limit access and availability for some patients.
The Work Group systematically reviewed evidence related to this recommendation.(24-28) Therefore,
this is a Reviewed, New-added recommendation. The Work Group’s confidence in the quality ofevidence was very low and the balance of desirable and undesirable outcomes was not able to be
determined. Patient values and preferences largely vary. Resource use for an advanced prosthesis, suchas the DEKA arm, can be high and difficult to achieve, from the high monetary cost to unique prosthetistand therapist expertise to extraordinary patient training requirements. This all may limit access andavailability for most patients. Thus, the Work Group decided upon a Neither for nor against
recommendation.

March 2022

Page 25 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Recommendation
2. For patients undergoing upper limb amputation surgery, there is insufficient evidence torecommend the use of any particular factors to predict the speed and quality of wound healing,
successful prosthesis fitting, or need for revision surgery.
(Neither for nor against | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review did not identify any studies that met inclusion criteria andaddressed the use of any particular factors including age, gender, race, co-occurring medical conditions,to predict the speed and quality of wound healing, successful prosthesis fitting, or need for revision
surgery in patients with ULA.
There were retrospective chart review data identified in two studies that were not included in this CPG’ssystematic evidence review due to significant biases in the selection of controls, determination of risk
factors, and difficulty in assessing true temporal relationships. Chinta et al. (2018) and Vlot et al. (2018)
addressed patient factors (e.g., gender, age, race, comorbid conditions) that predict wound healing
outcomes and/or need for revision surgery in patients with ULA.(30, 31) Other studies were identified
and excluded because they did not match the population or comparator of interest.(32, 33)
There is variability in patient preferences regarding wound healing, successful prosthesis training andfitting, and whether to pursue amputation revision surgery. The patient focus group noted individualized
rehabilitation plans are critical and should include aspects of functional goals, pain management, andpatient education. Speed and quality of wound healing, successful prosthesis fitting, and need forrevision surgery are associated with important outcomes that impact patient QoL and potential successwith ULA. The Work Group also considered the variability in goals and predicted outcomes with varying
levels of amputation and patient access to rehabilitation specialists and prosthetists that would allow
trials and training with different prosthetic devices. The decision to pursue revision amputation is also
individualized and may be based upon multiple factors such as pain, function, and cosmetic appearance.
The Work Group systematically reviewed evidence related to this recommendation; none met thecriteria for inclusion in the evidence base. Therefore, this is a Reviewed, New-added recommendation.
The Work Group could not determine the confidence in the quality of the evidence nor the balance ofbenefits and harms since this CPG’s systematic evidence review did not retrieve any evidence on this
topic. Patient values and preferences largely varied due to subgroup considerations such as level ofamputation, gender, and accessibility to equipment and therapists. Thus, the Work Group decided upona Neither for nor against recommendation.

March 2022

Page 26 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Recommendation
3. There is insufficient evidence to recommend for or against the use of any particular recent
treatment advances including hardware, software, surgical, technology, or supplemental
surgical interventions, such as:· targeted muscle reinnervation (TMR)· regenerative peripheral nerve interfaces (RPNI)· vascularized composite allotransplantation (VCA)· agonist-antagonist myoneural interface (AMI)· implantable myoelectric sensor system (IMES)· osseointegration (OI)
(Neither for nor against | Reviewed, New-added)

Discussion
Two observational studies and one RCT suggested that surgical advances, such as targeted muscle
reinnervation (TMR), may improve pain management and prosthetic control in individuals with ULA.(3436) However, the evidence was inconclusive. Dumanian et al. (2019) identified TMR as a promising
surgical intervention for improving phantom limb pain (PLP) and possibly residual limb pain.(35) Mioton
et al. (2020) found TMR helped with amputation-related pain and improved control for their myoelectric
prosthetic arms.(36) Salminger et al. (2019) evaluated 30 individuals after TMR and found many of theparticipants still discontinued the use of their prostheses even though the procedure resulted insuccessful nerve transfers and reduced neuroma pain.(34) Additional studies, conducted in a variety ofpatient populations, have reported results consistent with these findings which indicates TMR can help
reduce neuroma pain.(37-39)
A variety of potential treatments in addition to TMR were identified as options to help improveoutcomes in individuals with ULA. However, many did not meet inclusion criteria for this CPG's
systematic evidence review due to potential selection bias, minimal control for potential confounders,
and lack of blinding outcomes assessors. As a result, this CPG’s systematic evidence review did not findevidence that met the inclusion criteria for regenerative peripheral nerve interfaces (RPNI), vascularizedcomposite allotransplantation (VCA), agonist-antagonist myoneural interface (AMI), implantablemyoelectric sensor system (IMES), and osseointegration (OI).
The patient focus group participants reported pain management and prosthetic comfort as criticalcomponents when deciding if they were going to continue using their prostheses. While the evidence isstill inconclusive, the TMR procedure may address these concerns. Targeted muscle reinnervation has
also shown promise in improving PLP but it does not change the socket or lack of sensation. In responseto these concerns, additional procedures have been developed and are in the beginning stages ofgaining evidence to determine their level of success. Further, there is limited access to many of thesetreatments, including TMR, since there are few providers with adequate experience and training.
Some of the additional procedures that might be available include OI, IMES, RPNI, AMI, VCA.
Osseointegration was created as a way to potentially increase comfort by eliminating the socket resulting
in an immediate secure connection.(40) The OI attachment enables preservation of humeral internal andexternal ROM which is not possible with a socket prosthesis. Implantable myoelectric sensor systems are
small devices that can be surgically implanted into the muscles and will amplify the signal to the

March 2022

Page 27 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

myoelectric prostheses, which may help improve myoelectric control. An additional way to improve
prosthetic control is the AMI procedure, which includes connecting the agonist and antagonist muscles.
For the enhancement of sensation, VCA, upper limb transplant, is currently the only option.(41, 42)
Each of these options addresses distinctly different concerns and requires surgical intervention fromproviders with specialized training. When considering these treatment advances to improve prosthesis
acceptance, clinicians must understand why an individual chooses to minimize or discontinue use of
their prostheses and address those issues. As discussed in Salminger et al. (2019), some study
participants who experienced reduced PLP continued to experience socket discomfort, which may havecontributed to device abandonment.(34)
The Work Group systematically reviewed evidence related to this recommendation focusing on
TMR.(34-36) Therefore, this is a Reviewed, New-added recommendation. The Work Group’s confidence
in the quality of the evidence was very low. The body of evidence had limitations including small sample
sizes and confounders in the analysis. The evidence supporting potential benefits of the advances,including hardware, software, surgical, technology, or supplemental surgical interventions was limited.
While there were three articles to support TMR procedures, there are multiple other options such as
RPNI, AMI, OI, VCA, and IMES that do not currently have sufficient evidence to define the balance ofbenefits with the potential harms or adverse events. Patient values and preferences varied largely
because of differences in access to the medical teams with extensive experience. Thus, the Work Groupdecided upon a Neither for nor against recommendation.

B.

Rehabilitation

Recommendation
4. There is insufficient evidence to recommend for or against any particular training protocol toimprove function and outcomes.
(Neither for nor against | Reviewed, New-added)

Discussion
Although four studies were identified as potentially addressing this recommendation, none of thesestudies met the inclusion criteria for this CPG’s systematic evidence review due to small sample sizes,
limited study participants with ULA, and lack of relevant data to abstract.(43-46)
An SR by Soyer et al. (2016) noted that a variety of broad treatment concepts exist for rehabilitation
following ULA, “The studies pointed out the upper limb prosthetic rehabilitation protocols consist ofgeneral exercise programme, motor tasks, phantom exercises, Muscle Training System, edema control,
functional activities, signal strengthening, prosthetic education exercises, neuromuscular reeducation,
virtual image and virtual reality exercises.”(46) The SR broadly concluded that “prosthetic rehabilitation
seems promising especially for upper extremity amputees.” The SR did not meet the inclusion criteria
for this CPG but does generally indicate a value to the patient that may need more study.
While not meeting inclusion criteria for this CPG's systematic evidence review, Kwah et al. (2019)
surveyed other CPGs for the population of persons with upper and lower extremity amputation.(43) The
authors found that the overall evidence was of low to moderate quality and only a handful of therecommendations considered were derived from strong quality evidence. Although there are various

March 2022

Page 28 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

established treatments described in the literature, the evidence is lacking for a protocol thatencompasses a variety of treatments as a whole. Established protocols for a battery of treatment
techniques have insufficient evidence in the current literature to recommend for or against any
particular training protocol.(43)
There is very limited evidence that existing treatment protocols for upper extremity training improvefunction and outcomes for the limb loss population. This underscores the importance and need forfurther research. Some articles that professionals may seek out to inform their practice are largely basedon expert opinion and were not included in our systematic evidence review. Clinicians seeking further
information on prosthetic training should also refer to Appendix H.
Given the relatively small population, the cost and time associated with large scale, high quality researchstudies in this domain, evidentiary gaps in standard clinical practice will be inevitable. While some
protocols may be considered common knowledge and standard of care (e.g., strengthening a residual
limb before application of a prosthesis), research in this field has yet to provide high quality evidence tosupport basic clinical standards for rehabilitation interventions. This is partially due to therapy being astandard of care and withheld blinded treatments would be unethical for this population. Furthermore,
the development of overarching, composite protocols that include multiple distinct treatment regimens
will need to be studied with rigor. There is a great need to improve the quality of evidence for prosthesis
training and establish evidence-based protocols to support and grow the work of expert opinion.
The Work Group systematically reviewed evidence related to this recommendation and found noevidence available for inclusion. Therefore, this is a Reviewed, New-added recommendation. The WorkGroup could not determine the confidence in the quality of the evidence nor the balance of benefits andharms since this CPG’s systematic evidence review did not retrieve any evidence on this topic. Patient
values and preferences varied somewhat because patients may prefer various forms of therapy. In
addition, various forms of therapy may not be uniformly available to patients. Thus, the Work Groupdecided upon a Neither for nor against recommendation.

Recommendation
5. We suggest the use of mirror therapy for the short-term reduction of phantom limb pain.
(Weak for | Reviewed, New-replaced)

Discussion
The 2022 VA/DoD ULA CPG Work Group identified the need for evidence on the efficacy of nonpharmacologic treatment of PLP. Four studies were identified, and one study addressing this need met
the inclusion criteria for this CPG’s systematic evidence review. Barbin et al. (2016) found treatment
with mirror therapy resulted in improved pain outcomes when compared to the control patients with
ULA at 4 days to 6 weeks follow-up.(47)The Work Group determined there is likely some variability in the effectiveness of mirror therapy given
the wide range of PLP symptoms and severity associated with ULA. However, this treatment is welltolerated by patients and is an established element of care for this population. Mirror therapy is
inexpensive and readily available in a variety of settings, including in the clinic and at home. This allows
for intervention with therapy and carryover to home programs for continued pain management

March 2022

Page 29 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

following discharge. Mirror therapy is often utilized in conjunction with other interventions, such as painneuroscience education, laterality also known as left/right discrimination, and explicit motor imagery, as
part of a multi-modal treatment approach known as graded motor imagery (GMI). Factors such as mirror
placement, patient position, exercises and activities utilized, massage techniques of residual andcontralateral limbs, and therapist versus patient application of input can all be individualized based on
the patient’s specific needs and responses to the intervention.
The Work Group considered assessment of the evidence put forth in the 2014 VA/DoD UEAR CPG andsystematically reviewed newly identified evidence related to this recommendation.(47-49) Therefore,
this is a Reviewed, New-replaced recommendation. The Work Group’s confidence in the quality of theevidence was very low. The body of evidence had some limitations including the very serious risk of bias,
and serious indirectness and imprecision. No statistical analyses were performed and instead, theoutcomes relied on descriptive results. The potential benefits of mirror therapy as a non-pharmacologic
intervention to reduce PLP in upper extremity amputees outweighed the potential harms. Patient values
and preferences varied somewhat because of the variability of symptoms and severity associated with
PLP. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation
6. There is insufficient evidence to recommend for or against any particular treatment setting,intensity, or service delivery model.
(Neither for nor against | Reviewed, New-replaced)

Discussion
The 2022 VA/DoD ULA CPG Work Group identified the desire for evidence on the relationship between
treatment parameters (e.g., setting, treatment intensity, or service delivery model) and rehabilitation
outcomes. However, this CPG’s systematic evidence review did not retrieve any relevant studies.
Recommendation 1 from the 2014 VA/DoD UEAR CPG states, “An interdisciplinary amputation careteam (care team) approach, including the patient, family, and/or caregiver(s), is recommended in the
management of all patients with upper extremity amputation” was based solely on expert opinion. As
such, there were no studies identified in the 2014 systematic review that could be used to support a
recommendation on any specific treatment setting, intensity, or service delivery model.
This CPG’s systematic evidence review identified one potential study addressing the results of atelehealth program for persons with ULA that allowed these individuals to interact with peers and learn
about the management of both physical and psychological health conditions.(50) However, the study
was excluded from the evidence synthesis report because of its weak design (only pre-post data werereported) and small sample size (n=5).
Although not included in this CPG’s systematic evidence review, Resnik et al. (2021) provides someinsight into quality and satisfaction with prosthetic limb services and the relationship between thetreatment setting (VA, DoD, or private) and treatment recency on satisfaction.(51) This study found an
association between service provision within the past year and service quality satisfaction scores.
Veterans who received amputation care in the VA or DoD also had better, but not statistically different,mean service satisfaction scores when compared with those who received care outside the VA or DoD.

March 2022

Page 30 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

However, treatment setting and treatment recency were not linked with additional patient outcomes ofinterest, and the strength of the evidence was rated as very low.(51)Patient values, expectations, and preferences regarding treatment setting, intensity, quality, and service
delivery model varied somewhat because the geographic distance to expertise, facilities, and services
may influence preferences for service delivery for some patients. In addition, the Work Group
recognized that patient needs may vary and call for different service delivery approaches. For example,
patients with more complex rehabilitation needs, such as those with multiple limb involvement or more
proximal level amputations, may require more specialized services and/or more intensive treatment
settings. For adults with ULA, telemedicine and telerehabilitation services have the potential to improveaccess to specialized treatment teams; however, the availability of this service delivery model is not
uniform across the VA and DoD and evidence supporting the effectiveness of these care delivery models
is not yet available.
The Work Group systematically reviewed evidence related to this recommendation. Therefore, this is a
Reviewed, New-replaced recommendation. The Work Group could not determine the confidence in thequality of the evidence nor the balance of benefits and harms since this CPG’s systematic evidence
review did not retrieve any evidence on this topic. Patient values and preferences varied somewhat.
Thus, the Work Group decided upon a Neither for nor against recommendation.

C.

Prosthetic Restoration

Recommendation
7. For patients with major unilateral upper limb amputation (i.e., through or proximal to the wrist),
we suggest use of a body-powered or externally powered prosthesis to improve independence
and reduce disability.
(Weak for | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review found one study suggesting that the use of body-powered or
externally powered prosthesis interventions improve independence and reduce disability in patientswith major unilateral ULA, referring to those performed through or proximal to the wrist joint.(52)Resnik et al. (2020) performed a telephone survey of 755 persons with unilateral ULA, including those
who used either passive, body powered or externally powered prostheses as well as those who were notprosthesis users.(52) The study compared patient-reported outcomes of disability, activity difficulty, andhealth-related quality of life (HRQoL) by prosthetic device use and configuration and also identified
factors associated with these outcomes.(52) The study found that the use of such active prostheses inthis population was associated with less difficulty performing activities, less disability, and higher
physical function in most patients.(52) However, there was no evidence in the systematic evidence
review to recommend one type of prosthetic system over another.
Six other observational studies were identified but excluded from this recommendation as they did notprovide relevant data to the development of this recommendation. Of the studies excluded, threefocused only on the DEKA arm, two studies examined QoL and satisfaction of general prosthesis use

March 2022

Page 31 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

without specific attention to prosthesis type and/or upper limb loss, and one study involved comparisonof cosmetic and body powered devices in Iran.(29, 53-57)
Numerous challenges exist for patients with ULA. VA/DoD best-practice has recognized thatprescriptions for upper extremity prostheses should be based on a collaborative decision between thepatient and the care team. The patient focus group participants expressed the importance of shareddecision making and a team-based approach. There is some variability with patient preferences
regarding prosthesis intervention. The patient focus group generally noted that prosthetic functionality
is more important than cosmesis. However, the patient focus group participants also valued having a
range of prosthetic devices available to meet their unique functional goals, including passive,
myoelectric, body-powered, and activity-specific prostheses. Receiving a properly designed and fitting
prosthesis can be burdensome because it requires patience, frequent visits, the establishment ofrealistic expectations based on appropriate patient education, and follow-up training. Further, there
may be limited access to providers with adequate experience and training within this field.
The Work Group systematically reviewed evidence related to this recommendation.(29, 52-57)
Therefore, this is a Reviewed, New-added recommendation. The Work Group’s confidence in the qualityof the evidence was very low and the body of evidence is limited. The potential benefits of using anactive prosthesis, including improved function, less disability, and reduced difficulty with activities,
outweighed the potential burdens of potential discomfort, investment of time to achieve and maintainproper fit/function, or the risk of unsuccessful functional outcomes. Patient values and preferences
largely varied because of their different needs, amputation levels, goals, and expectations from theutilization of a prosthesis. Thus, the Work Group decided upon a Weak for recommendation.

Recommendation
8. There is insufficient evidence to recommend for or against any specific control strategy, socket
design, suspension method, or component.
(Neither for nor against | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review did not identify any SRs or RCTs addressing outcome variation bycontrol strategy, prosthesis type, socket design and/or suspension method, and/or prosthesis
component selection that met inclusion criteria. Seven observational trials addressing various outcomesby prosthesis type and control strategy for the treatment of persons with ULA were identified.(29, 5257) Three studies were cross-sectional studies, one study was observational, and three studies werequasi-experimental. All seven of these studies had poor methodological quality, potential selection bias,
minimal control for potential confounders, and lack of blinding of outcome assessors.
No clear evidence was identified to support for or against specific control strategies, socket designs,
suspension methods, or components. One of the challenges in addressing this topic is that each
prosthesis is custom-made for the patient based on their level of amputation, goals, needs, and specificanatomy. In addition to a patient’s individual needs for a prosthesis, providers should be mindful of thenecessity of lifelong access to care. This lifelong care includes the patient’s eligibility for care, device
cost, and access to ULA rehabilitation subject matter experts.

March 2022

Page 32 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Although there was poor quality evidence, factors critical to patient outcomes and prosthetic wear rates
have been identified. The patient focus group noted prosthetic fit and appropriate components werecritical to prosthesis wear and use. Thus, appropriate considerations of prosthetic components anddesign are clinically significant.
The Work Group systematically reviewed evidence related to this recommendation.(29, 52-57)
Therefore, this is a Reviewed, New-added recommendation. The Work Group’s confidence in the qualityof the evidence was very low. The body of evidence had some limitations including potential selection
bias, minimal control for potential confounders, and lack of blinding of outcomes assessors. The
potential benefits of choosing the optimal prosthesis for a patient that allows them to meet theirindividual goals and needs outweighed the potential harms of making the wrong assessment for apatient resulting in an insufficient prosthetic prescription that keeps the patient from obtaining theirfunctional goals. Patient values and preferences largely varied because each patient’s needs, ability, andlevel of amputation are unique. Thus, the Work Group decided upon a Neither for nor against
recommendation.

D.

MedicalRecommendation
9. There is insufficient evidence to recommend for or against a particular intervention for theprevention of phantom and/or residual limb pain.
(Neither for nor against | Reviewed, New-replaced)

Discussion
This CPG’s systematic evidence review did not identify any studies that met inclusion criteria andaddressed the prevention of PLP or residual limb pain for persons with ULA. In addition, there was no
relevant evidence identified from the 2014 VA/DoD UEAR CPG.
A small study by Valerio et al. (2019) concluded that preemptive surgical intervention of amputatednerves with TMR at the time of limb loss should be strongly considered to reduce pathologic PLP andsymptomatic neuroma-related residual limb pain.(58) However, the study was not included in this CPG’ssystematic evidence review because it was a non-comparative study with only five persons with an ULA.
Also, it did not report pain outcomes for the ULA subgroup. Thus, this study did not influence thisrecommendation’s strength.(58)
Post-amputation PLP and residual limb pain have a high reported prevalence, experienced in up to 70%
and 85% of patients, respectively.(58) Both PLP and residual limb pain can be functionally limiting anddisruptive to an individual’s daily life, especially when trying to adjust to the new loss of a limb. Optimal
management of pain symptoms can vary greatly from one patient to another as symptom severity is
broad. Unfortunately, it is unclear at this time what factors or patient subgroups correlate withsymptom severity due to the paucity of evidence.
There is likely some variation in treatment preferences, in part due to lack of clear guidance and thepotential high risk or cost of surgical and procedural interventions. Also, complex or technically difficult
surgical procedures may be of limited access given the variable availability of specialists. Once identified,effective medication options should be more feasible to deliver as most immediate postoperative courses

March 2022

Page 33 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

occur in the hospital setting. It is important to consider that the patient focus group participants indicatedpain management as a critical component of their ULA rehabilitation. However, they noted it was often
poorly controlled. Coping with the pain was reported as psychologically challenging and difficult to
describe. Further, participants expressed frustration with ineffective strategies currently offered.
The Work Group systematically reviewed evidence related to this recommendation. Therefore, this is a
Reviewed, New-replaced recommendation. The Work Group could not determine the confidence in thequality of the evidence nor the balance of benefits and harms since this CPG’s systematic evidence
review did not retrieve any evidence on this topic. Patient values and preferences vary somewhat
because PLP and residual limb pain severity are variable but effective pain and symptom management
are considered to be a critical component of amputation rehabilitation. Also, the risk and/or cost of anintervention, especially if benefits are unclear, may not be justified for the level of symptoms anddysfunction. Thus, the Work Group decided upon a Neither for nor against recommendation.

Recommendation
10. There is insufficient evidence to recommend for or against any particular pharmacologic
intervention for the management of phantom and/or residual limb pain.
(Neither for nor against | Reviewed, New-replaced)

Discussion
There is limited evidence on the effectiveness of pharmacologic treatment for PLP and residual limb pain
and inconclusive evidence about specific interventions, despite being recognized as an important andcommon clinical issue. This CPG’s systematic evidence review identified one RCT meeting inclusion
criteria and addressing pharmacologic interventions.(59)
An RCT by Ilfeld et al. (2021) with moderate quality evidence suggested that ropivacaine as a 6-day
perineural infusion (n=71) compared to a six day perineural infusion of normal saline (n=73) for the
management of PLP and residual limb pain provided clinical benefit in the short term for PLP and
residual limb pain.(59) Most participants underwent lower limb amputation (LLA) (84%) rather than ULA(16%). Baseline pain scores for eligibility included PLP intensity of at least a 2 or higher on the Numeric
Rating Scale (NRS) and PLP frequency of at least three times each week for eight weeks. Patients weredischarged home with their portable infusion pump and perineural catheter. At four weeks, the average
PLP intensity had an average mean difference of 1.3 (95% confidence interval [CI]: 0.4 to 2.2; p=0.003)
and the decrease in PLP severity from baseline was 1.4 (95% CI: 0.5 to 2.4; p=0.002). The initial follow-up
period was four weeks, with uncertain benefit after four weeks. Some patients (2%) experienced
infection at the catheter implantation site and one patient experienced worsened PLP after initiation oftreatment.(59) Thus, it was concluded that although continuous peripheral nerve block (PNB) may havebenefits in the short term, the clinical significance of the reduction in pain is not clear. Further, longterm benefits after four weeks are uncertain. Additionally, from a feasibility and acceptability
standpoint, PNB may be burdensome as it requires a six day continuous catheter implant in an
ambulatory setting.
This CPG’s systematic evidence review found no additional studies on pharmacologic treatment for the
management of PLP and residual limb pain and no studies from the 2014 VA/DoD UEAR CPG wererelevant to this topic. Despite the paucity of evidence to support any particular agent(s) for the

March 2022

Page 34 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

treatment of PLP and residual limb pain, an SR by Alviar et al. (2016) evaluated treatment
considerations, although no one agent demonstrated high or moderate quality evidence of benefit in
the management of PLP.(60) If pharmacotherapy is offered, providers and patients should understandthe uncertainties of the short- and long-term effectiveness and safety of treatment, and require thepatient to have regular follow-ups to reassess risks and benefits and modify treatment as needed.
Some patient focus group participants indicated pain management was a critical component of theirtreatment, and they experienced limited benefit with medications they were prescribed. Although notincluded in the evidence review findings, the results of a large survey of U.S. Veterans (n=2,694) withupper or lower extremity post-amputation pain highlights the need for improved therapeuticinterventions by reporting that, despite the use of a variety of therapies, only 1% of the 512 treatedpatients had clinically important lasting benefits, and only 8.4% were considered by the authors to haveobtained any real benefit.(61) However, there is some variability in patient preferences regarding theuse of pharmacologic management for PLP. Medications vary significantly in side effect profiles, and theburden of continuous PNB may be unacceptable to some.(59)
The Work Group systematically reviewed evidence related to this recommendation.(59) Therefore, thisis a Reviewed, New-replaced recommendation. The Work Group’s confidence in the quality of theevidence was moderate. The body of evidence had some limitations including indirectness since mostparticipants had LLA. The evidence was further limited with wide variation around the effect estimate.
Additionally, the clinical significance was unclear despite statistical significance in the results. The
potential harms of a continuous PNB were considered significant compared with the potential benefits.
Patient values and preferences varied somewhat due to the wide range of available pharmacologic
modalities, the variation in adverse event profiles, and the variation in burdens associated with anintervention or procedure such as a PNB. Thus, the Work Group decided upon a Neither for nor against
recommendation.

Recommendation
11. There is insufficient evidence to recommend for or against the use of non-invasive brain
stimulation for the management of phantom limb pain.
(Neither for nor against | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review identified two crossover RCTs that evaluated the effectiveness ofnoninvasive brain stimulation (NIBS) for the management of PLP and residual limb pain in persons with
ULA.(48, 49) The intervention in Bocci et al. (2019) involved 20-minute sessions of direct current
stimulation to the cerebellum (n=14).(49) The intervention was provided over five days with outcomes
assessed at two and four weeks. While this study suggested improvement in paroxysmal pain for NIBS
compared to sham treatment at four weeks follow-up, there was no difference in either PLP or residual
limb pain intensity between NIBS and sham treatment at either the two- or four-week follow-ups.
Kikkert et al. (2019) evaluated one-week outcomes associated with a single session of NIBS to theinvolved somatosensory cortex.(48) This investigation indicated some potential improvement in PLP
with NIBS compared to sham treatment in patients with ULA at six days follow-up. No long-term followup was provided. The methodological quality of the two crossover RCTs was fair.

March 2022

Page 35 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

For persons with ULA, NIB appears to be a novel and emerging technology that may hold promise for the
management of PLP and residual limb pain. Although there were some promising findings from thesestudies, the strength of the evidence was insufficient to make a recommendation for or against thisintervention at present. Study limitations were the fair quality design, small sample size, and very shortfollow-up time (between 1 – 4 weeks). Further, the two studies used different stimulation techniquesdelivered to different areas of the brain.
The benefits of this intervention are yet to be determined. Although typically well-tolerated, the longterm risks of NIBS have not been studied and the treatment burden varies depending on the protocol.
Further, the treatment burden and feasibility of delivering NIBS will be impacted by the limited
geographic access to the equipment and specialized expertise required to administer the treatment.
Given the unknown risk/benefit ratio of NIBS treatment, the Work Group determined there would be alarge variation in patient values and preferences. As an emerging technology, some patients may behesitant about the intervention due to unfamiliarity and some patients with less severe symptoms may
be less willing to accept the treatment burden.
In addition to NIBS, the Work Group acknowledges that there are additional non-pharmacologic
interventions that have been used clinically for the management of PLP and residual limb pain inpersons with ULA. However, no studies meeting the search criteria were identified that addressed theuse of these non-pharmacologic interventions: acceptance and commitment therapy (ACT),
biofeedback, cognitive behavioral therapy (CBT), desensitization, GMI, meditation, mindfulness-based
stress reduction (MBSR), pain neuroscience education, spinal cord stimulation, peripheral nerve
stimulation, psychotherapy, radiofrequency ablation, relaxation therapy, or virtual/augmented reality.
The Work Group systematically reviewed evidence related to this recommendation.(47-49) Therefore,
this is a Reviewed, New-added recommendation. The Work Group’s confidence in the quality of theevidence was low. The body of evidence had significant limitations including small sample sizes, shortterm follow-up only, and heterogeneity of intervention protocols. The potential benefits of NIBS are yet
to be proven and although typically well-tolerated, the longer-term potential harms are unknown.
Patient values and preferences largely vary because some patients may be hesitant about theintervention due to unfamiliarity and variability in symptom severity. The potential need for travel toreceive the intervention may also impact the acceptance of treatment burden. Thus, the Work Groupdecided upon a Neither for nor against recommendation.

E.

Outcomes

Recommendation
12. There is insufficient evidence to recommend for or against the use of any specific assessment
tool to guide the determination of prosthetic candidacy, the need for therapy, or for identifying
improvement or worsening of function and quality of life.
(Neither for nor against | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review identified three observational studies supporting thisrecommendation.(26, 28, 62) In the first small (n=30) observational study, Werner & Alawi (2021),

March 2022

Page 36 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

prospectively considered the association of Hand Bionic Scale (HBS) scores to measure injury severity,
disability, function, and QoL and to establish HBS cutoff scores.(62) The cutoff scores could be used tohelp determine which patients would benefit from elective amputation and provision of a handprosthesis. Werner & Alawi (2021) studied adult patients with severe hand injuries, predominantly
occupational injuries, who received previous reconstructive surgery. Ultimately, higher HBS scores (>10
points) were associated with higher severity of injury and greater impairment in terms of hand strength,
function, and QoL. The authors concluded that HBS could differentiate patients based on cutoff scoresto guide clinical recommendations. One strength of the study is its ability to inform clinicalrecommendations in patients with a hand injury. However, it is limited to hand injuries, which limits
generalizability to the larger population of patients with upper limb injury, including more proximal
amputation. Additionally, the clinical recommendations lack specificity.(62)
Two additional observational studies, Resnik et al. (2016) and Resnik et al. (2015) assessed whether
selected outcome measures were responsive to change in terms of function and disability in persons
with ULA who received training with the DEKA arm.(26, 28) Function and disability were assessed atbaseline, after 10 hours of training, and again following training that lasted an average of 18 hours.
Selected outcome measures’ responsiveness based on ULA level were also considered, as was theirability to assist in determining the amount of training necessary to optimize outcomes with the use of
the DEKA arm. Responsiveness of the outcomes were determined by calculating the change in effectestimates of the measures from baseline to final testing, baseline to 10 hours of training, and from 10hours of training to final testing.
Findings concluded that the Box and Blocks, Jebsen Taylor Hand function (JTHF; light and heavy canitems), University of New Brunswick Skill and Spontaneity scales, Activity Measure for Upper Limb
Amputation (AM-ULA), Patient-Specific Functional Scale, and QuickDash all appear responsive tochange. Conversely, all remaining JTHF items and the Upper Extremity Functional Scale did not appear
responsive to change. Further, responsiveness varied by amputation level. Box and Blocks appeared
responsive at all three amputation levels (radial, humeral, and shoulder). Dexterity tests seemed to be
more responsive at the shoulder amputation level. The authors concluded the selected outcomes andfindings may be useful in guiding clinicians regarding the quantity of training required to optimize
outcomes in patients using the DEKA prosthetic system. Limitations to these two studies include smaller
samples (n=39 and 44, respectively) and the specific use of the DEKA prosthetic system, which may not
be accessible to most users of upper limb prosthetic arm systems. It is unknown if the responsivenessfindings are generalizable to other prosthetic systems.(26, 28)
In addition to the lack of generalizability, all three studies were very low quality. The following
methodological issues resulted in the further downgrading: convenience sampling resulting in potential
selection bias, minimal control for potential confounders, and lack of blinding of study assessors.
The Work Group systematically reviewed evidence related to this recommendation.(26, 28, 62)
Therefore, this is a Reviewed, New-added recommendation. The Work Group’s confidence in the qualityof the evidence was very low. The body of evidence had some limitations including small sample sizes
and limited generalizability. The potential benefits of using an assessment measure to determine themost appropriate decision for a prosthetic device outweighed the potential harms of a time burden on
clinicians and patients. Patient values and preferences varied somewhat because patients may findMarch 2022

Page 37 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

repeated testing undesirable. Thus, the Work Group decided upon a Neither for nor against
recommendation.

F.

Psychosocial Considerations

Recommendation
13. We suggest screening patients for cognition, mental health conditions such as posttraumaticstress disorder and depression, and pain during the initial evaluation and across the continuumof care.
(Weak for | Reviewed, New-added)

Discussion
This CPG’s systematic evidence review identified nine observational studies in 12 papers that assessed
the association between patient-related factors and rehabilitation outcomes. This evidence suggested
cognitive, mental health conditions, and pain as factors that may influence patient outcomes following
ULA. Other factors (e.g., gender, race) may also influence patient outcomes but require additional study
before any recommendation statements can be made.(52, 63-67)
An observational study by Hancock et al. (2017) aimed to identify cognitive domains involved with theuse of the DEKA arm.(68) The authors provided a working definition of cognition that included cognitive
control functions that may also be termed working memory, supervisory, or executive functions. These
include cognitive functions “that organize, regulate, or modify information processing in accordancewith current behavioral goals and context (1) encoding of control actions in memory, (2) recall of control
actions, (3) organization of control actions, (4) selection of the appropriate hand grip amongst the six
options, (5) prediction of choice outcomes, (6) outcome evaluation and (7) the integration of evaluative
feedback to initiate corrective actions.”(68) While this list is not exhaustive, it does capture a functional
definition of cognition that is useful to understand the relationship between mental and physicalfunction and should be considered for use in future studies.
One specific finding from Hancock et al. (2017) was that cognitive domains of attention and processing
speed were significantly associated with higher scores on measures of function in patients receiving
training on the DEKA arm. These findings are specific to the DEKA arm, an advanced upper limb
prosthesis, and the generalizability of evidence to other prosthetic arm systems is limited.(68)
The following studies addressed the association of mental health conditions and pain and rehabilitation
outcomes following ULA. An observational study by Armstrong et al. (2019) examined predictors ofclinically significant levels of psychological distress among 307 persons with ULA, resulting in a suggested
association between greater pain interference, PTSD, and depression.(66) A study of cross-sectional
design by Kearns et al. (2018) examined associations between levels of ULA and psychologicalwellbeing.(69) The study found partial hand loss to be associated with higher pain interference and PTSD
compared with higher levels of ULA.
Resnik et al. (2021) also examined pain as a patient factor and used QuickDASH scores to evaluate pain
and QoL in persons with ULA.(63) In this study, disability QuickDASH scores were 7.9 points higher(worse) on average for those with ULA and severe back pain, and scores were 4.4 and 12.3 points higher
for those with ULA and moderate and severe neck pain respectively, compared to those with no pain.

March 2022

Page 38 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

QuickDASH scores were also significantly higher for those with contralateral limb pain (7.1 points), PLP(7.2 points), and residual limb pain (3.5 points).(63) The final observational study, Walsh et al. (2016),
included 202 persons with traumatic ULA and found no significant association between resilience or pain
and PTSD or depression.(70)
The overall methodological quality of the included studies was poor due to potential selection bias
(patients were selected into studies based primarily on convenience), minimal control for potential
confounders, and lack of independent or blinded outcomes assessors.
The evidence was limited in quantity and quality, with only a few variables reflected across this verybroad inquiry. The potential harm in not assessing these variables could be quite high, inclusive of selfharm and death. There is some variability in patient preferences regarding this treatment. One patient
focus group participant sought out mental health services as part of their amputation rehabilitation.
Others noted the stigma associated with seeking mental health treatment and commented on theircoping strategies as methods for managing mental health concerns. The focus group participant whosought out mental health services now advocates for seeking this treatment.
The Work Group systematically reviewed evidence related to this recommendation.(52, 63-73)
Therefore, this is a Reviewed, New-added recommendation. The Work Group’s confidence in the qualityof the evidence was very low. The body of evidence had several limitations including potential selection
bias, minimal control for potential confounders, and lack of independent or blinded outcomes assessors.
The potential benefits of screening patients for these factors during the initial evaluation and across thecontinuum of care outweigh the potential harms. Patient values and preferences varied somewhat
because of the stigma associated with seeking mental health. Thus, the Work Group decided upon a
Weak for recommendation.

Recommendation
14. We suggest offering peer support services.
(Weak for | Reviewed, New-replaced)

Discussion
The 2022 VA/DoD ULA CPG Work Group suggests offering peer support services to persons with ULA. Thisdiffers slightly from the 2014 VA/DoD UEAR CPG, which stated that the care team should facilitate theearly involvement of a trained peer visitor. This recommendation has been modified to recognize peer
support as all-encompassing: integrating trained peer visitor visits under the umbrella of peer support.
Peer support is widely used in the rehabilitation of persons with amputation and is recognized as
beneficial by clinicians and patients alike. Although no new studies were identified in this CPG’ssystematic evidence review, the Work Group reviewed a peer support study from the 2014 VA/DoD
UEAR CPG. An RCT by Wegener et al. (2009) (n=502; 12.2% were upper limb loss) compared existingsupport group activities to the Promoting Amputee Life Skills (PALS) program activities, a selfmanagement group.(74) Participants engaged in 90-minute group sessions for eight weeks. This selfmanagement group program includes topics such as an overview of self-management, pain
management, building positive mood, managing negative mood, interacting with family and friends,
working with the health team/community resources, building healthy habits, relapse prevention, andMarch 2022

Page 39 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

maintaining progress. The self-management program participants showed an overall improvement in
self-efficacy, state-of-mind, and functional limitations. The study also found that the odds of being
depressed were 50% lower in persons involved in the self-management program.(74)
While the article was not included in this CPG’s systematic evidence review, the Work Group also
identified another RCT that supported self-management groups. Turner et al. (2021) (n=147) was a multisite RCT that found that group-based self-management improved psychosocial functioning and QoL in
persons with amputation due to chronic limb-threatening ischemia.(75) However, this study was excluded
from this CPG’s systematic evidence review since the population was exclusively persons with LLA.
Concern for potential lack of acceptance by friends and family, loss of function, and alteration in body
image are some common responses that patients experience before or after having an ULA. Persons
with an amputation report that peer support programs are often very helpful and provide a sense ofhope in recovery and for a life with a sense of normalcy. Support groups may be social, recreational, or
educational. Patient values and preferences varied somewhat. Some patients may be unwilling or
unable to commit to the time for peer support. However, many patient focus group participants strongly
valued peer support.
The Work Group systematically reviewed evidence related to this recommendation and considered theassessment of the evidence put forth in the 2014 VA/DoD UEAR CPG.(74) Therefore, this is a Reviewed,
New-replaced recommendation. The Work Group’s confidence in the quality of the evidence was very
low. The body of evidence had limitations including limited representation of minorities with
amputation, study design, and discrepancy of contact time between the control group and the selfmanagement group. However, the potential benefits (e.g., improving self-efficacy and mental health)outweighed the potential harms (e.g., time commitment of sessions). This treatment milieu isconsidered fairly low risk with potential strong benefits (e.g., increasing the patient’s confidence toimprove their QoL). Patient values and preferences varied somewhat. Access to resources can vary per
patient and by location. While the feasibility of peer support increases with virtual platforms such as
telehealth, remote or virtual platforms may not be available or of interest to everyone. The VA and DoD
have an established telehealth program, but civilian settings may not. In addition, not all patients aretechnologically capable or interested so this may be a limiting factor in implementing virtual programs.
Thus, the Work Group decided upon a Weak for recommendation.

X.

Research Priorities

During the development of the 2022 VA/DoD ULA CPG, the Work Group identified numerous areas
where future research would be beneficial, including areas requiring stronger evidence to support
current recommendations and research exploring new areas to guide future CPGs. These areas are
summarized below. Additionally, the Work Group identified research designs/approaches that we
believe would contribute the highest quality of evidence for inclusion in future systematic evidence
reviews. These designs/approaches were chosen while taking into consideration this CPG’s systematic
evidence review inclusion criteria and GRADE methodology. While a minimum sample size of 20 persons
per treatment arm (in an RCT) will generally be required for inclusion in VA/DoD CPG systematic
evidence reviews, each study must be sufficiently powered to detect meaningful clinical differences.

March 2022

Page 40 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

With specific regard to crossover designs, a total sample size of 20 would likely be sufficient, provided
that it is adequately powered.
Researchers should carefully consider and review the research priorities outlined herein. These priorities
were identified in part by a lack of research found that met inclusion criteria following the developmentof key questions and associated systematic evidence review.
It is highly recommended that investigators consider research rating tools and checklists in planningstudies to assure the highest methodologic quality and rigor and to minimize the risk of bias. Some toolsthat may be useful include:·

For clinical trials: Physiotherapy Evidence Database (PEDro)
https://pedro.org.au/english/resources/pedro-publications/·

For clinical trials and other study designs SIGN50:
https://www.sign.ac.uk/what-we-do/methodology/checklists/

A. Prevention and Treatment of Phantom and Residual Limb Pain
Phantom and residual limb pain are highly prevalent in this patient population. Unfortunately, limited
evidence is available on pharmacologic or non-pharmacologic interventions for the prevention ortreatment of PLP and residual limb pain. Future research should evaluate the immediate (perioperative),short-term (0 – 4 weeks), and long-term (3, 6, and 12 months) periods. In addition to pain, improvementof function and QoL are important outcomes. Of interest are well-designed RCTs, including at least 20
persons per treatment arm assessing (or a total sample of 20 subjects for crossover trials):·

The efficacy of commonly used and promising new or alternative pharmacologic agents andnon-pharmacologic interventions for the prevention of PLP and residual limb pain. Nonpharmacologic interventions of particular interest include traditional therapies, complementary
and alternative treatments, and advanced surgical techniques such as TMR or RPNI and OI.
Studies are needed to evaluate the efficacy of commonly used and promising pharmacologic
agents and mode of medication delivery (e.g., oral, injected, inhaled, topical) on reduction of
PLP and residual limb pain.

·

The efficacy of non-pharmacologic agents in managing PLP and residual limb pain. Potential
interventions of interest include NIBS, ACT, biofeedback, CBT, desensitization, GMI, meditation,
MBSR, pain neuroscience education, peripheral nerve stimulation, psychotherapy,
radiofrequency ablation, relaxation therapy, or virtual/augmented reality.

B. Clinical Assessments and Outcomes Tools
Although a wide variety of outcome measures are available for use in ULA, the field still lacks data to
guide the selection of the best tools for specific purposes. Studies of outcome metrics, by necessity,
involve different types of study design and should follow appropriate standards.(76)·More research is needed on the psychometric properties of outcome measures for ULA to assist
in selecting the optimal measures. Such studies should evaluate reliability, validity, theresponsiveness of measures and identify the minimal detectable change (MDC) and minimallyclinically important difference (MCID) of measures.

March 2022

Page 41 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

Research is needed to identify and validate predictive assessments and prognostic factors that
can inform decisions on overall prosthetic candidacy or the appropriate choice of prosthesis
type and component. Such research requires well-designed, sufficiently powered prospective
cohort studies with measures and assessments administered in the pre-prosthetic phase but
may also be possible using retrospective study designs.

·

Research is needed to identify factors (e.g., utility, function, cosmesis, prosthetic weight)
associated with prosthesis acceptance and adoption. Such research requires well-designed,
sufficiently powered prospective cohort studies with measures and assessments administered in
the pre-prosthetic phase but may also be possible using retrospective study designs.

·

Patient-centered outcomes research to develop and validate outcome measures that aremeaningful to patients (e.g., more holistic outcomes like employability, financial health,psychological/spiritual/physical health).

C. Psychosocial Interventions
While psychosocial interventions are commonly provided throughout the phases of amputation
rehabilitation, little data is available on the effectiveness or efficacy of specific interventions. Studies oftreatment efficacy ideally should be well-designed, adequately powered RCTs. We suggest, based oncommon inclusion/exclusion criteria used in screening papers for evidence-based guidelines, that
researchers recruit a minimum of 20 persons per intervention group. However, observational studies
using EHR, or other data may provide evidence (albeit weaker) on this topic. Additionally, the WorkGroup recognized that further data on long-term psychosocial functioning and outcomes of persons
with amputation would clarify the needs of this patient population. Research that could address theseevidence gaps include:·

RCTs that evaluate the efficacy of interventions to improve psychosocial functioning andoutcomes, as well as the most effective elements of interventions.

·

Well-designed, appropriately powered, retrospective cohort studies that identify the optimaldose, timing, and content of behavioral health/psychosocial interventions to improve health andfunctioning. Such studies would likely describe patterns of care and compare the effectivenessof various treatment approaches and timing.

·

Longitudinal studies of psychosocial functioning and outcomes, adverse events, and suicidality inpersons with ULA, studies that compare these outcomes by gender/sex, race, and ethnicity.
Such studies should be appropriately powered.

D. Surgical Procedures and Medical Interventions
Advances in surgical treatment such as TMR, RPNI, vascularized allotransplantation, AMI, OI, andimplantable myoelectric sensors have been introduced in the past decade with little data from welldesigned studies on the efficacy or effectiveness of these advances. Despite this paucity of research,some of these advances are increasingly used in clinical care and are often considered standard practice.
Research to address this evidence gap includes:·

RCTs or large prospective longitudinal cohort studies evaluating the efficacy of various advanced
surgical techniques (e.g., TMR, RPNIs, vascularized allotransplantation, AMI, OI, and implantable

March 2022

Page 42 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

myoelectric sensors) compared to traditional surgical care with follow-up at 6 months and 1 or
2 years.
·

Studies to determine optimal surgical and post-amputation medical management addressing
speed and quality of wound healing, reducing time to fitting, and using a prosthesis.

·

Studies to determine optimal surgical and post-amputation medical management addressing
speed and quality of wound healing, reducing time to starting prosthesis fitting, and potential
factors associated with a need for revision surgery.

E. Rehabilitation and Prosthetic Outcomes
Additional research is needed to understand key rehabilitation and prosthetic outcomes, factors
associated with these outcomes, and the efficacy of non-surgical rehabilitation interventions (e.g.,
occupational and physical therapy, prosthetic training). Observational, epidemiologic studies would
provide valuable evidence on factors associated with rehabilitation outcomes. Such studies would
ideally be longitudinal with the potential to follow persons with amputation over their lifetime. Research
efforts of this magnitude would benefit from the creation of a national registry of Veterans and Service
Members with ULA. In contrast, studies of the efficacy of rehabilitation and prosthetic interventions will
likely require experimental or quasi-experimental designs.

a. Epidemiologic Studies
In terms of epidemiologic studies, the following research is needed:·

Research to understand the impact of co-occurring conditions (e.g., PTSD, SUD, depression,
pain, and other medical conditions) on amputation rehabilitation outcomes. Such researchrequires well-designed, sufficiently powered prospective cohort studies with longitudinal followup or retrospective cohort studies that evaluate impacts of comorbid conditions over time.
Studies should provide short-term (three months) and long-term follow-up (a minimum of oneyear), with long-term follow-up considered highly desirable.

·

Research is needed to identify factors (e.g., utility, function, cosmesis, prosthetic
weight) associated with prosthesis acceptance and adoption. Such research requires welldesigned, sufficiently powered prospective cohort studies with measures and assessments
administered in the pre-prosthetic phase but may also be possible using retrospective study
designs.

·

Development of a registry for Veterans with ULA, with robust data elements and outcomes,
would provide valuable data for future longitudinal studies on rehabilitation outcomes
including:March 2022¨

Prospective cohort studies to examine the patterns of interventions (type, dose, andfrequency) that lead to the best outcomes for the patient; and¨Prospective cohort studies to track associations between amputation level and surgicalprocedure type on functional outcomes and QoL over time, adjusted matching forcomparators.

Page 43 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationb. Efficacy and Effectiveness Studies
The strongest designs for the study of rehabilitation and prosthetic interventions are sufficiently
powered RCTs, and follow-up periods of sufficient length to provide clinically meaningful information on
effectiveness and/or device adoption. Studies should employ psychometrically sound outcome metrics
that are meaningful to patients. However, RCTs are not feasible in many situations, and observational
study design may provide quality evidence on effectiveness. The following types of studies on
rehabilitation interventions are needed:·

Studies that examine the efficacy and effectiveness of telerehabilitation versus usual care for avariety of outcomes (e.g., self-efficacy, independence, QoL, disability, prosthetic use, andsatisfaction)·

Studies comparing the efficacy and effectiveness of usual care to more intensive rehabilitation
services post amputation·

Studies comparing outcomes of life skills intensive training for persons with bilateral amputation
to usual care·

Well-designed, appropriately powered, observational studies examining the comparative
effectiveness of various models of amputation rehabilitation (e.g., comparing team-based care
to non-team-based care)

The following types of studies of prosthetic interventions are recommended:·

Efficacy and effectiveness trials of upper limb prosthetic components·

Efficacy and effectiveness trials comparing prosthesis control strategies·

Efficacy and effectiveness trials comparing prosthesis suspension methods and socket/interfaces

March 2022

Page 44 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix A: Guideline Development Methodology
A.

Developing Key Questions to Guide the Systematic Evidence Review

To guide this CPG’s systematic evidence review, the Work Group drafted 12 KQs on clinical topics of thehighest priority for the VA and DoD populations. The KQs followed the population, intervention,comparison, outcome, timing, and setting (PICOTS) framework, as established by the Agency for
Healthcare Research and Quality (AHRQ) (see Table A-1).
Table A-1. PICOTS (77)
PICOTS
Element

Description

Population orPatients

Patients of interest. It includes the condition(s), populations or sub-populations, disease
severity or stage, co-occurring conditions, and other patient characteristics or demographics.

Intervention or Treatment (e.g., drug, surgery, lifestyle changes), approach (e.g., doses, frequency, methods ofExposureadministering treatments), or diagnostic/screening test used with the patient or population.
Comparator

Treatment(s) (e.g., placebo, different drugs) or approach(es) (e.g., different dose, different
frequency, standard of care) that are being compared with the intervention or exposure ofinterest described above.

Outcomes

Results of interest (e.g., mortality, morbidity, quality of life, complications). Outcomes can include
short, intermediate, and long-term outcomes.

Timing, if
applicable

Duration or follow-up of interest for the particular patient intervention and outcome to occur(or not occur).

Setting, if
applicable

Setting or context of interest. Setting can be a location (e.g., primary, specialty, inpatient care)or type of practice.

Abbreviation: PICOTS: population, intervention, comparison, outcome, timing, and setting

Due to resource constraints, all KQs of interest to the Work Group could not be included in thesystematic evidence review. Thus, the Work Group selected the 12 highest priority KQs for inclusion in
the systematic evidence review (see Table A-2).
Using the GRADE approach, the Work Group rated each outcome on a 1 – 9 scale (7 – 9, critical for
decision making; 4 – 6, important, but not critical, for decision making; and 1 – 3, of limited importancefor decision making). Critical and important outcomes were included in the evidence review (seeOutcomes); however, only critical outcomes were used to determine the overall quality of evidence (seeDetermining Recommendation Strength and Direction).

a. Population(s)·Key Questions 1 – 9, 12¨·

Including: Adults (≥18 years, including Veterans as well as deployed and non-deployed
active duty Service Members, their beneficiaries, and retirees and their beneficiaries)
with ULAKey Questions 10, 11¨

March 2022

Including: Adults who are candidates for UE surgery (surgery and/or pre-prosthetic)

Page 45 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationb. Interventions·

Key Question 1:¨·

Key Question 2:¨··

ULA rehabilitation centers/Upper Limb Focused Center, tele-rehabilitation,
telehealth/virtual care, remote gaming/monitoring for rehabilitation, telephone visits,
residential rehab program, acute inpatient rehab, inpatient rehab center, outpatient
clinic setting, day rehab program

Key Question 4:¨

Dexterity: Jebsen-Taylor Hand Function (JTHF), Nine-Hole Peg (NHP), Box and Block Test
(BBT), Southampton Hand Assessment Procedure (SHAP), Clothespin Relocation Test,
Assessment of Capacity for Myoelectric Control (ACMC)¨

Activity/Function: [Brief] Activities Measure for Upper Limb Amputees ([B]AM-ULA),
timed measure of activity performance (T-MAP), Disabilities of the Arm, Shoulder and
Hand Score (QuickDASH), University of New Brunswick (UNB) Test of Prosthetic
Function, Patient-Specific Functional Scale (PSFS), need for help with ADL¨

Psychological: PTSD Checklist for DSM-5 (PCL-5), Patient Health Questionnaire (PHQ)-9,
General Anxiety Disorder (GAD)-7, Trinity amputation and prosthesis experience scales(TAPES)¨

Other: Community Reintegration of Injured Service Members-Computer Adapted-Test(CRIS-CAT), Veteran RAND 12 Item Health Survey (VR-12) – Physical Component
Score/Mental Component Score (PCS/MCS), Orthotics and Prosthetics User’s Survey(OPUS) Satisfaction with Devices (CSD), Orthotics and Prosthetics User’s Survey (OPUS)
Upper Extremity Functional Status (UEFS), NASA Task Load Index (TLX)

Key Question 5:¨·

Education, counseling services, social work services, peer support (Individual Peer Visits
and Peer Support Groups), amputee support groups, psychotherapy, ACT, CBT, MBSR,
mindfulness/meditation, psychotherapy

Key Question 3:¨·

TMR, RPNI, VCA – [hand transplant], AMI – [Ewing procedure], IMES system, OI

Use of device, modifiable patient-related factors, amputation etiology, amputationlevel, laterality (Uni-Bil), time since amputation, prosthetic training, self-efficacy, age,gender/identity, ethnicity, ROM, strength, vision, cognition, motivation, depression,
PTSD, SUD, goals, emotional adjustment, associated injuries including traumatic brain
injury or comorbidities, weight, function, cosmesis, sleep disorders, personality
disorders, pain

Key Question 6:¨

March 2022

Terminal devices (TDs): passive hand, body-powered hook (e.g., Hosmer hook)(voluntary opening, voluntary closing), single-degree-of-freedom (DOF) body-powered

Page 46 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

hand, motorized hooks and hands (Single-DOF powered hand, powered hook (Griefer),
multiarticulating powered hand (i-Limb), sensor hand)

·

·

¨

Control strategies: On/Off control (i.e., crisp control, finite state machine control, onset
analysis), proportional control, pattern recognition control, regression control¨

Prosthesis type: passive prostheses (cosmetic), body-powered prostheses, externallypowered prostheses (myoelectric, modular Prosthetic Limb (MPL), DEKA (or Luke arm),
Hybrid prostheses¨

Socket design and/or suspension method: Harness (active transhumeral harness, 21A35
harness, 21A36 harness), rigid lamination, flexible materials, gel inserts, vacuum
suspension

Key Question 7:¨

Medications: antidepressants, anticonvulsants, opioids, skeletal muscle relaxants, nonsteroidal anti-inflammatory drugs, acetaminophen (APAP), ketamine, marinol, vitaminD, benzodiazepines, topical lidocaine, any topical preparations, capsaicin, NMDA
receptor antagonist (broader group that includes ketamine)¨

Non-pharmacologic: TENS, mirror therapy, desensitization, peripheral nerve stimulation,
spinal cord stimulation, radiofrequency (RF) ablation, GMI, ACT, biofeedback, CBT,
MBSR, mindfulness/meditation, pain neuroscience education, psychotherapy, relaxation
therapy, complementary and alternative medicine (e.g., acupuncture)

Key Question 8:¨·

Key Question 9:¨·

Antidepressants, anticonvulsants, opioids, skeletal muscle relaxants, non-steroidal antiinflammatories, acetaminophen (APAP), ketamine, marinol, vitamin D, benzodiazepines,
topical lidocaine, any topical preparations, capsaicin, NMDA receptor antagonist(broader group that includes ketamine), notox/botulinum, other anticonvulsants(Keppra, lacosamide, cannabidiol/Epidiolex), DBS, ECT, TMS, VNS

TENS, mirror therapy, biofeedback, desensitization, peripheral nerve stimulation, spinal
cord stimulation, RF ablation, GMI, ACT, CBT, MBSR, mindfulness/meditation, painneuroscience education, psychotherapy, relaxation therapy, complementary andalternative medicine (e.g., acupuncture), virtual/augmented reality (like mirror therapy)

Key Question 10:

March 2022¨

Level of amputation: fingers or partial hand (transcarpal), at the wrist (wrist
disarticulation), below the elbow (TR), at the elbow (elbow disarticulation), above theelbow (transhumeral), at the shoulder (shoulder disarticulation), above the shoulder(forequarter)¨

Surgical procedure: myodesis, myoplasty, OI, TMR, revision, Ertl procedure, peripheral
nerve stimulation implants, spinal cord stimulation

Page 47 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

Key Question 11:¨·

Skin condition, infection, pain, palpable pulse, scintigraphic skin perfusion pressure(SPP), angiographic patency score, ischemic features, diabetes, known peripheral
vascular disease, other medical conditions, age, gender, race, ethnicity

Key Question 12:¨

Physical therapy (PT), occupational therapy (OT), specific PT/OT protocols, timing oftherapy interventions, provision of durable medical equipment, provision of adaptive
equipment, provision of assistive technology, prosthetic training, strengthening,
functional training, range of motion, therapeutic exercise, neuromuscular education,
mirror therapy, residual limb strengthening, desensitization, scar massage, education,
activity analysis, community reintegration, wound care and management, TD education,
efficiency training with TD, change of dominance training, adaptive sports training,
biofeedback, recreational therapy, preservation techniquesc. Comparators·

Key Question 1: Standard intervention surgery, no comparator, standard of care with no surgicalintervention, amputation surgery without any of the six listed interventions·

Key Question 2: Other intervention strategy, usual care, waitlist control·

Key Question 3: Another treatment setting; standard of care, no services·

Key Question 4: Clinical experience, normal values, published values on MDC or MCID·Key Question 5: Absence of factor·

Key Question 6: Other listed intervention·

Key Questions 7 – 9: Standard/usual care (active treatment), other listed intervention, no
treatment, placebo·

Key Question 10: A different level or procedure·

Key Question 11: Absence of condition·

Key Question 12: Standard of cared. Outcomes·

Key Question 1:

March 2022¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability, pain
– residual limb pain and phantom pain and compensatory pain in other upper body
locations – neck, shoulders, and intact limb (if unilateral amputation)¨

Important outcomes: Adverse events/complications (e.g., skin breakdown, surgicalrevision), mental health (e.g., depression, mood disorders, suicide), prosthesis related
outcomes (e.g., prosthesis satisfaction; prosthesis use; prosthesis use intensity;
prosthesis acceptance; prosthetic competence), QoL/HRQoL/satisfaction with life

Page 48 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

·

·

·

·

·

·

Key Question 2:¨

Critical outcomes: Adjustment to disability, mental health (e.g., depression, mooddisorders, suicide), QoL/HRQoL/satisfaction with life¨

Important outcomes: Community integration, functional status, independence, IADLs,
ADLs, and/or disability, independence/employment, satisfaction with body
image/cosmesis/appearance

Key Question 3:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability,
prosthesis related outcomes (e.g., prosthesis satisfaction; prosthesis use; prosthesis use
intensity; prosthesis acceptance; prosthetic competence)¨

Important outcomes: Community integration, independence/employment, mental
health (e.g., depression, mood disorders, suicide), pain – residual limb pain andphantom pain and compensatory pain in other upper body locations – neck, shoulders,and intact limb (if unilateral amputation), QoL/HRQoL/satisfaction with life

Key Question 4:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability,
prosthesis related outcomes (e.g., prosthesis satisfaction; prosthesis use; prosthesis use
intensity; prosthesis acceptance; prosthetic competence)¨

Important outcomes: Adjustment to disability, independence/employment, pain –residual limb pain and phantom pain and compensatory pain in other upper body
locations – neck, shoulders, and intact limb (if unilateral amputation),
QoL/HRQoL/satisfaction with life, satisfaction with body image/cosmesis/appearance

Key Question 5:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability,
QoL/HRQoL/satisfaction with life¨

Important outcomes: Adoption of device, independence/employment, mental health(e.g., depression, mood disorders, suicide), pain – residual limb pain and phantom pain
and compensatory pain in other upper body locations – neck, shoulders, and intact limb
(if unilateral amputation), prosthesis related outcomes (e.g., prosthesis satisfaction;
prosthesis use; prosthesis use intensity; prosthesis acceptance; prosthetic competence)

Key Question 6:¨

Critical outcomes: Prosthesis satisfaction measures¨

Important outcomes: Functional status, independence, IADLs, ADLs, and/or disability,
QoL/HRQoL/satisfaction with life

Key Questions 7, 8:¨

March 2022

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability, pain
– residual limb pain and phantom pain and compensatory pain in other upper body
locations – neck, shoulders, and intact limb (if unilateral amputation)

Page 49 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

¨

·

·

·

·

Important outcomes: Adverse events/complications (e.g., skin breakdown), duration ofuse and dosage of pain medication, mental health (e.g., depression, mood disorders,suicide), prosthesis related outcomes (e.g., prosthesis satisfaction; prosthesis use;
prosthesis use intensity; prosthesis acceptance; prosthetic competence),
QoL/HRQoL/satisfaction with life

Key Question 9:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability¨

Important outcomes: Duration of use and dosage of pain medication,
independence/employment, mental health (e.g., depression, mood disorders, suicide),
pain – residual limb pain and phantom pain and compensatory pain in other upper body
locations – neck, shoulders, and intact limb (if unilateral amputation), prosthesis related
outcomes (e.g., prosthesis satisfaction; prosthesis use; prosthesis use intensity;
prosthesis acceptance; prosthetic competence), QoL/HRQoL/satisfaction with life

Key Question 10:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability,
prosthesis related outcomes (e.g., prosthesis satisfaction; prosthesis use; prosthesis use
intensity; prosthesis acceptance; prosthetic competence)¨

Important outcomes: Adverse events/complications (e.g., skin breakdown),
independence/employment, mental health (e.g., depression, mood disorders, suicide),
pain – residual limb pain and phantom pain and compensatory pain in other upper body
locations – neck, shoulders, and intact limb (if unilateral amputation),
QoL/HRQoL/satisfaction with life

Key Question 11:¨

Critical outcomes: Prosthesis fitting/timing of prosthesis fitting, wound-related
outcomes (e.g., quality, speed of healing)¨

Important outcomes: Surgical revisions

Key Question 12:¨

Critical outcomes: Functional status, independence, IADLs, ADLs, and/or disability¨

Important outcomes: Prosthesis satisfaction measures, QoL/HRQoL/satisfaction with life

e. Timing·

Key Questions 1 – 12: Any

f. Settings·

B.

Key Questions 1 – 12: Inpatient or outpatient. Can pertain to stay at comprehensive inpatient
rehabilitative unit/program.

Conducting the Systematic Review

Based on the Work Group’s decisions regarding the CPG’s scope, KQs, and PICOTS statements, the Lewin
Team produced a systematic evidence review protocol before conducting the review. The protocol

March 2022

Page 50 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

detailed the KQs, PICOTS criteria, methodology to be used during the systematic evidence review, andthe inclusion and exclusion criteria to be applied to each potential study, including study type andsample size. The Work Group reviewed and approved the protocol.
Figure A-1 below outlines the systematic evidence review’s screening process (see also theGeneral Criteria for Inclusion in Systematic Review and Key Question Specific Criteria). In addition,
Table A-2 indicates the number of studies that addressed each of the questions.
Figure A-1. Study Flow Diagram

Abbreviations: CS: clinical study; KQ: key question; SR: systematic review

Alternative Text Description of Study Flow Diagram
Figure A-1. Study Flow Diagram is a flow chart with nine labeled boxes linked by arrows that describe theliterature review inclusion/exclusion process. Arrows point down to boxes that describe the nextliterature review step and arrows point right to boxes that describe the excluded citations at each step(including the reasons for exclusion and the numbers of excluded citations).
1. Box 1: 3,631 citations identified by searchesa. Right to Box 2: 1,906 citations excluded at the title leveli. Citations excluded at this level were off-topic, not published in English, or
published prior to inclusion dateb. Down to Box 3

March 2022

Page 51 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

2. Box 3: 1,725 abstracts reviewed
a. Right to Box 4: 1,474 citations excluded at the abstract leveli. Citations excluded at this level were not an SR or CS, clearly did not address a
KQ, did not report on or an outcome of interest, or were outside cutoff
publication datesb. Down to Box 5
3. Box 5: 251 full-length articles reviewed
a. Right to Box 6: 163 citations excluded at 1st pass full article leveli. 38 citations excluded at this level had the wrong study design or did not address
a KQ
ii. 13 citations excluded at this level did not have an intervention or comparator ofinterestiii. 0 citations excluded at this level were superseded by more comprehensive
review or included in an SR
iv. 12 citations excluded at this level had relevant reviews with no data to extract
v. 10 citations excluded at this level had inadequate sample sizevi. 30 citations excluded at this level had no outcomes of interestvii. 25 citations excluded at this level did not study a population of interestviii. 0 citations excluded at this level had inadequate follow-up for the KQ
ix. 35 citations excluded at this level were excluded for another reason (e.g., notpublished in English, not a CS or SR, published outside date range)b. Down to Box 7
4. Box 7: 88 articles reviewed
a. Right to Box 8: 55 citations excluded at 2nd pass KQ leveli. 16 citations excluded at this level had the wrong study design or did not address
a KQ
ii. 14 citations excluded at this level did not have an intervention or comparator ofinterestiii. 2 citations excluded at this level were superseded by more comprehensive
review or included in an SR
iv. 5 citations excluded at this level had inadequate reporting of data or no data to
extract
v. 0 citations excluded at this level had an inadequate sample sizevi. 10 citations excluded at this level had no outcomes of interestvii. 4 citations excluded at this level did not study a population of interest

March 2022

Page 52 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

viii. 0 citations excluded at this level had unclear or inadequate follow-up
ix. 4 citations excluded at this level were excluded for another reason(e.g., abstract, published outside date range, or data wholly covered in aprevious review)b. Down to Box 9
5. Box 9: 33 included studies
Table A-2. Evidence Base for KQs

KQ

Numberand StudyType

1

In adults with ULA, what is the impact of treatment advances, including hardware,
software, surgical, technology, or supplemental surgical interventions on outcomes?

1 RCT, 2observational

2

In adults with ULA, do psychosocial interventions affect outcomes?

No studies
identified

3

In adults with ULA, what treatment parameters (e.g., setting, treatment intensity, orservice delivery model) are most effective in improving outcomes?

No studies
identified

4

In adults with ULA, what assessment measures are effective in guiding prosthesis
candidacy determination, determining the need for therapy, or identifying
improvement or worsening of function and quality of life?

3
observational

5

In patients with ULA, with and/or without prostheses, what patient-related factors
and/or co-occurring conditions are associated with rehabilitation outcomes?

12
observational6

How do outcomes vary by control strategy, prosthesis type, socket design and/or
suspension method, and/or prosthesis component selection?

7
observational

7

In patients with ULA, what is the effectiveness of pharmacologic and nonpharmacologic interventions for the prevention of phantom and residual limb pain?

No studies
identified

8

In patients with ULA, what is the effectiveness of pharmacologic interventions for the
management of phantom and residual limb pain?

1 RCT

9

In patients with ULA, what is the effectiveness of non-pharmacologic interventions
for the management of phantom and residual limb pain?

1 SR, 2
randomized
crossovertrials10

In patients with ULA, does level of amputation and/or amputation surgical procedure
type impact patient outcomes?

2 SRs, 3observational

11

In patients undergoing ULA surgery (initial or revision), what factors predict speed
and quality of wound healing, prosthesis fitting, or need for revision surgery?

No studies
identified

12

In patients with ULA, what therapy interventions (e.g., PT/OT), therapy intervention
timing, or therapy protocols are associated with better function and healthoutcomes?

No studies
identified

KQ
NumberTotal Evidence Base 33 studies* One SR was included in both KQ 1 and KQ 2; one paper was used in both KQ 5 and KQ 6** One study in KQ 11 was published in two papers
Abbreviations: RCT: randomized controlled trial; SR: systematic review

March 2022

Page 53 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationa. General Criteria for Inclusion in Systematic Evidence Review·

Systematic reviews or clinical studies published on or after February 1, 2013, to April 30, 2021. If
multiple SRs addressed a KQ, we selected the most recent and/or comprehensive review.
Systematic reviews serve as the first line of evidence for all key questions. In the absence of asystematic review for an intervention, RCTs or prospective clinical studies were considered forinclusion, according to a best-evidence approach.

·Studies must be published in English.

·

Publication must be a full clinical study or systematic review; abstracts alone were not included.
Similarly, letters, editorials, and other publications that are not full-length clinical studies were
not accepted as evidence.

·

Systematic reviews must have searched MEDLINE or EMBASE for eligible publications,performed a risk of bias assessment of included studies, and assessed the quality of evidence
using a recognizable rating system, such as GRADE or something compatible (e.g., the Strengthof Evidence grading used by the Evidence-based Practice Centers of the AHRQ). If an existing
review did not assess the overall quality of the evidence, evidence from the review must bereported in a manner that allows us to judge the overall risk of bias, consistency, directness, andprecision of evidence. We did not use an existing review as evidence if we were not able toassess the overall quality of the evidence in the review.

·

Study must have enrolled at least 20 patients (10 per study group).
¨·

ECRI typically applies a downgrade in precision for small sample sizes for conditions that
affect a large number of patients (e.g., hypertension, MDD, or sleep disorders).
However, given the relative rarity of upper extremity amputation (UEA) patients, ECRI
did not downgrade for sample size.

Study must have reported on at least one outcome of interest.

b. Key Question Specific Criteria for Inclusion in Systematic Evidence Review·

For all KQs, except KQs 4, 5, and 11 studies included in the SRs or as independent papers must
be prospective, RCTs with an independent control group.
¨·

KQs 4, 5, and 11 also include observational trials, including cohort trials and case series.

For KQs focusing on a solely ULA population, the study must have enrolled at least 80% of
patients who meet the study population criteria: adults aged 18 years or older with ULA
rehabilitation. For studies examining mixed patient populations (UEA and LEA), studies musthave enrolled at least 80% of patients with the relevant condition (unless otherwise specified). If
the studies have presented data in a manner that ECRI can isolate the population of interest,
studies with less than 80% of patients with the target condition would be included.
¨

March 2022

KQs 1, 2, 8, and 9 potentially include mixed ULA and LEA populations, the 80% cutoff
was not be applied.

Page 54 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationc. Literature Search Strategy
Information regarding the bibliographic databases, date limits, and platform/provider can be found in
Table A-3. See Appendix M for additional information on the search strategies, including topic-specificsearch terms and search strategies.
Table A-3. Bibliographic Database Information
Name

Date Limits

Platform/Provider

CINAHL

February 1, 2013, through April 30, 2021

EBSCO

EMBASE (Excerpta Medica) and MEDLINE

February 1, 2013, through April 30, 2021

Elsevier

PsycINFO

February 1, 2013, through April 30, 2021

Ovid

PubMed (In-process, Publisher, andPubMedNotMedline records)

February 1, 2013, through April 30, 2021

National Library ofMedicine

Agency for Healthcare Research and Quality(AHRQ)

February 1, 2013, through April 30, 2021

AHRQ

U.S. Department of Veterans Affairs (VA)
Evidence Synthesis ProgramFebruary 1, 2013, through April 30, 2021

VA

d. Rating the Quality of Individual Studies and the Body of Evidence
The Lewin Team assessed the methodological risk of bias of individual diagnostic, observational, andinterventional studies using the USPSTF method. Each study is assigned a rating of Good, Fair, or Poor
based on a set of criteria that vary depending on study design. Detailed lists of criteria and definitions
appear in Appendix VI of the USPSTF procedure manual.
Following this, the Lewin Team assessed the overall quality of the body of evidence for each critical andimportant outcome using the GRADE approach. This approach considers the following factors: overall
study quality (or overall risk of bias or study limitations), consistency of evidence, directness of evidence,and precision of evidence. The overall quality of the body of evidence is rated as High, Moderate, Low,
and Very low.

C.

Developing Evidence-based Recommendations

In consultation with the VA Office of Quality and Patient Safety and the Clinical Quality Improvement
Program, DHA, the Lewin Team convened a four-day virtual recommendation development meeting on
August 2 – 5, 2021, to develop this CPG’s evidence-based recommendations. Two weeks before themeeting, the Lewin Team finalized the systematic evidence review and distributed the report to theWork Group; findings were also presented during the recommendation development meeting.
Led by the Champions, the Work Group interpreted the systematic evidence review’s findings anddeveloped this CPG’s recommendations. The Work Group also considered carrying forward andmodifying recommendations from the 2014 VA/DoD UEAR CPG (see Categorization of 2014 Clinical
Practice Guideline Recommendations). The Work Group also developed new recommendations notincluded in the 2014 VA/DoD UEAR CPG based on the 2021 evidence review.

March 2022

Page 55 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

The strength and direction of each recommendation were determined by assessing the quality of theoverall evidence base, the associated benefits and harms, patient values and preferences, and other
implications (see Determining Recommendation Strength and Direction).

a. Determining Recommendation Strength and Direction
Per GRADE, each recommendation’s strength and direction is determined by the following fourdomains:(9)1. Confidence in the Quality of the Evidence
Confidence in the quality of the evidence reflects the quality of the body of evidence supporting a
recommendation (see Rating the Quality of Individual Studies and the Body of Evidence). The options forthis domain include: High, Moderate, Low, or Very low. This is a direct reflection of the GRADE ratingsfor each relevant critical outcome in the evidence review (see Outcomes). Per GRADE, if the quality ofevidence differs across the relevant critical outcomes, the lowest quality of evidence for any of thecritical outcomes determines the overall quality of the evidence for a recommendation.(11, 12)
The recommendation strength generally aligns with the confidence in the quality of evidence. For
example, Strong recommendations are typically supported by High or Moderate quality evidence.
However, GRADE permits Low or Very low quality evidence to support a Strong recommendation incertain instances (e.g., life-threatening situation).(9)2. Balance of Desirable and Undesirable Outcomes
The balance of desirable and undesirable outcomes (i.e., benefits and harms) refers to the relative
magnitudes or tradeoffs of anticipated benefits (e.g., increased longevity, reduced morbidity, improved
QoL, decreased resource use) and harms (e.g., decreased longevity, increased complications, impaired
QoL). The options for this domain include: benefits outweigh harms/burden, benefits slightly outweighharms/burden, benefits and harms/burdens are balanced, harms/burdens slightly outweigh benefits, andharms/burdens outweigh benefits. This domain assumes most clinicians will offer patients anintervention if its advantages exceed the harms. The Work Group’s understanding of the benefits andharms associated with the recommendation influenced the recommendation’s strength and direction.

3. Patient Values and Preferences
Patient values and preferences is an overarching term that includes patients’ perspectives, beliefs,
expectations, and goals for health and life as they may apply to the intervention's potential benefits,harms, costs, limitations, and inconvenience. The options for this domain include: similar values, somevariation, or large variation. For instance, there may be some variation in patient values and preferences
for a recommendation on the use of acupuncture, as some patients may dislike needles. When patient
values seem homogeneous, this domain may increase the recommendation’s strength. Alternatively,
when patient values seem heterogeneous, this domain may decrease a recommendation’s strength. Aspart of this domain, the Work Group considered the findings from the patient focus group carried out aspart of this CPG update (see Appendix I).

March 2022

Page 56 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

4. Other Implications
Other implications encompass the potential consequences or other impacts that might affect thestrength or direction of the recommendation. The options for this domain include, e.g.: resource use,
equity, acceptability, feasibility, and subgroup considerations. The following are example implications
related to equity and subgroup considerations, respectively: some of the indicated population may begeographically remote from an intervention (e.g., complex radiological equipment); a drug may becontraindicated in a subgroup of patients.
Table A-4. GRADE Evidence to Recommendation Framework
Decision Domain

Questions to Consider

Judgment

Confidence in thequality of theevidence

Among the designated critical outcomes, what is thelowest quality of relevant evidence?
How likely is further research to change theconfidence in the estimate of effect?

Balance of desirable
and undesirable
outcomes

What is the magnitude of the anticipated desirable
outcomes?
What is the magnitude of the anticipatedundesirable outcomes?
Given the best estimate of typical values andpreferences, are you confident that benefits
outweigh harms/burdens or vice versa?

High
Moderate
Low
Very low
Benefits outweigh harms/burdens
Benefits slightly outweighharm/burden
Benefits and harms/burdens arebalanced
Harms/burdens slightly outweighbenefits
Harms/burdens outweigh benefits

What are the patients’ values and preferences?
Are values and preferences similar across the target
Patient values andpopulation?
preferences
Are you confident about typical values andpreferences?
What are the costs per resource unit?
Is this intervention generally available?
Other implications(e.g., resource use,
What is the variability in resource requirements
equity,across the target population and settings?
acceptability,
Are the resources worth the expected net benefit
feasibility, subgroup from the recommendation?
considerations)
Is this intervention and its effects worth withdrawing
or not allocating resources from other interventions?

Similar values
Some variation
Large variation

Various considerations

b. Recommendation Categorization
A summary of the recommendation categories and definitions is available in Table 4.

1. Categorizing Recommendations with an Updated Review of the Evidence
Reviewed refers to recommendations on topics included in this CPG’s systematic evidence review.
Reviewed, New-added recommendations are original, new recommendations (i.e., not included in theprevious CPG). These recommendations are based entirely on evidence included in the current CPG’ssystematic evidence review.
Reviewed, New-replaced recommendations were in the previous CPG but revised based on the updated
evidence review. These recommendations may have clinically relevant edits. Reviewed, Not changed
recommendations were carried forward from the previous CPG unchanged. Reviewed, Amended

March 2022

Page 57 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

recommendations were carried forward from the previous CPG with a nominal change. This allowed forthe recommendation language to reflect GRADE approach and any other not clinically meaningful edits
deemed necessary. These recommendations can be based on a combination of evidence included in thecurrent CPG’s systematic evidence review and the evidence base that supported the recommendation in
the previous CPG.
Reviewed, Deleted refers to recommendations from the previous CPG that were deleted after a reviewof the evidence. This may occur if the evidence supporting the recommendation is outdated (e.g., there
is no longer a basis to recommend use of an intervention and/or new evidence suggests a shift in care),rendering the recommendation obsolete.

2. Categorizing Recommendations without an Updated Review of the Evidence
There were also cases in which it was necessary to carry forward recommendations from the previous
CPG without an updated review of the evidence. Given time and resource constraints, the systematic
evidence review carried out for this CPG update could not cover all available evidence on ULA;
therefore, its KQs focused on new or updated research or areas not covered in the previous CPG.
For areas in which the relevant evidence was not changed and for which recommendations made in theprevious CPG were still relevant, recommendations could have been carried forward to the updated CPG
without an updated review of the evidence. The evidence supporting these recommendations was thus
also carried forward from the previous CPG. These recommendations were categorized as Not reviewed.
If evidence had not been reviewed, recommendations could have been categorized as Not changed,
Amended, or Deleted. Not reviewed, Not changed recommendations were carried forward from theprevious CPG unchanged. Not reviewed, Amended recommendations were carried forward from theprevious CPG with a nominal change. Not reviewed, Deleted recommendations were determined by theWork Group to not be relevant. A recommendation may not be relevant if it, for example, pertained to a
topic (e.g., population, care setting, treatment) outside of the updated CPG’s scope or if it wasdetermined to be common practice.
The recommendation categories for the current CPG are noted in the Recommendations. The
recommendation categories from the 2014 VA/DoD UEAR CPG are noted in Appendix K.

D.

Drafting and Finalizing the Guideline

The Work Group wrote, reviewed, and edited three drafts of the CPG using an iterative review process
to solicit feedback on and make revisions to the CPG. The first and second drafts were posted online for
20 and 14 business days, respectively, for the Work Group to provide feedback. Draft 2 was madeavailable for a 14-day peer review and comment (see External Peer Review). The Work Group reviewed
all feedback submitted during each review period and made appropriate revisions to the CPG. Following
the Draft 2 review and comment period, the Work Group reviewed external feedback and created a final
draft of the CPG. The Champions then presented the CPG to the VA/DoD EBPWG for approval. The WorkGroup considered the VA/DoD EBPWG’s feedback and revised the CPG as appropriate to create the final
version. To accompany the CPG, the Work Group produced toolkit products, including a provider
summary, pocket card, and patient summary. The VA/DoD EBPWG approved the final CPG and toolkit
products in March 2022.

March 2022

Page 58 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix B: Summary of Assessments and Interventions in Rehabilitation Phases
Table B-1. Summary of Assessments and Interventions in Rehabilitation Phases
Perioperative

Pre-prosthetic· Complete initial assessment · Continue medical
1. Physicalof medical comorbidities andinterventions and provide
Health Statusprovideconsultationasreferrals and education as(nutritional, CV,appropriate, especially if notneededendocrine,
addressed preoperatively
neurologic,· Initiate medical interventions
bowel &and education as needed
bladder, skin,
MSK)· Initiate discharge planning· Determine new needs and2. Discharge
Planning····

3. Level of
Function·

3.1- Range of
Motion···3.2 Gross
Motor Strength ·and Skills

March 2022

during the initial assessment
update discharge plan as
appropriate
Develop discharge planCommunicate discharge planwith family and/or caregiver
Assess current ROM in· Maximize ROM of scapula,
proximal joints of residual
shoulder girdle, elbow,
limb and on contralateral side
wrist, and hand as applicable
Preoperatively, treat· Advance to active ROM ofidentified contractures
residual and contralateral
Initiate passive ROM oflimbs
residual and contralaterallimb in all available planes of
motionEducate on importance ofproper positioning to prevent
contracture
Progress to active-assistive
ROM in all planes of motion
for residual and contralateral
limb
Assess for strength deficits of · Continue therapeutic
upper and lower limbs andexercise program fortreat as appropriate
strengthening upper
Initiate strengthening
extremity to include
program for major muscle
periscapular muscles
groups in the arms and legs

Prosthetic Training· Assess changes in medical

Lifelong Care
· Assess changes in medicalcomorbidities, and perform
interventions and education
as needed··· Determine new needs andupdate discharge plan as
appropriate· Arrange appropriate followup plans··

comorbidities and perform
interventions and education
as needed
Address strategies forprevention of secondary
complications
Specialty referrals as
indicated
Implement appropriate
follow-up plans
Assist with care transitions
including relocation or major
life changes· Continue contracture· Reassess ROM and review
prevention with stretchinghome stretching program if
programneeded· Maximize ROM for prosthetic · Initiate therapy services if
fit and use
needed· Progress therapeutic exercise · Reassess general strength
program for all extremities

and educate on maintenanceof strength for long-term
activity

Page 59 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative· Initiate trunk and core·
3.3 Core
Stabilization
and Balance

3.4 Home
Exercise
Program (HEP)

·
·
·
·

·

3.5
Cardiovascular
(CV)

·
·

·

·
3.6 ADL and
IADL

·
·
·

March 2022

stabilization exercises
Assess and initiate a balance
progression:o Static sitting balanceo Sitting weight shifts
Assess and initiate corestabilization:
Pelvic tilts
Bridges
Determine and provide HEP
addressing deficiencies andmaximize above ROM
strength, balance, etc.
Assess current CV fitness andincorporate a CV component
into the therapy program
Educate regarding energy
demand with active
prosthesis use
Establish cardiac precautions
for rehabilitation (heart rate,
blood pressure, perceived
exertion scales) as indicated
Assess activity level andindependence in ADL and
IADL to help establish goals
and expectations
Initiate ADL training such as
eating, dressing, grooming,bathing, toileting
Provide training for any
strategies to perform basic
ADL with one hand
Ensure patient safety
Initiate change of dominancetraining as appropriate

Pre-prosthetic

Prosthetic Training· Advance trunk and core

· Advance balance activities

stabilization exercises· Progress dynamic balanceand challenge upper limb
functional reach· Give patient supplies and· Advance HEP to focus on full

instruction in exercise
program for home

· Advance CV aspect of
rehabilitation program tomeet needs of patient· Maintain cardiac
precautions as indicated· Encourage reducing risk
factors· Teach adaptive techniques

ROM, strength, andendurance

Lifelong Care
· Reassess core strength andbalance as it relates tofunctional activities using theprosthesis· Address new physicalrequirements as patient
goals change· Establish maintenance· Establish maintenanceprogram for endurance andprogram for endurance andfitness
fitness· Maintain cardiac precautions · Maintain cardiac precautions
as indicated
if indicated· Encourage reduction of CV· Encourage reduction of CV
risk factors
risk factors· Instruct in proper care andfor dressing, bathing,
maintenance of prosthesis
grooming, and toileting· Instruct and train inwithout a prosthesis
prosthetic donning and· Continue change ofdoffing strategies
dominance training as· Practice ADL and IADL withappropriate
prosthesis as appropriate· Begin IADL training· Progress independence withmore complex IADL training· Reassess functional needs
and provide any necessary
training to maximize
independence· Teach energy conservation
principles· Teach injury prevention
techniques

Page 60 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative· Obtain recreational interests· Offer and promote trained

3.7 Community
Integration

3.8 Home
Evaluation

3.9 Equipment

March 2022

Pre-prosthetic· Initiate outings into theProsthetic Training

Lifelong Care

· Initiate recreational training· Reassess community
activities with a prosthesis
integration needs and referto recreation therapy as
peer visitation· Practice use of a prosthesis
necessaryduring recreational training
activities· Provide education on
opportunities and· Offer and maintain individual
precautions for long-termand group peer support
sport specific, recreation
skills or resources, andprosthesis or assistive
devices available· Provide counseling andcontact information
regarding opportunities in
sports and recreation· Assess patient’s home for· Assess patient’s home for· Reassess home modification
accessibility and safety andaccessibility and safety if notneeds with any significant
provide information on homealready completedchanges to medical condition
modifications· Provide education about· Assess for personal· Assess for personal· Reassess for any personal
available assistive devices or
equipment and assistiveequipment and any
equipment or necessary
adaptive equipment
devices to perform ADL
necessary accommodations
accommodations to perform
to perform IADL (i.e., voice
ADL, vocation, and· Educate regarding available· Provide training for personal
recognition,one
handedavocational IADL as needs
home modifications, ramps,
equipment and assistive
keyboard, Bluetooth devices)and goals evolveetc.
devices to perform ADL
andprovidetraining·
Provide necessary training· Assess for home adaptation
for identified personalneeds, environmental
equipment and assistive
modifications, anddevice needs
equipment
community without aprosthesis· Complete recreational
training activities without
the prosthesis(es)· Offer and maintainindividual and group peer
supportPage 61 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative

Pre-prosthetic

Prosthetic Training

Lifelong Care

· Assess for driving evaluation · Consult Certified Driving· Reassess driving modification
Specialist to complete driving
needs with any significant
evaluation
changes to medical conditionor amputation status· Complete driver’s training
with recommended adaptive
equipment as needed· Educate patient, family,
and/or caregiver to comply
with local state driving laws
and individual insurancecompany policies
Assess and treat residual· Assess and treat residual· Reassess and adjust
limb pain and PLP (transition
limb pain and PLP (transition
treatment for residual limb
to non-narcotic modalities
to non-narcotic modalities
pain and PLP (transition to
including pharmacologic,
including pharmacologic,
non-narcotic modalities
physical, psychological, andphysical, psychological, andincluding pharmacologic,
mechanical)
mechanical)
physical, psychological, andmechanical)· Assess and treat associatedMSK pain and overuse
syndromes
Evaluate and address· Evaluate and address· Evaluate and address
psychosocial
psychosocial
psychosocial
symptoms/issues
symptoms/issues
symptoms/issues
Evaluate and address· Evaluate and address· Assess changes incognitive issues
cognitive issues
psychosocial support
Offer or maintain individual · Offer or maintain individual · Assess changes in cognitiveand group peer support
and group peer support
issuesactivities
activities
needs or need for vehicle
modifications or adaptive
driving equipment

3.10 Driving
Evaluation andTraining─· Assess for existing pain·
4. PainManagement·
5. Behavioral
and Cognitive
HealthMarch 2022··

before surgery and treat
aggressively
Following amputation, assess
and aggressively treat
residual limb pain and PLP(liberal narcotic use, regional
anesthesia, and non-narcotic
medications especially forneuropathic pain)
Complete psychologicalassessment
Evaluate and address
psychosocial
symptoms/issues
Complete cognitive
assessment

·

·
·
·

Page 62 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative
·
·
·
·
·
·
·
·
·
·
6. Patient
Education

·
·
·
·
·
·
·
·
·
·
·
·

March 2022

Pain control
Patient safety
Prevention of complications
Procedural/recovery issues:
Level of amputation
Prosthetic options
Postoperative dressing
Sequence of amputation care
Equipment
Role of the care teammembers
Psychosocial anticipatory
guidance
Expected functional
outcomes
Positioning
Rehabilitation process
Pain control
Residual limb care
Edema control
Compression wrapping
Wound care
Prosthetic timeline
Coping methods
Contracture prevention

Pre-prosthetic
·
·
·
·
·
·
·
·
·
·
·
·

Positioning
Rehabilitation progress
Pain control
Residual limb care
Edema control
Application of shrinker
Prosthetic timeline
Equipment needs
Coping methods
Prevention of complications
Contracture prevention
SafetyProsthetic Training
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

Positioning
Rehabilitation process
Pain control
Residual limb care
Energy expenditure
Prosthetic education
Donning & doffing
Care of prosthesis
Skin integrity
Sock management
Equipment needs
Coping methods
Prevention of complications
Weight management
Contracture prevention
Injury prevention techniques
SafetyLifelong Care
·
·
·
·
·
·
·
·
·
·
·
·

Positioning
Rehabilitation process
Pain control
Residual limb care
Equipment needs
Coping methods
Prevention of complications
Weight management
Contracture prevention
Injury prevention techniques
SafetyTechnological advances in
the field that may benefit
patient to achieve individual
needs and desired goals

Page 63 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative· Manage postoperative··

7. Residual
LimbManagement···

dressings
Monitor the surgical wound
for signs and symptoms ofischemia or infection
Control edema and shaperesidual limb with the use of
postoperative dressing andcompression wrap; progress
to shrinker once cleared bysurgeonTeach compression wrap
application or shrinker
application
Promote skin and tissue
integrity with the use of aresidual limb dressing
Promote ROM andstrengthening of proximal
joints and muscles· Determine optimal residual

8. Prosthetic
Management

March 2022

limb length per patient goals· Residual limb care
· Postoperative dressing if
appropriate

Pre-prosthetic· Continue to monitor wound
·
·
·
·
·

healing
Continue shaping andshrinkage of residual limb
Teach compression wrap
application or shrinker
application
Teach patient care ofresidual limb
Promote ROM andstrengthening of proximal
joints and muscles
Instruct in desensitization
exercises

Prosthetic Training· Optimize limb shaping and
·
·
·
·
·
·
·
·

· Initial prosthetic·prescription generation··

shrinkage before prosthetic
fitting
Teach donning/doffing of
prosthetic system
Instruct in use of shrinker orcompression wrap when outof prosthesis
Teach skin checks and skinhygieneTeach management of sockply (if appropriate)
Progress wear schedule
Optimize pain management
to promote ROM andrestoration of function
Instruct patient to observe
pressure points
Monitor skin and tissue
integrity with progressive
wearing time and frequent
skin checks in the newly
fitted socket
Prosthetic fabrication, fitting,alignment, and modification
as applicable
Test various prosthesis
components
Consider activity-specificprosthesis to meet goals

Lifelong Care
· Reinforce education
regarding skin care

· Educate regarding signs andsymptoms of ill-fitting socket· Monitor effectiveness of pain
management· Continue limb volume
management· Prosthetic fabrication, fitting,alignment, and modification
as applicable· Prosthetic device repairs as
indicated· Schedule routine
maintenance (components,
upgrades, socket changes,
and specialty use devices)· Consider activity-specificprosthesis to meet newly
established goals

Page 64 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Perioperative· Obtain vocation interests

Pre-prosthetic· Complete vocational
rehabilitation evaluation if
indicated

9. Vocational
Rehabilitation

Prosthetic Training

Lifelong Care

· Conduct worksite evaluation· Reassess vocational needs

if indicated· Identify worksite
modifications to enhancefunction· Initiate vocational training
activities with a prosthesis· Practice use of a prosthesis
during vocational training
activities

and refer as needed toachieve new or ongoing
vocational goals· With any significant changes
to medical condition,
reassess for any additional
workplace modification
needs

Abbreviations: ADL: activities of daily living; CV: cardiovascular; HEP: Home Exercise Program; IADL: instrumental activities of daily living; MSK: musculoskeletal; ROM: range of
motion; PLP: phantom limb pain

March 2022

Page 65 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix C: Outcome Measures
The International Classification of Functioning, Disability, and Health (ICF) model was endorsed by theWorld Health Organization (WHO) in 2001 to create a common language to describe health and healthrelated status. It classifies human functioning into four multi-dimensional domains: body functions andstructures, activities and participation, environmental factors, and personal factors, and includes
elaborate classification taxonomy.(78) The ICF model is increasingly utilized in clinical settings as a way
to conceptualize functional status, identify goals, plan and monitor treatment, and as a framework foroutcome measurement. The use of the ICF allows clinicians and researchers from different fields andlocations to use a common language to understand health and disability.
Appropriate selection and administration of outcome measures, linked to the ICF taxonomy, can be used
to identify the impact of a health or health-related condition, evaluate needs, and track health andfunction over time.(79, 80) Many authors have attempted to link specific outcome measures to ICF
taxonomy across a variety of disciplines, including ULA rehabilitation.(81-83) Most outcome measures
were not developed based upon the ICF conceptual model, and as such, may not cover all the aspects ofhuman functioning that are pertinent to specific clinical conditions. Therefore, clinicians may need to
employ a “toolkit” of outcome measures when seeking a comprehensive view of the patient’s status andprogress.(82-85)
In 2014, the UEAR CPG Work Group performed a systematic evidence review to ensure the most current
information was included for recommendation development. The 2014 CPG’s systematic evidence
review intended to identify outcome measures to assess function in persons with ULA and evaluate eachmeasure’s focus, content, clinimetric, and psychometric properties. This 2014 CPG systematic evidence
review was, in part, an update of one completed in 2012 by the Measurement Group for the VA
Amputation System of Care Repository. In 2022, the tables from the 2014 CPG systematic evidence
review were updated using the same inclusion and exclusion criteria.

A. Inclusion Criteria·

The manuscript employed a standardized outcome measure developed or used with adult
amputee patients/subjects to measure the specified domain for evaluating or predicting
outcome·The research used the measure with a sample of at least 10 persons with ULA·

The paper was written in English (or translated)·

An abstract was available for review

B. Exclusion Criteria·

Dissertation, thesis, book chapter, or conference proceedings·

The full text publication was unavailable for review·

Exclude if used only with a pediatric population·

Exclude if sample was only non-disabled persons using a prosthetic simulator

March 2022

Page 66 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Based on findings from the literature search, data on outcome measure psychometric properties were
updated where indicated. The new literature search update also yielded five additional pertinent
outcome measures: The Brief Activity Measure for Upper Limb Amputation (BAM-ULA), the Timed
Measure of Activities Performance (T-MAP), the PROMIS-9 UE, the Capacity Assessment of Prosthetic
Performance for the Upper Limb (CAPPFUL) and the Nine Hold Peg Test.(82, 83, 86-91) This review
is not an exhaustive list of all outcome measures available for use with the ULA population or those thathave been used in small studies or studies of prosthetic simulators. The 2014 VA/DoD UEAR CPG tables
included the SHAP because of its popularity, evidence of content validity, and use in multiple small
studies of TR amputees (1 – 6 subjects), plus several studies of prosthetic simulation.(92-101) Data on
the psychometric properties of the SHAP was updated given a recent publication and led to inclusion of
the performance measure Prosthesis Index of Functionality (P-IOF).(91)
All measures and their subscales are summarized in Table C-1. Some of the listed measures also include
the MDC. These numbers can be very useful in interpreting MDC scores, however, scores vary by
population, and may or may not be clinically significant. This table provides a rating of the evidence
supporting important measurement properties of the identified outcome measures as documented in theliterature. Table C-2 lists the same outcome measures categorized according to broad ICF categories,
utility, and functional element assessed to facilitate clinical judgment. The review focuses on physicalfunction and does not include measures designed to assess important domains such as social participationor satisfaction with the prosthesis. The intent is to supply clinicians with information to help them choose
the best measures of physical function appropriate for their patients and their facility.
Both the VA and the DoD have developed systems for collecting amputation-related outcome measures.
The VA is using embedded outcome measures available within the EMR; the DoD is using a SharePoint
based system to collect outcome measures. The VA and DoD Champions for this CPG update can assist
anyone with questions about the respective agency systems. This updated literature also highlights that
additional research is needed to evaluate the psychometric properties of outcome measures in persons
with ULA to evaluate those measures that are most responsive to change and would be most suited for
tracking patient outcomes over time.

March 2022

Page 67 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Table C-1. Review of Evidence in Support of Measurement Properties of Functional Status Measures for Upper Extremity
Amputation
Reliability Evidence

Validity

Interrater

Testretest

IRT/Rasch

Internal
consistency

Construct
ValidityNo
Floor/Ceiling

Sensitivity to change/
Responsiveness (MDC)

Overall
Rating

UK

UK

+

N/A

+

?

UK

UK

+

+

N/A

+

+

UK

+
(MDC 90 3.7)+

Actual Use Index (AUI)
Assessment of Capacity for
Myoelectric Control (ACMC)
Assessment of Capacity for
Myoelectric Control (ACMC) V2
Box and Block Test of Manual
Dexterity (BBT)
Brief Activity Measure Upper
Limb (BAM-ULA)
Carroll test (Upper Extremity
Function Test)

N/A

UK

N/A

UK

+

UK

UK

UK

+

UK

+

N/A

+

+

UK

+

+

+

+

N/A

+

+

+
MDC 950.55-0.69 logits

++

+

+

N/A

N/A

+

+

+
(MDC 90 6.5)

++

*

*

UK

*

+

UK

UK

+

UK

UK

N/A

UK

UK

UK

UK

UK

Carroll test (modified)
Capacity Assessment of
Prosthetic Performance for theUpper Limb (CAPPFUL)
Disability of the Arm, Shoulder
and Hand (DASH)
Jebsen-Taylor Hand Function Test
– modified (mJTHFT)

UK

UK

N/A

UK

UK

UK

UK

UK

*

?

UK

*

UK

UK

UK

UK

N/A

UK

N/A

UK

+

UK

?

UK

+

+

N/A

N/A

+

0

(MDC 90 0.09-0.18
items/second)

?

UK

+

+

+

+

UK

UK

UK

UK

UK

0

UK

UK

UK

UK

0

MeasureABILHAND-ULA
Activities Measure for Upper
Limb Amputees (AM-ULA)PROMIS-9 Upper Extremity (UE)
Orthotics and Prosthetics Users
Survey (OPUS) Upper Extremity
Functional Scale (UEFS)

March 2022

Page 68 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Reliability Evidence
MeasureOPUS UEFS modified (Burger)
OPUS UEFS modified rating scale(Jarl)
OPUS UEFS modified 27 item
scale (Jarl)
OPUS UEFS modified 22 item
scale (Resnik)
OPUS UEFS UsePatient-Specific Function Scale(PSFS)
Prosthesis Index of Functionality(P-IOF)
Purdue Pegboard
Southampton Hand Assessment
Procedure (SHAP)
Timed Based Measure of Activity
Performance (T-MAP)
Total Skill Score
University of New Brunswick(UNB) Skill
University of New Brunswick
Spontaneity
QuickDASH

Validity

Interrater

Testretest

IRT/Rasch

Internal
consistency

Construct
ValidityNo
Floor/Ceiling

UK

UK

+

UK

+

UK

UK

UK

N/A

+

UK

N/A

UK

UK

+
(MDC 95 14.8)

UK

N/A

UK

+

N/A

+

0

UK

UK

N/A

+

UK

N/A

0

+

0
(MDC 90 12)

0

N/A

?

N/A

UK

0

+

0
(MDC 90.39)

0

N/A

UK

N/A

UK

+

+

+

UK

N/A

UK

UK

+

+

+

UK

+

N/A

UK

N/A

UK

?

UK

UK

UK

UK

N/A

*

*

Floor effects +

UK

0

UK

+

N/A

+

+

UK

UK

+

UK

UK

N/A

UK

+

UK

UK

UK

+

+

N/A

UK

+

UK

+
(MDC 90 0.8)

+

+

+

N/A

UK

+

UK

+
(MDC 90 0.7)

+

N/A

+

N/A

+

+

UK

(MDC 90 13.9)(MDC 95 17.4)(28)+

Sensitivity to change/
Responsiveness (MDC)

Overall
RatingMeasurement property rating scheme(++) Excellent = evidence from 2 or more separate studies with strong methodology supporting the property(+) Good = evidence from 1 study with strong methodology supporting the property(?) Fair = evidence from 1 or more studies with fair methodology supporting the property, more research needed

March 2022

Page 69 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation(0) Poor = evidence from poor quality study/studies, and/or results from well-constructed studies did not strongly support the property or indicated serious
issues(UK) Unknown = to date no research has been conducted on the measurement property. MDC 90 = Minimal Detectable Change at 90% confidence interval
Overall rating scheme(++) Excellent = evidence from 2 or more separate studies with strong methodology supporting both reliability and validity(+) Good = evidence from 1 study with strong methodology supporting both reliability and validity(?) Fair = evidence from 1 or more studies with fair methodology supporting both reliability and or validity, more research needed(0) Poor = evidence from poor quality study/studies, and/or results from well-constructed studies did not strongly support both reliability and validity orindicated serious issues(UK) Unknown = to date insufficient research has been conducted on measurement properties

March 2022

Page 70 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Table C-2. Utility, Elements Assessed, Content, and Evidence Rating of Upper Extremity Functional Outcome Measures

Dressing

Other daily activities

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

5-10

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

5-10

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

N

5-10

Y

Y

Y

Y

Y

Y

Y

Y

All

Y

Y

5-10

Y

Y

Y

Y

Y

Y

Y

PSFS

All

Y

Y

5-10

Y

QuickDASH

All

Y

Y

5

Y

?

DASH

Y

10-15

Y

QuickDASH

All

Y

Y

5

Y

OPUS UEFS

All

Y

N

5-10

Y

OPUS UEFS (Burger)

All

Y

N

5-10

OPUS UEFS modified
rating scale (Jarl)

All

Y

N

OPUS UEFS modified
27 item scale (Jarl)

All

Y

OPUS UEFS modified
22 item scale (Resnik)

All

OPUS UEFS Use

Difficulty/skill

Y

Y

Speed

Y

All

Burden (minutes tocomplete)

Pros

Easy to interpret score

AUI

Y
Y

Y
Y

Y

Y

Social activities

Bathing/grooming

Y

N

Recreation

Food preparation

Y

Y

Sexual activities

Eating/drinking

YAll

Use of visual feedback

10

ABILHAND-ULA

Hand grips/grasping

Y

Sleep

Y

Pain/tingling/stiffness

Y

Skillfulness of prosthetic
device use

Y

AssistanceY

Movement quality

Y

Y

Spontaneity of
prosthetic use

YAll

Task completion

Y

ABILHANDSpecial equipment(prosthesis use)

15

Easy to score

Household activities

Body Functions
Carry and handle objects

Elements Assessed

Phase of rehabilitation

Self-Report Measures

Utility

ICF Content Areas
Activities and Participation

Y

Y

Y

Y

Y

Y

Y

Y

PROMIS-9 UE

March 2022

Patient lists tasks of importance
Y

Y

Y

Y

Y

Page 71 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation RehabilitationY

CAPPFUL

Pros

Y

Y

25-35

Y

Y

Carroll test

Pros

N

Y

25 ?

Y

Y

Carroll test
(modified)

Pros

N

Y

20 ?

Y

Y

JTHF - modified

Pros

Y

Y

15+

Y

P-IOF

Pros

N

N

?

Y

Purdue Pegboard

Pros

Y

Y

5

Y

SHAP

Pros

N

N

?

Y

Y

T-Map

All

Y

Y

10-20

Y

Y

Total Skill Score

Pros

Y

Y

?

Y

UNB Skill (1 subtest)

Pros

Y

Y

20-40

UNB Spontaneity (1subtest)

Pros

Y

Y

20-40

March 2022

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Social activities

2

Y

Y

Recreation

Y

Y

Sexual activities

Y

Y

Other daily activities

Pros

Y

Dressing

BBTYY

Bathing/grooming

10-20

Y

Food preparation

Y

Y

Y

Eating/drinking

Y

Y
Y

Y

Household activities

Pros

Y

Carry and handle objects

BAM-ULAYY

Use of visual feedback

30

Hand grips/grasping

10-15

Y

Y

Sleep

Y

Y

Y

Pain/tingling/stiffness

N

Pros

Y

Skillfulness of prosthetic
device use

Pros

AM-ULAY

Body Functions

Assistance

ACMC v 2

Y

Movement quality

10-15

Spontaneity of
prosthetic use

Y

Task completion

N

Special equipment(prosthesis use)

Burden (minutes tocomplete)

Pros

Difficulty/skill

Easy to interpret score

ACMC

Speed

Easy to score

Elements Assessed

Phase of rehabilitation

Performance Measures

Utility

ICF Content Areas
Activities and Participation

Y

Y

Y
Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y
Y
Y

Y
Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y
Y

Page 72 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix D: Essential Elements of the Annual Contact
Persons with ULA should be contacted annually at a minimum. Contact can occur via telephone,telehealth visits, in-person visits, or secure messaging as clinically appropriate. Assessment of thefollowing elements should be completed at the time of the annual contact.

A. Medical Considerations·

Changes in medical status and new medical conditions·

Medication changes including the use of non-prescription supplements·

Tobacco, alcohol, or illegal substance use·

Physical activity level and exercise program·

Nutritional status and changes in weight (increase or decrease)

B. Functional Status·

Current level of functional independence and changes in functional status (mobility, ADL
function)·

Changes or new functional goals·

Need for new or replacement durable medical equipment·

Need for home or work environmental modifications·

Need for assistive technology for ADL and/or vocational support·

Need for occupational and physical therapy services to address a change in functional status,
new functional goals, or address equipment needs

C. Prosthesis-related Considerations·

Fit and function of the prosthesis·

Prosthesis utilization and barriers to greater use·

Need for replacement prosthetic components or supplies·

Need for new prosthetic componentry or technology to achieve functional goals·

Need for activity-specific prosthesis to better perform recreational or vocational activity

D. Pain and Residual Limb Considerations·

Residual limb skin condition and complications·

Pain issues (residual limb, PLP, musculoskeletal pain issues [i.e., neck, shoulder, back])·

Overuse symptoms in the proximal amputated limb or contralateral limb

E. Psychosocial Considerations·

Family and caregiver support or changes in support system

March 2022

Page 73 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

New psychosocial stressors·

New emotional, behavioral, or psychological considerations·

Recreational or community resources and support·

Vocational issues or concerns·

Leisure activity participation·

Engagement in peer support activities

F. Secondary Amputation Prevention·

Risk factors for more proximal or additional amputation

March 2022

Page 74 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix E: Advantages and Disadvantages of Prostheses
Table E-1. Advantages and Disadvantages of Prostheses by TypeNo
Prosthesis

Passive
Prosthesis

Bodypowered
Prosthesis

Advantages

Disadvantages+ Comfort (no device/harness/suspension)+ Tactile sensation through the residual limb
+ Proprioceptive feedback available throughthe residual limb

− No active prehension or mechanical grasp− Limited ability to do bimanual tasks− Increased potential for overuse injuries inthe sound limb
− Increased risk of asymmetry and back pain
− No functional grasp− Can be very expensive− Latex and PVC glove or prosthetic skinproducts stain easily

+
+
+
+
+
+
+

+
+
+
+
+
+

HybridProsthesis

+
+
+
+
+
+

ExternallyPowered
Prosthesis

Taskspecific
Prosthesis++

Lightweight
Good cosmetic appearance
Minimal harnessing
Low maintenanceNo control cables
Silicone products resist staining
Durable and can be used in tasks orenvironments that could damage externally
powered prosthesis (i.e., conditions
involving excessive water, dust, or vibration)
Secondary proprioceptive feedback
Lower maintenance costs than electric
options
Preferred for heavy duty jobs or activities
Less training required
Can be used with an activity specific TD
Simultaneous control of elbow and TD or
wrist
Lighter than fully electric elbow prosthesis
Increased grip force compared with VO
body-powered options
Advantage of electric TD and wrist operation
Proportional or variable speed grip/rotation
Advantage of electric TD and wrist operation
Potential for a more natural/ cosmetic
appearance
Potential for pattern recognition andsimultaneous control
Less shoulder motion required for TD
operation+ TD and arm allow the capability to perform
specific activities+ May have minimal harnessing+ Often has limited or no control cables+ Durable, low maintenance+ Protects primary prosthesis from damage− Harnessing over shoulder is required− Less grip force with VO TD compared withelectric options− Appearance of hook and cables− Requires a harness for elbow− Susceptible to damage from moisture orexcessive vibration− Requires battery maintenance− Increased training time
− More complicated to control; inadvertent
motions are common− Harness is required for TH level amputations− Requires battery maintenance− Typically heavier than body-powered− Repairs are more complex− Susceptible to damage from moisture orexcessive vibration− More expensive− No functional grip
− Not appropriate for a broad range offunctions− May need multiple TDs to perform different
activities

Abbreviations: PVC: polyvinyl chloride; TD: terminal device; TH: transhumeral; VO: voluntary opening

March 2022

Page 75 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix F: Surgical Considerations
A.

Surgical Considerations
a. Partial Hand Amputation

The mangled or mutilated hand is a common traumatic injury, most commonly occurring fromagricultural, industrial, household, and motor vehicle mishaps, as well as combat-related injuries. The
surgical goal is to retain or reestablish an acceptable hand, defined as “one which has three fingers ofnear normal length with near normal PIP joint motion and good sensibility along with a functioning
thumb.”(102) Because of the thumb’s functional importance, special consideration should be taken topreserve it.(103, 104) The ring and small finger are also critical for grip strength and power grasp,
essential in ADL.(105) More proximal amputation levels should be discouraged if preservation of basic
prehensile function with two sensate digits able to oppose one another may be accomplished. However,a more stable terminal pinch can be expected with preservation of the thumb and at least two
additional digits.(106) While outside the scope of this CPG, the decision to perform digital salvage versus
amputation can be difficult, and there is currently no specific algorithm or extremity scoring system toguide the surgeon. Consultation with an upper limb specialist is highly recommended, if available.
Surgeon experience, a patient-centered approach to treatment, and multi-specialty consultation all help
guide decision-making.
Amputations through the carpal bones require special consideration. Reconstruction to allow pinching
and grasping are not possible at this level. Consideration can be made to revise the amputation to awrist disarticulation or TR level. However, if the radiocarpal joint is preserved, consideration can bemade to salvage a transcarpal level when soft tissue coverage is available. The advantage of this level isthe long limb that may allow functional use for rudimentary tasks, or to assist a contralateral normal
extremity, without the need for a prosthesis. The perceived disadvantage is the same as that for wrist
disarticulation; historically, this level has been difficult to fit with a highly functional prosthesis whencompared to the TR level. However, this may be changing with advanced prosthesis technology and theemergence of hand transplantation procedures.

b. Wrist Disarticulation Amputation
The advantages of wrist disarticulation level amputation include:·

Full forearm rotation is preserved when the distal radioulnar joint (DRUJ) is preserved·

There is no risk of impingement of the distal radius and ulna as seen in TR amputations·

The large surface of the distal radius can allow weight-bearing through the terminal end·

The long sensate residual limb increases functional length·

It is a better platform for the self-suspension of the prosthesis

The main disadvantage, historically, has been limited prosthesis options due to the very short working
length between the end of the residual limb and the TD, while attempting to achieve an acceptable limb
length and cosmetic result. A survey of U.S. surgeons by Tooms (1972), before the introduction ofmodern wrist components, indicated a preference for distal TR amputations over wrist

March 2022

Page 76 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

disarticulations.(107) However, advances in prosthesis design and materials have greatly improved
function for the wrist disarticulation patient.(108)c. Transradial Amputation
The TR level amputation is the most common major ULA.(109) This level of amputation also has thehighest prosthesis acceptance rates in the upper limb. In distal TR amputations, the long lever arm,
available forearm rotation, and preserved shoulder and elbow function allow the patient to easily
position the TD and prosthesis in space. The TR amputation level is also cosmetically appealing due tothe ability to fit body-powered or myoelectric prostheses with quick-disconnecting components, whilestill maintaining equal limb lengths. When practical, at least two-thirds of the forearm should bemaintained. Removal of 6 – 8 centimeters (cm) of bone is recommended to offer a robust soft-tissue
envelope and permit a wide variety of prosthetic options. At least 5 cm of the residual ulna is required
to allow for prosthetic fitting and elbow motion.(110, 111) At this level, consideration should be madeto transfer the distal biceps tendon to the proximal ulna.(112) The obvious prosthesis and mechanicaladvantages of the TR level coupled with the superior prosthetic acceptance rates should prompt thesurgeon to consider all reconstruction options, including free tissue transfer, to preserve an amputation
at this level.

d. Elbow Disarticulation Amputation
Elbow disarticulation and distal TH amputations are functionally quite similar, with both maintaining aflare to the distal humerus allowing improved suspension and improved rotational control of a
prosthesis when compared to more proximal amputation levels. The major disadvantage of this level isthe cosmetic appearance of length inequality with the prosthetic elbow joint distal compared to thecontralateral normal elbow, or with the center of rotation placed lateral to the axis of the humerus tominimize the length inequality.(110, 113) However, the improved suspension and rotational control
usually outweigh any cosmetic considerations for most patients. Shortening osteotomy of the humerus
to improve the cosmetic result may be considered, but this is rarely indicated or performed.

e. Transhumeral Amputation
If the condyles of the distal humerus are not preserved, the ideal level for TH amputation isapproximately 3 – 5 cm proximal to the elbow joint. Adequately suspended and standard prosthetic
components are expected at this level, but rotational control is decreased compared to elbow
disarticulation. Anterior angulation osteotomy, described by Neusel et al. (1997), can be performed tothe distal humerus to improve the rotational stability of the prosthesis while still allowing a free-moving
shoulder.(114) The osteotomy is generally angulated 70 degrees anterior, and fixation with either interfragmentary screw fixation, or a compression plate and screw construct is performed.
With a proximal TH amputation level, maintenance of length is critical, with most sources
recommending the preservation of at least 5 – 7 cm of length from the glenohumeral joint to preserve
maximum function. As in the TR amputation level, the use of dermal substitutes, skin grafting, and local
and free flaps are strongly considered to preserve adequate length.(115) Preservation of the deltoid,
pectoralis major, and latissimus dorsi insertions to the humerus will allow for body-powered or
myoelectric prosthesis control.

March 2022

Page 77 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

f. Shoulder Disarticulation Amputation
Amputation proximal to these named tendon insertions will functionally result in a shoulder
disarticulation level amputation. In such instances, preservation of the humeral head will improve body
contour and the cosmetic result of the amputation as well as possibly aid in force transmission during
prosthesis use. Unless stabilizing myodesis can be performed with available muscles, the unopposed pullof the rotator cuff muscles may result in painful or disfiguring abduction contracture or subluxation. As aresult, glenohumeral arthrodesis, often as a planned, staged procedure, is strongly recommended.(108,111, 113)

g. Forequarter Amputation
Forequarter amputation consists of removal of the entire upper limb plus the scapula, part or all of theclavicle, and potentially part of the chest wall, typically as treatment for solid tumors. Free flaps,
harvested from the amputated limb, are a reliable method for wound closure.(116) Preservation of asmuch of the shoulder as possible will enhance cosmesis and fitting for any prostheses. The primary
purpose of a prosthesis in this group is to protect the chest wall; rehabilitation and prosthesis fit ischallenging.(117) While rare, traumatic forequarter amputations do occur. The majority of those aretraction injuries although other etiologies can include direct trauma to the upper quarter.(118) These
cases present greater management difficulties as there may not be an amputated limb or viable tissue
available to harvest for wound closure.

h. Surgical Muscle Balancing Strategies and Wound Closure Techniques
Myodesis, the process of attaching muscle tendon units directly to the bone, is the surgical techniquethat provides the most stable construct over the distal bone end. This is typically achieved by suturing
the muscle and/or tendon to the bone end, usually through drill tunnels, or less commonly, to theperiosteum. Myoplasty, attaching agonist muscles to antagonist muscles over the bone end to create
physiologic tension, and myofascial closure, or suturing of muscle and fascia together, are less stable
constructs that may be indicated when myodesis cannot be achieved for secondary muscles once
primary myodesis is performed, or to contour remaining muscles before closure. While there is no data
to support the superiority of myodesis over myoplasty, the expert consensus is myodesis in ULA
provides the most stable residual extremity and best isolates muscle signals for use in myoelectric
prosthetic control.
Stabilizing the muscle-tendon units of the residual extremity near physiologic tension at the time of
amputation closure serves two main purposes. First, it provides robust coverage over the distal bone
end, providing comfortable padding for the prosthetic socket while preventing the formation of painful
bursa from mobile muscle units. Second, optimal contractility characteristics of the muscle arepreserved, improving muscle signal quality, and maximizing myoelectric prosthetic control.
Local tissue flaps or free tissue transfer should be considered in the following cases to preserve:·

A functional shoulder joint and a TH amputation level·

A functional elbow joint and a TR amputation level·

A partial carpal or hand amputation level for future reconstructive efforts

March 2022

Page 78 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

When residual tissue flaps are inadequate to provide distal amputation coverage, and shortening willdiminish prosthetic fitting and functional outcomes, additional soft tissue coverage options, including
skin grafts and flaps, should be strongly considered. This is perhaps most important in shoulder andelbow joint preservation and when optimizing the length of the TH and TR amputation.
Studies have demonstrated that residual extremities can still have excellent function with a terminal
skin graft, provided otherwise robust soft tissue coverage is present. The use of dermal substitutes as an
adjunct to skin grafting has proven successful in ULA, providing a more durable skin graft prosthetic
interface, and allowing direct surgical approaches for future reconstructive procedures.(119, 120)
The use of microvascular free tissue transfer in well-selected patients to maximize length and provide
durable soft tissue coverage has been successful in ULA.(115, 121, 122) Indications for free tissuetransfer include:·

Shoulder joint preservation by preserving a TH amputation level·

Elbow joint preservation·

Preservation of bone greater than 7 cm below the shoulder or elbow·

Preservation of a partial hand or carpal level amputation to allow for future reconstructive
surgery

Relative indications include wrist joint preservation and skeletal preservation between 5 – 7 cm below
the shoulder or elbow. While ULA requiring skin grafts or flaps will take longer to heal, the functional
benefits of joint and/or length preservation will usually outweigh any delays in rehabilitation andprosthetic fitting.

B.

Emerging Surgical Techniques

At this time, some emerging surgical techniques may support greater patient function, reduce pain, andintegrate with evolving technological advances in prosthetic devices. These techniques show promise inearly studies but may not yet be considered standard of care. Providers need to be aware that suchprocedures exist and understand that there are implications for length and type of rehabilitation, typesof prostheses, and other considerations over the continuum of care.

a. Targeted Muscle Reinnervation
Targeted muscle reinnervation involves “transferring distally innervating peripheral nerves from muscles
that are no longer present or functional to more proximal available or functional musculature.”(123)This technique allows the creation of up to six sites for myoelectric control of the prosthesis.(36)
Emerging research shows additional potential for reduced PLP and residual limb pain, although some of
the risks involved in TMR include neuromas of the dissected nerve, local wound problems, andcompromised limb/socket interface due to scarring or hypersensitivity.(123, 124)b. Regenerative Peripheral Nerve Interface
The RPNI is another form of neural interface that may decrease neuroma formation, post-amputation
pain, PLP, and sensation.(125) The described procedure involves implanting the free end of a transected
peripheral nerve into a segment of free autologous muscle. This surgical procedure can be performed

March 2022

Page 79 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

prophylactically at the time of the index amputation or as a staged procedure for symptomatic
neuromas.

c. Agonist Antagonist Myoneural Interface
The AMI is another emerging technology in limb amputation surgical management that has shownpromise to improve patient outcomes by providing bidirectional neural feedback and proprioceptive
feedback in the residual limb.(126) This theory was developed using a rat animal model to connect
agonist and antagonist muscles in the healthy tissues of the distal residual limb following
amputation.(126, 127) The first description of AMIs being used in the human extremity was a case seriesof three below the knee amputations (BKA) with encouraging results for increased proprioception of the
distal residual limb and decreased PLP.(128) Although trialed in persons with ULA, there is currently no
published literature supporting the safety or outcomes of the AMI procedure in this population.(129)d. Osseointegration
For the attachment of the prosthesis to the residual limb, OI has been used in Europe for more than 20
years for both lower and upper extremities and in the U.S. for over a decade. This includes emerging
work with osseointegrated digits.(123, 129-131) It involves inserting a titanium implant into the distalbone of the residual limb. A percutaneous implant component allows the prosthesis to attach directly tothe skeleton without the use of a socket. As a result, the residual limb is free of skin complications
commonly associated with the use of a socket suspension system and is available for tactile feedback.
The inclusion criteria for this procedure include skeletal maturity, sufficient bone stock to support the
fixture, and the ability to complete rehabilitation.(132) Minor complications are most common, such assoft tissue infections, and may be mitigated in the future by improvements in surgical technique andimplant design.(133)

March 2022

Page 80 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix G: Control Strategies for Body-Powered and ExternallyPowered Prostheses
A.

Control of a Body-Powered Prosthesis

A body-powered or cable driven prosthesis is controlled by one’s own body motions. Depending on thelevel of amputation, gross muscle movements are captured by a cable traversing from a harness to theTD.(134, 135) Specific combinations of proximal motions produce tension through the cable that results
in prosthetic function.
For a TR amputation patient, glenohumeral flexion and scapular protraction will produce TD function. It
is important to train the patient to minimize motions of the contralateral shoulder and scapula to allow
for optimal control of a unilateral prosthesis.(134)
For a TH amputation patient, the cable from the harness to TD will pass through an anchor(s) near the
elbow joint. Glenohumeral flexion and scapular protraction will produce elbow flexion when the elbow
is unlocked and TD open or closed, depending on the type of TD used (voluntary open or voluntaryclose).(134, 135) Locking and unlocking of the elbow unit is captured through a strap attached to theharness and routed to the anterior aspect of the shoulder into the elbow unit. The application of tension
through the locking strap locks the elbow and unlocks the elbow. Locking the elbow unit in various
positions is achieved with oblique glenohumeral extension of the residual limb and scapular
depression.(136) To unlock the elbow, the locking strap must recoil first and then the same motion forlocking is used to unlock.(135) The elbow will not lock if tension has not been removed from the locking
strap which is achieved through scapular elevation with the shoulder in neutral or slightly flexed. For
new users, glenohumeral abduction may be exaggerated during glenohumeral extension and scapular
depression to lock or unlock the elbow however as proficiency improves abduction will be used lessfrequently.(134)

B.

Control of an Externally Powered Prosthesis

An externally powered prosthesis is one characterized by at least one motorized joint, powered througha battery, and actuated by the user through one or more control inputs.
The most common control inputs for externally powered prostheses are electromyography (EMG)
surface electrodes embedded into the socket. Externally powered prostheses that utilize EMG
electrodes are commonly referred to as “myoelectric” prostheses. The EMG electrodes can be thoughtof as antennae that pick up the electrical signal given off by muscle tissue as it contracts. These signals
are then amplified and converted into commands used to control the movement of a given motorizedjoint. Adjustments and programming are possible using various software packages, specific to theprosthesis product being used.
It is important to understand that EMG sites are not required to consider externally powered
components. Other control inputs, such as force sensitive resistors (FSRs), linear transducers, toggle androcker switches, and inertial measurement units (IMUs) are available to increase the potential for using
externally powered joints.

March 2022

Page 81 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Depending on the level of amputation, types of components, and number of available “joints” that makeup the myoelectric prosthesis, various control strategies may be utilized. The control strategy is themethod used to translate the user’s intent, with regards to operating the prosthesis, by converting that
intention into an electric signal and using that electric signal to actuate a particular motion of a powered
joint. Various control configurations can be programmed into the prosthesis by the prosthetist with
input from the patient and therapist. They include sequential, and/or simultaneous, control strategies.
Sequential control refers to a system where each joint is controlled by the same input signals and theuser must cycle through each “mode” (e.g., “hand mode,” “wrist mode,” or “elbow mode”) to get to thejoint motion they wish to control. To switch from one mode to another, the control configuration may
involve strategies such as co-contraction of two myosites, use of a hard/fast versus a soft/slow
contraction, use of a separate input. Alternatively, it may be set to automatically switch to a specificmode after a predetermined time delay.
Simultaneous control refers to the use of additional control inputs that can be designated for specificmovements. The most common example is that of a powered TH prosthesis that uses a linear transducer
to control a powered elbow and two antagonistic myosites that are programmed to control thepowered TD and/or wrist. This setup allows the user to simultaneously activate the elbow with the TD or
wrist since the elbow is always active. Control of the wrist and TD would be navigated using a sequential
strategy as described above.
Electromyography pattern recognition systems designed for use with prostheses may improve the abilityof a patient with ULA to obtain more intuitive control of externally powered prostheses. Patternrecognition systems utilize an array of numerous surface EMG electrodes and are capable of discerning
more diverse muscle contraction patterns, as compared to the traditional single-site or dual-site set ups.
The patterns can be differentiated and assigned to specific motor commands of the externally powered
prosthesis using computer software. Pattern recognition may benefit patients with higher amputationlevels and those who have undergone TMR.(137-139)
Another developing control strategy option is that of “end-point control.” This strategy allows the user
to actuate multiple powered joints, in simultaneous coordinated movement, to bring the TD to a desired
point in space. Inertial measurement units or EMG pattern recognition inputs are more suited for thiscontrol. As an example, an externally powered upper limb prosthesis which includes a powered
shoulder, elbow wrist, and hand has a large number of powered degrees of freedom. Rather than plan
the motion of each powered joint to get the prosthetic TD into a desired position, the control
commands, using endpoint control, may be simplified as “hand up/down,” hand left/right,” “handforward/back,” etc. Endpoint control reduces the number of required control inputs in the system andcan enable coordinated movement of the shoulder, elbow, wrist, and hand. This control strategy
provides an alternative reference point for prosthetic control and provides the potential to improveanthropomorphic movements in prostheses for more proximal levels of limb loss.(140)

March 2022

Page 82 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix H: Training for Body-Powered and Externally Powered
Prostheses
A.

Overview of Training

Quality training in the use of a prosthesis is essential to ensure the best outcomes for the limb loss
population. Occupational and physical therapists train the limb loss patient from basic operation of thedevice up to seamless incorporation of the device in complex tasks without having to think about
movement. Coaching and practice assists the patient in motor relearning, normal quality of motion,
anticipatory skills, and carry over of learned techniques to a variety of tasks. Among other goals, therapy
aims to teach the patient how best to operate a prosthetic device and how to analyze tasks toincorporate the device into daily activities. The real skill of prosthesis training comes in the patient
looking at the environment with a critical eye of anticipating how the prosthesis will best assist themand or how to adapt to the environment. Having another efficient functional grasp helps the patient be
more functional as well as gives them a sense of fulfillment. If a patient has learned the following
essential skills with a trained professional, then they have achieved a level of competence and areencouraged to use or not use a prosthesis at their discretion. The following is a general guideline forclinicians to follow to ensure general concepts are covered in training.

B.

Residual Limb Management·

Scar massage and desensitization: Important for reducing scarring and preparing to tolerateweight and pressure of a socket. This also serves to make them aware of any sensitive areas of
their residual limb.

·

Therapeutic exercise for residual limb: Use of cuff weights, theraband, or strap with metal D-ringfor use with cable machine.
¨··

Important to initiate in preparation for a prosthesis. Promotes tolerance of the weightof the prosthesis, pressure, and muscular endurance for long-term wearing.

ROM:¨

Prevent loss of ROM in the proximal joints of the residual limb initiate early inrehabilitation.

¨

Myosite deep pressure massage to stretch muscle site.

¨

Stretching of residual musculature is important long-term to ensure symmetry due tocompensatory movements, loss of weight of the limb, and less use of the distal extremity.

Strengthening:

March 2022¨

Increase strength to tolerate weight of a prosthesis with use of cuff weights or cablemachine to strengthen and desensitize the residual limb.

¨

Strengthening proximal joints will promote symmetry and may decrease atrophy to theaffected limb.

¨

Postural training, exercise, and yoga/pilates may prevent pain and deformity due toasymmetry.

Page 83 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

C.

Skin checks and wearing schedule:¨

Limit prosthesis wear time to 1 to 2 hours initially, then increasing an hour or so every
few days.

¨

Monitor skin for signs of excessive pressure, blister, or wound formation. This isespecially important if there is impaired sensation or skin grafts.

¨

Use a mirror to self-monitor daily.

Prosthesis Training Concepts

Prosthesis training provides the opportunity for a patient to become familiar with the device andprogress to a level of expertise. Patients should be encouraged to experiment through this process withhow tasks are performed and be assisted with determining how the device may best assist theindividual. The ability to accurately control a device may vary from person to person and from body
powered to myoelectric, but the therapist’s role is to help each individual identify appropriate
challenges and have realistic expectations in task performance. Expectation management andappropriate sub-task selection is key to success. Therapists are encouraged to review these concepts
with their patients to ensure covering the necessary skills (see below).
··

Control of prosthesis: operating all joints individually and combined.
¨

Body powered: teach the patient to operate all device motions by gross body
movements. Challenge patient to operate the device at various heights and distancesaway from the body¨

Myoelectric: begin by using software programs to maximize control accuracy, especiallyfor patients with more complicated muscle activation controls like quick/slow,
double/triple impulse, linear potentiometer, and pattern recognition.
oPerform accuracy testing: have the patient perform four motions of wrist andTD outlined below. Repeat three times for open, rotate clockwise, close, androtate counterclockwise. Then record if they were a) correct, b) performed thewrong motion/stalls with number of attempts, or c) were unable. The individual
1) opens the TD ¾ of the full finger extension, 2) supinates 180 degrees,3) closes TD to ¼ extension, and 4) pronates 180 degrees. This is repeated threetimes and the therapist should cue the patient to the next motion, so they don’t
have to guess the next motion. The clinician can make a list of 1 to 12, markwhen there is an error or delay and get a percentage of accuracy by dividing thecorrect motions from the 12 motions to track progress over time.

oMake sure to involve the prosthetist as they may have more adjustments
available to improve myoelectric signal and control.

Quality of movement: teach the patient to maintain supporting joints in the appropriate
positions to prevent strain and awkward movements. Use mirrors and therapist cues to help
patients be aware of compensatory movements such as shoulder hiking, extreme shoulder
flexion, elbow abduction, or excessive internal humeral rotation. Therapist cues, mirrors, andvideo feedback (with patient permission) may be used so patients learn to maintain thoracic

March 2022

Page 84 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

spine extension, ensure scapular retraction/depression, keep the elbow adducted, and avoid
aberrant compensatory movements listed above.
·

Prepositioning: educate the patient to anticipate the appropriate position that the prosthetic
devices need to be in for optimal engagement in a selected task. For example, make sure when
preparing to grasp that the tines or fingers face the appropriate direction to optimize grasp. Or
more explicitly, having the prosthetic hand open and rotated to face the intact hand prior toreceiving an object from the other hand.

·

Rote tasks:

·

·

·

¨

Pass objects to and from prosthesis to contralateral hand in different positions. Do thiswithout vision, behind the back, between the legs, and in all positions of elbow andshoulder movement.

¨

Grasp and release objects in various planes of movement to optimize use of theprosthesis for all tasks.
oBody powered difficulties: operating with full elbow flexion, shoulder at 90
degrees of flexion, overhead, or behind back. Patients should be educatedabout the 3-dimensional functional envelope for using the prosthesis (the areaaround the body where the prosthesis can be operated most easily) in front of
them.

o

Myoelectric power difficulties: overhead, reaching, holding heavy items, andmaintaining grasp to prevent dropping items.

Experiment with use of the TD with bilateral tasks: have the patient try to perform bilateraltasks (see below task list) in a few different methods/strategies and see what works best forthem. Discuss advantages and disadvantages of performance, focus on efficiency of movements.
¨

Tying shoe or lacing board: have the patient identify how many pinches are the mostefficient and how fast they can perform once they find the best method.

¨

Try performing other tasks three different ways and discuss what works best.

Adjustments to the arm: patients should learn, when appropriate, how to adjust the prosthesisor prosthetic control system and master the subtleties of control.
¨

Body powered: how to adjust control cable length. How to tighten or lock TD in place.
Pad or prevent chafing from prosthesis. How to repair a broken control cable or strap.

¨

Myoelectric: how to alter gain of the electrodes. When to turn the device off or disablefeatures, such as turning off the hand/wrist or locking a joint.

¨

Sockets: how to relieve or change pressure from the socket or strapping and how tomake various socket suspension adjustments.

Holding objects while performing tasks. Developing trust and learning where and when tasks
can be performed consistently. Three points of control on the object is optimal.

March 2022¨

Holding coffee while operating keys and open door.

¨

Holding stabilizing utensil while cutting.

Page 85 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·¨

Leather lacing tasks.

¨

Beading strings.

¨

Cutting fruit and placing on a wooden skewer.

Dexterity: encourage performing things rapidly to increase efficiency and improve function.
¨

Timing simple tasks with a stopwatch such as stacking cones or moving blocks.

¨

Asking the patient to anticipate how long it will take to perform a particular task and see
if they were correct.

¨

Challenge the patient to find a way to perform faster or compete for fun against another
patient.

·

Light touch: practice performing light touch to prevent deforming or breaking certain objects.
Can be performed with foam blocks or thin disposable plastic cups.

·

Performing tasks without vision, such as in the dark or with vision excluded to facilitate
proprioceptive knowledge and skill with TD in space. For example, tasks such as: don/doff glove,
pants, shirt, jacket, and tie shoes.

·

Rote complete task performance: more practice with repetitive tasks to increase automatic
performance and increase dexterity·¨

Folding laundry/towels, washing dishes, cleaning tasks, vacuum, or sweeping.

¨

Wallet management tasks, filing files, lacing, or sewing tasks.

Bimanual task list: therapist reviews the list of activities in Table H-1, identifies meaningfulactivities to the patient, and then coaches and discusses what approaches are efficient and whatworks best for the patient. Therapist discusses strategies for adapting tasks or objects to beadapting tasks or objects to be adapted to perform tasks more easily.

Table H-1. Prosthetic Training: Bimanual Task List
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

Bimanual Task List
Feed self with utensils· Clean prosthesis
Cut food with knife· Don/doff prosthesis
Open variety of food packages· Re-charge batteries
Eat finger foods· Change TD
Drink from cup or bottle· Remove/apply harness
Don/doff bra· Turn prosthesis on/off
Don/doff pull-over shirt· Apply compression garment or sleeve
Dress button-down shirt: cuffs and front· Skin care management – visual inspection
Manage zippers and snaps· Wash clothes
Don/doff pants· Hang clothes
Don/doff belt
· Fold clothes
Don/doff socks· Set up ironing board
Don/doff shoes, boots· Iron clothes
Lace and tie shoes· Hand wash dishes
Screw/unscrew cap of toothpaste tube
· Dry dishes with a towel
Squeeze toothpaste· Load and unload dishwasher

March 2022

Page 86 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

Bimanual Task List
Use toothbrush to brush teeth· Use broom and dustpan
Floss teeth· Operate vacuum cleaner
Open/close bottle of pills or pillbox· Use wet and dry mop
Manipulate pills· Sweep/mop the floor
Shave· Dust the furniture
Perform residual limb care
· Clean countertops
Wash back· Clean the toilet/sink/tub
Apply deodorant· Make bed/change sheets
Wash/dry hand
· Change garbage/trash bag
Bathe/dry upper body
· Open/close jar – tight or new
Bathe/dry lower body
· Open lid of can
Wash/blow dry hair
· Cut vegetables
Blow nose· Peel vegetables
Toilet paper management· Peel banana
Feminine hygiene· Crack an egg
Flushing toilet· Stir food in bowl
Wipe self· Manipulate hot pots
Apply lotion· Turn an egg or pancake with spatula
Apply make-up· Use measuring cups
Clean fingernails· Use measuring spoons
Cut and file fingernails· Scoop ice cream
Polish fingernails· Use toaster
Use/remove contacts· Open pop-top
Place and remove glasses· Wrap/unwrap food in foil and or plastic wrap
Patient specific tasks· Put dishes in overhead cabinet
Open/close safety pin· Pour milk from carton
Change diapers· Use mixer
Brush/arrange child’s hair
· Use lock-type plastic bags
Use phone and take notes simultaneously· Light a match
Operate door knob
· Sew a button
Place chain on chain lock· Turn key in lock
Plug/unplug cord into wall outlet· Carry a suitcase
Set time on watch· Operate window blinds
Receive change/ count coins· Open pet food container
Remove keys or wallet from pocket· Attach and hold dog leash
Take dollar bill from wallet· Change litter box
Write signature· Fill water dishAnswer phone· Play cards or board game
Text message on cell phone· Operate TV remote control
Open mail· Manipulate radio
Hold/turn pages of paperback, magazine, newspaper · Use computer: typing, mouse
Operate lamp
· Use CD/DVD player
Use an umbrella· Grocery shopping – push a cart, load, unload
Change a light bulb
· Carry grocery bags
Hang a picture· Use vending machine
Use scissors· Make change/receive change
Use ruler· Use ATM
Remove and replace ink pen cap· Use public transportation

March 2022

Page 87 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

·
·
·
·
·
·
·
·
·
·
·
·
·
·
·

Sharpen pencil
Fold and seal letter
Use paper clip
Use stapler
Thread a needle
Wrap package
Carry a tray
Don/doff pantyhose
Tie a tie or scarf
Don/doff glove
Assembling a tent
Rowing a boat
Mowing lawn
Painting a room
Construct a moving box

Bimanual Task List
· Open and close car doors, trunk, and hood
· Perform steps required to operate vehicle· Open/close gas cap and door
· Operate gas pump
· Fill windshield wiper fluid· Test level and add oil· Wash windows· Scrape ice/snow from car· Fasten/unfasten seat belt
· Start ignition· Making a fire in a fire pit· Cooking on a grill· Weed whacking/hedge trimming· Setting up and climbing a ladder· Operate controls

Abbreviations: TD: terminal device·

Compare and contrast different TDs and advantages/disadvantages with a variety of tasks.

·

Unilateral performance with prosthesis: increases proficiency with control and creative use of
the prosthesis with more complex challenges.

·

·

¨

Eat a snack and drink with only the prosthesis.

¨

Using a key to unlock a door.

¨

Build a construction task only with the TD like Lincoln Logs or large LEGO bricks.

¨

Make a sandwich or cook an egg with only the prosthesis.

Adaptive sports/fitness/recreation/leisure tasks:¨Complex, multi-step tasks such as setting up a campsite and tent.

¨

Activity specific devices for specific sports or activities. How to find a way to make otherdevices work if needed.

¨

Educate patient on how to incorporate prosthesis into high level fitness tasks.

¨

Select whole tasks to be performed and how to perform them, such as going camping,
going to the beach, packing for a picnic, taking photographs, and planning to go on
vacation with devices needed.

¨

Practice return to meaningful recreational or leisure tasks that the patient may want toresume performing.

Multitasking with prosthesis: increase cognitive load to increase difficulty to process prosthesis
use.

March 2022¨

Make a three-course meal simultaneously.

¨

Perform a construction task quickly while listening to a podcast. Attempt to remember
all details of the podcast to be questioned after task completion.

Page 88 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation··

Adapting tasks or objects for success with prosthesis.
¨

Increase or reduce friction of some objects with use of self-adherent wrap (e.g.,
CobanTM), DycemTM non-slip, or moisturizer.

¨

Prevent scratching from metal hooks by adding rubber tubing to prosthesis tines.

¨

Adding built up foam handles or making custom interface to allow grasp to be
performed easier with prosthesis and prevent rotation of the object in the device.

Work tasks: practice set up and performance.
¨

D.

Ergonomics assessment and look at how to incorporate prosthesis into office tasks while
ensuring good body mechanics.

Education Topics

Medical providers should take every opportunity to educate patients early and often throughout therehabilitation process. The patient can make informed decisions when educated about prostheses andvarious prosthetic limb options for control and function. However, the information presented must not
be overwhelming for the patient. These topics serve to stimulate awareness about the field of
prosthetics to encourage the patient to advocate for their needs and seek out answers to the many new
physical challenges they face daily.
·

Scar massage·

Adaptive equipment·

How prosthetics realistically assist function·

How to protect and decrease stress on an intact limb·

The importance of humor in recovery·

The importance of peer support and success stories·

Casting and prosthesis fitting process·

Prosthesis suspension types·

How to best exercise, stretch, and strengthen·

Educate about the muscles involved in operation of devices·

How myoelectric prostheses operate·

How myoelectric software can identify a switch between prostheses actions (quick/slow, cocontraction, double/triple impulse)·

Pattern recognition systems such as CoApt and Myo Plus from Otto Bock·

Clarify that although there are more devices and control systems available, using microvolts
traveling in muscles to act as switches is not a perfect system. Errors happen and precise control
is not guaranteed.

·

Review safety and situations that would be dangerous, such as holding on to heavy machinerywithout a way to automatically release/open TD

March 2022

Page 89 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation·

Types of TDs for body powered or myoelectric prostheses·

Advantages and disadvantages of different TDs

March 2022

Page 90 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix I: Patient Focus Group Methods and FindingsA.

Methods

VA and DoD Leadership recruited nine participants for the focus group, with support from theChampions and other Work Group members as needed. While participant recruitment focused on
eliciting a range of perspectives likely to be relevant and informative in the CPG development process,patient focus group participants were not intended to be a representative sample of VA and DoD
patients. Participants were not incentivized for their participation or reimbursed for travel expenses.
The Work Group, with support from the Lewin Team, identified topics on which patient input was
important to consider in developing the CPG. The Lewin Team developed, and the Work Groupapproved and patient focus group guide covering these topics. The focus group facilitator led thediscussion used the guide to elicit the patients’ perspectives about their treatment and overall care.
Given the limited time and the range of interests of the focus group participants, not all questions wereaddressed.

B.

Patient Focus Group Findings
a. Participants believed that an individualized rehabilitation plan is critical,
including goals, prescribing prostheses to achieve functional goals, patient
education, and pain management. Patient-provider communication is extremely
important in identifying an optimal set of physical/occupational therapies andprostheses.
·

Participants reported difficulty seeking and finding information related to ULAs, including
information on prosthetic devices.

·

Participants emphasized the importance of communicating their functional goals with theirproviders and having these goals supported and achieved throughout their ULA rehabilitation.

·

Two participants expressed disfavor for testing and assessments (e.g., box and blocks) during
rehabilitation as these diagnostic tools did not parallel their ADLs.

·

Two participants noted that pain management is an important component of rehabilitation.

b. Participants strongly valued peer support and emphasized the importance ofconnecting with peers who have similar experiences, amputations, andfunctional goals. Informal peer networks also provide a useful forum forsharing information about real-world adaptation to upper extremity
amputations, accomplishing ADLs/functional goals, coping with limitations, andas a source of information on devices and prosthetic choices.
·

Participants reported that it is important to feel understood and connected following ULAL.

·

Participants reported relying on peer support networks for advice and information.

·

Participants reported it is important to be matched with peers who have similar experiences,
amputations, and functional goals.

March 2022

Page 91 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitationc. While participants valued having a range of prosthetic devices available to meettheir varied functional needs, they noted fitting was often challenging, leadingsome to discontinue prosthetic use.
·

Participants valued having a range of prosthetic devices available to meet their uniquefunctional goals.

·

Participants shared struggling with prosthetic fit and function and noted this is an ongoing topic
of discussion with their providers.

·

Generally, participants reported prosthetic functionality is more important than cosmesis.

·

Several participants reported discontinuing use of one or all of their prosthetic devices.

d. Participants stated that they did not wear their prostheses all day since theyfound some activities easier to do without a device by adapting to theiramputation. Generally, participants reported prosthetic functionality was more
important than cosmesis. Women reported finding prostheses to be toolarge/sized for men and too heavy for their body habitus. Women asked forprostheses to be designed for a woman’s body size and muscle strength.
·

Some participants reported discontinuing use of one or all of their prosthetic devices.

·

Generally, participants reported prosthetic functionality is more important than cosmesis.

·

Female participants requested prostheses to be designed for their body sizes and muscle strength.

e. Participants reported that a team-based approach to care is important,including pre-surgical coordination between surgeons, prosthetists, nurse casemanagers, and occupational and physical therapists. Participants also reported
valuing regular, private, in-person consultation with their prosthetists.
·

Participants emphasized the importance of pre-surgical prosthetic consultations when possible.

·

Participants also emphasized the importance of defined clinical care coordinators, such as nurse
case managers.

·

Participants also reported valuing regular, private, in-person communication with their providers.

f. Participants reported that adaptive sports programs and behavioral healthinterventions were valuable additions to routine occupational and physicaltherapy.
·

Participants valued adaptive sports programs and other physical activities.

·

Although participants valued the opportunity to participate in behavioral health interventions,few did.

·

Except for children and in some cross-cultural contexts, participants reported facing minimal
stigma regarding their amputation.

March 2022

Page 92 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix J: Evidence Table
Table J-1. Evidence Tablea,b,c,d#

Recommendation

1.

There is insufficient evidence to assess the impact of the level of amputationor amputation surgical procedure type on functional status and prosthesisrelated outcomes.

2.

3.

4.

a

b

c

d

For patients undergoing upper limb amputation surgery, there is insufficientevidence to recommend the use of any particular factors to predict the speed
and quality of wound healing, successful prosthesis fitting, or need forrevision surgery.
There is insufficient evidence to recommend for or against the use of any
particular recent treatment advances including hardware, software, surgical,
technology, or supplemental surgical interventions, such as:· targeted muscle reinnervation (TMR)· regenerative peripheral nerve interfaces (RPNI)· vascularized composite allotransplantation (VCA)· agonist-antagonist myoneural interface (AMI)· implantable myoelectric sensor system (IMES)· osseointegration (OI)
There is insufficient evidence to recommend for or against any particulartraining protocol to improve function and outcomes.

2014 Strength of
Recommendation
Not applicable2022 Strength of Recommendation
Evidence Recommendation
Category(24-28)Additional
Neither for nor
Reviewed, Newreferences:againstadded(29)

Not applicable

Additionalreferences:(30-33)Neither for nor
against

Reviewed, Newadded

Not applicable(34-36)
Additionalreferences:(37-42)Neither for nor
against

Reviewed, Newadded

Not applicable

Additionalreferences:(43-46)Neither for nor
against

Reviewed, Newadded

2014 Strength of Recommendation column: “Not applicable” indicates that the 2022 VA/DoD ULA CPG recommendation was a new recommendation, and therefore does
not have an associated 2014 strength of recommendation.
Evidence column: The first set of references listed in each row in the evidence column constitutes the evidence base for the recommendation. To be included in the evidencebase for a recommendation, a reference needed to be identified through a systematic evidence review carried out as part of the initial development or update of this CPG.
The second set of references in the evidence column (called “Additional References”) includes references that provide additional information related to therecommendation, but which were not identified through a systematic evidence review. These references were, therefore, not included in the evidence base for therecommendation and did not influence the strength and direction of the recommendation.
2022 Strength of Recommendation column: The 2022 VA/DoD ULA CPG was developed using the GRADE approach to determine the strength of each recommendation.
Refer to the Grading Recommendations section for more information.
Recommendation Category column: Refer to the Recommendation Categorization section for more information on the description of the categorization process and thedefinition of each category.

March 2022

Page 93 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation2014 Strength of
Recommendation

Evidence

We suggest the use of mirror therapy for the short-term reduction ofphantom limb pain.

Not applicable(47-49)

Weak for

Reviewed, Newreplaced

6.

There is insufficient evidence to recommend for or against any particulartreatment setting, intensity, or service delivery model.

Not applicable

Additionalreferences:(50, 51)

Neither for nor
against

Reviewed, Newreplaced

7.

For patients with major unilateral upper limb amputation (i.e., through or
proximal to the wrist), we suggest use of a body-powered or externally
powered prosthesis to improve independence and reduce disability.

Not applicable(29, 52-57)

Weak for

Reviewed, Newadded

8.

There is insufficient evidence to recommend for or against any specificcontrol strategy, socket design, suspension method, or component.

Not applicable(29, 52-57)

Neither for nor
against

Reviewed, Newadded

9.

There is insufficient evidence to recommend for or against a particularintervention for the prevention of phantom and/or residual limb pain.

Not applicable

Neither for nor
against

Reviewed, Newreplaced

There is insufficient evidence to recommend for or against any particular
10. pharmacologic intervention for the management of phantom and/or residual
limb pain.

Not applicable

Neither for nor
against

Reviewed, Newreplaced

There is insufficient evidence to recommend for or against the use of noninvasive brain stimulation for the management of phantom limb pain.

Not applicable(47-49)Neither for nor
against

Reviewed, Newadded

Not applicable(26, 28, 62)

Neither for nor
against

Reviewed, Newadded

Not applicable(52, 63-73)

Weak for

Reviewed, Newadded

Not applicable(74)
Additionalreferences:(75)

Weak for

Reviewed, Newreplaced#

Recommendation

5.

11.

There is insufficient evidence to recommend for or against the use of any
specific assessment tool to guide the determination of prosthetic candidacy,
12.
the need for therapy, or for identifying improvement or worsening offunction and quality of life.
We suggest screening patients for cognition, mental health conditions such
13. as posttraumatic stress disorder and depression, and pain during the initial
evaluation and across the continuum of care.
14. We suggest offering peer support services.

March 2022

Additionalreferences:
(58)
(59)
Additionalreferences:(60, 61)2022 Strength of Recommendation
Recommendation
Category

Page 94 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix K: 2014 Recommendation Categorization Table

a
b
c

d

e

f

2014 CPG
Recommendation
Category

2022 CPG
Recommendation
Category

2022 CPG
Recommendation #2014 CPG Strength of
Recommendation2014 CPG
Recommendation #Table K-1. 2014 UEAR CPG Recommendation Categorization Tablea,b,c,d,e,f

1.

An interdisciplinary amputation care team (care team) approach, including the patient, family
and/or caregiver(s), is recommended in the management of all patients with upper extremity
amputation.

ExpertOpinion-Not reviewed,
Deleted-2.

Care teams should communicate on a regular basis to facilitate integration of a comprehensive
treatment plan.

ExpertOpinion-Not reviewed,
Deleted-

3.

Comprehensive interdisciplinary assessments and reassessments should be completed during eachof the first three phases of care (perioperative, pre-prosthetic and prosthetic training).

ExpertOpinion-Not reviewed,
Deleted-4.

Annual comprehensive interdisciplinary screening should be conducted for all patients with an
upper extremity amputation throughout lifelong care.

ExpertOpinion-Not reviewed,
Deleted-

5.

Functional status measures should be utilized during assessments and reassessments throughout
all phases of care to document outcomes and monitor the efficacy of rehabilitation.

ExpertOpinion-Not reviewed,
Deleted-

6.

A shared decision making model, incorporating patient goals, should be used throughout all phasesof rehabilitation to ensure patient-centered care.

ExpertOpinion-

Reviewed,
New-replaced

6

2014 CPG Recommendation Text

2014 CPG Recommendation # column: This indicates the recommendation number of the recommendation in the 2014 VA/DoD UEAR CPG.
2014 CPG Recommendation Text column: This contains the wording of each recommendation from the 2014 VA/DoD UEAR CPG.
2014 CPG Strength of Recommendation column: The 2014 VA/DoD UEAR CPG used a variation of the USPSTF grading framework to provide for a rating of EO for “Expert
Opinion.”2014 CPG Recommendation Category column: Recommendation categories were not assigned during the development of the 2014 VA/DoD UEAR CPG. Refer to the
Recommendation Categorization section for more information on the description of the categorization process and the definition of each category.
2022 CPG Recommendation Category column: This is the recommendation category assigned during the development of the 2022 VA/DoD ULA CPG. Refer to the
Recommendation Categorization section for more information on the description of the categorization process and the definition of each category.
2022 CPG Recommendation # column: For recommendations that were carried forward to the 2014 VA/DoD UEAR CPG, this column indicates the new recommendation(s) towhich they correspond.

March 2022

Page 95 of 146

2014 CPG
Recommendation
Category

2022 CPG
Recommendation
Category

2022 CPG
Recommendation #2014 CPG Strength of
Recommendation2014 CPG
Recommendation #VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

7.

A comprehensive, interdisciplinary, patient-centered rehabilitation plan should be developed as
early as possible and updated throughout all phases of care based on patient’s progress, changes infunctional status, emerging needs, and goals.

ExpertOpinion-Not reviewed,
Deleted-8.

Patient-centered physical and functional rehabilitation interventions should be initiated based on
the rehabilitation plan and the patient’s physical and psychological status.

ExpertOpinion-Not reviewed,
Deleted-

9.

Various types of pain following upper limb loss should be managed appropriately and individually
throughout all phases using pharmacological and non-pharmacological treatment options.

ExpertOpinion-

Reviewed,
New-replaced

5, 9,
10

10.

The care team should provide appropriate education and informational resources to patients,
family and caregiver(s) throughout all phases of care.

ExpertOpinion-Not reviewed,
Deleted-11.

The care team should facilitate early involvement of a trained peer visitor.

C-

Reviewed,
New-replaced

14

12.

The decision for amputation should be made based upon accepted surgical and medical standardsof care.

ExpertOpinion-Not reviewed,
Deleted-

13.

Communication must occur between the surgical and non-surgical members of the care team inorder to optimize surgical and functional outcomes.

ExpertOpinion-Not reviewed,
Deleted-14.

The care team should ensure that the patient is optimized for rehabilitation to enhance functional
outcomes.

ExpertOpinion-Not reviewed,
Deleted-

15.

Following amputation, the care team should ensure that the patient has achieved his or her highest
level of functional independence without a prosthesis.

ExpertOpinion-Not reviewed,
Deleted-16.

The care team should ensure that patients undergo pre-prosthetic training to help determine themost appropriate type of device to achieve functional goals.

ExpertOpinion-Not reviewed,
Deleted-17.

Once the appropriate type of prosthesis is identified, the care team should write a prostheticprescription including all necessary components.

ExpertOpinion-Not reviewed,
Deleted-

18.

Initiate upper extremity prosthetic fitting as soon as the patient can tolerate mild pressure on theresidual limb.

ExpertOpinion-Not reviewed,
Deleted-2014 CPG Recommendation Text

March 2022

Page 96 of 146

2014 CPG
Recommendation
Category

2022 CPG
Recommendation
Category

2022 CPG
Recommendation #19.

Upon delivery of the prescribed prosthesis, or change in the control scheme or componentry, thecare team must engage the patient in prosthetic training and education.

ExpertOpinion-Not reviewed,
Deleted-20.

The care team should frequently reassess the patient’s prosthetic fit and function throughout theprosthetic training phase and modify as appropriate.

ExpertOpinion-Not reviewed,
Deleted-21.

The final check out of the prosthesis should take place with appropriate members of the care team
to verify that the prosthesis is acceptable.

ExpertOpinion-Not reviewed,
Deleted-22.

The care team should offer active prosthesis users at least one back up device to ensure
consistency with function.

ExpertOpinion-Not reviewed,
Deleted-23.

Prescription of activity specific or alternate design prostheses may be considered, dependent upon thepatient’s demonstration of commitment, motivation, and goals.

ExpertOpinion-Not reviewed,
Deleted-24.

Upon completion of functional training, and to ensure continuity, the care team should coordinate
patient transition into the lifelong care phase.

ExpertOpinion-Not reviewed,
Deleted-25.

The care team should provide routine, scheduled follow-up contact for patients with upper
extremity amputation at a minimum of every 12 months, regardless of prosthetic use or non-use.

ExpertOpinion-Not reviewed,
Deleted-26.

Upon notification of patient relocation to a new catchment area, the care team should
communicate with the receiving care team and coordinate transition of patient care.

ExpertOpinion-Not reviewed,
Deleted-27.

The care team should provide education to the patient, family, and caregiver(s) regarding
advancements in technology, surgical, and rehabilitation procedures related to the management ofupper extremity amputation.

ExpertOpinion-Not reviewed,
Deleted-2014 CPG
Recommendation #2014 CPG Recommendation Text

2014 CPG Strength of
Recommendation

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

March 2022

Page 97 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix L: Participant List
Irina Agranova-Breyter, MPT
Amputation Rehabilitation Coordinator
National Center of Expertise for Upper
Extremity Amputee Rehabilitation
James J. Peters VA Medical Center
Bronx, NY
Erin Andrews, PsyD, ABPP
Psychology Program Manager
VA Texas Valley Coastal Bend Health Care
SystemAustin, TX
Shannon Barnicott, MOT, OTR/L
Occupational Therapy Supervisor
Center for the Intrepid
Brook Army Medical Center
Fort Sam Houston, TX
Josef Butkus, MS, OTR/L
Occupational Therapy Supervisor
Walter Reed National Military Medical Center
Bethesda, MD
Rachael Coller, PharmD, BCPS, BCPP
Clinical Pharmacist – Pain & Psychiatry
Naval Medical Center
San Diego, CA
Andrea Crunkhorn, PT, DPT
Chief, Clinical Programs
Extremity Trauma and Amputation Center of
Excellence
Department of the Army
Office of the Surgeon General
Falls Church, VA
Roxanne Disla, OTD, OTR/L
Occupational Therapy
National Center of Expertise for Upper
Extremity Amputee Rehabilitation
James J. Peters VA Medical Center
Bronx, NY

March 2022

Selina Doncevic, MSN, RN, CRRN
VA/DoD Polytrauma Rehab Nurse Liaison/PFAC
Transition Care Management
Washington, DC
Christopher Fantini, MSPT, CP, BOCO
National Program Manager
VA Orthotic, Prosthetic and Pedorthic Clinical
Services
Rehabilitation and Prosthetics Service
New York, NY
LCDR Joseph Happel, MD
Deputy Chief, Internal Medicine
Walter Reed National Military Medical Center
Bethesda, MD
Louise Hassinger, CP
Orthotic and Prosthetic Service
Walter Reed National Military Medical Center
Bethesda, MD
M. Jason Highsmith, PhD, DPT, CP, FAAOP
National Program Director
VA Orthotic, Prosthetic & Pedorthic Clinical
Services
Rehabilitation and Prosthetics Service
Washington, DC
Denise Lester, MD
Algologist, Pain Management Services &Chronic Pain Clinic
Hunter Holmes McGuire VA Medical Center
Richmond, VA
Maj Megan Loftsgaarden, DO
Chief, Physical Medicine and Rehabilitation
Service
Center for the Intrepid
Consulting Physician
Brooke Army Medical Center
San Antonio, TX

Page 98 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

William C. Mayes, MSPO, CPO
Certified Prosthetist/Orthotist Specialist
National Center of Expertise for Upper
Extremity Amputee Rehabilitation
James J. Peters VA Medical Center
Bronx, NY
Michelle Nordstrom, MS, OTR/L
Research Occupational Therapist
Uniformed Services University of the Health
Sciences
Bethesda, MD
Annemarie Orr, OTD, OTR/L
Human Performance Program Manager
Naval Special Warfare Center
San Diego, CA
Billie Randolph, PT, PhD
Deputy Director
Extremity Trauma & Amputation Center of
Excellence
VHA Rehabilitation and Prosthetic Services
Washington, DC

Maj Casey M. Sabbag, MD
Hand Surgeon
Teaching Faculty
Brooke Army Medical Center
San Antonio, TX
Bradley Tucker, MD
Medical Director, VA Amputation System ofCare
Corporal Michael J. Crescenz VA Medical Center
Assistant Professor of Clinical Physical Medicine
and Rehabilitation
Perelman School of Medicine at the Universityof Pennsylvania
Philadelphia, PA
Joseph Webster, MD
Staff Physician
Central Virginia VA Healthcare System
National Director VHA Amputation System ofCare
Washington, DC

Linda Resnik, PT, PhD, FAPTA
Research Career Scientist
Providence VA Medical Center
Professor, Health Services, Policy & PracticeBrown University
Providence, RI

March 2022

Page 99 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix M: Literature Review Search Terms and Strategy
A.

EMBASE and MEDLINE with EMBASE.com syntax (all questions)

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

UE prostheses
population((‘arm prosthesis’/exp OR ‘finger implant’/exp OR ((‘bionics’/de OR ‘electric limb
prosthesis’/exp OR ‘limb prosthesis’/de OR ‘myoelectric control'/de OR ‘orthopedic
prosthesis’/de OR ‘prosthesis fixation’/de) AND 'upper limb'/exp)) OR ‘artificial
hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands OR
upper)):ti,ab OR (((bionic* OR ‘man-machine’ OR myoelectric* OR ‘myo electric*’ ORneuroprosth* OR prosthes* OR prosthet* OR ‘robot* manipulat*’) NEAR/2 (arm OR
arms OR carpal OR digit OR digits OR elbow* OR finger* OR forearm* OR forequarter
OR hand OR hands OR humeral OR humerus OR metacarp* OR palm OR palms OR
phalang* OR phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal
OR transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper
limb*’)):ti,ab) OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR arms
OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab,kw OR ((((artificial*OR ‘body power*’ OR bionic* OR electric* OR electronic OR ‘external* power*’ OR‘man-machine’ OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robot*) NEAR/3 (extremit* OR limb*)):ti,ab OR ('body power*' OR bionic* OR'external* power*' OR ‘man-machine’ OR myoelectric* OR neuroprosth* OR
prosthes* OR prosthet*):ti) AND (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ‘trans radial’ OR ulnar OR ‘upper arm*’ OR ‘upper limb*’ OR‘upper extremit*’ OR ‘upper or lower’):ti,ab))#3

General terms(((advance* OR new OR update* OR novel) NEAR/2 (device* OR hardware OR
implant* OR intervention* OR prosthes* OR prosthet* OR reconstruct* OR software
OR surger* OR surgical OR technolog* OR treatment*)):ti,ab) OR (((arm OR arms OR
hand OR hands OR extremit* OR finger* OR forearm* OR limb* OR 'upper extremit*'
OR 'upper limb*') NEAR/2 transplant*):ti,ab,kw) OR (advances OR advancement* OR
emerging OR future OR innovat* OR 'state of the art’ OR trend* OR novel):ti

KQ 1

March 2022

Strategy

Page 100 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#4

Specific terms‘composite graft’/de OR ‘hand transplantation’/de OR ‘limb transplantation’/de OR‘muscle innervation’/de OR ‘muscle reinnervation’/de OR ‘neuromuscularjunction’/de OR ‘osseointegration’/de OR ‘osseointegrated implant’/de OR‘reinnervation’/exp OR ‘targeted muscle reinnervation’/de OR ‘vascularizedcomposite allograft’/de OR ‘vascularized composite allotransplantation’/de OR‘antagonist interface*’ OR AMI:ti,ab OR ‘composite allotransplant*’ OR ‘composite
allograft*’ OR ‘composite graft*’ OR 'ewing amputation*' OR ‘ewing procedure*’ OR‘implant* sensor*’ OR (implant* NEAR/2 myoelectric*) OR IMES:ti,ab OR reinnervat*
OR ‘myoelectric* interface*’ OR ‘myoelectric* sensor*’ OR ‘myoneural interface*’
OR (neuromuscular NEAR/6 (interface* OR myoelectric* OR myoneural OR osseo*
OR sensor*)) OR ‘nerve interface*’ OR osseointegrat* OR ‘osseo integrat*’ OR OI:ti
OR (regenerat* AND ‘peripheral nerve*’) OR (regenerat* NEAR/3 interface*) OR
RPNI:ti,ab OR ‘targeted muscle’ OR TMR:ti,ab OR 'vascularised composite' OR‘vascularized composite’ OR VCA:ti,ab#5Combinepopulation sets

#1 OR #2

#6

Combineintervention sets

#3 OR #4

#7

Combinepopulation andintervention sets

#5 AND #6#8

Apply limits,
remove unwanted
publication types

See limits and hedges at the end of this table#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

General terms‘behavioral health’/de OR 'motivation'/exp/mj OR ‘psychosocial’/de OR ‘social
adaptation’/de OR ‘social behavior’/de OR ‘social competence’/de OR 'behavioral
health':ti,ab,kw OR communit*:ti OR (communit* AND (assist* OR integrat* OR
interact* OR live OR living OR particip* OR reintegrat* OR relation* OR support*))OR ‘general communit*’ OR happiness:ti,ab,kw OR ‘patient engagement*’ OR
psychosocial* OR 'psycho social*' OR (social* NEAR/3 (adapt* OR adjust* OR
behavior* OR competent* OR integrat* OR interact* OR particip* OR rehab* ORreintegrat* OR skill*))

KQ 1(cont.)KQ 2

March 2022

Strategy

Page 101 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#3

Peer/group/mentor ‘community’/de OR ‘community based rehabilitation’/de OR ‘community care’/exp OR/community‘community reintegration’/de OR ‘group therapy’/de OR ‘mentor’/de OR‘mentoring’/de OR ‘peer acceptance’/de OR ‘peer counseling’/de OR ‘peer
guidance’/de OR ‘social support’/de OR ‘support group’/exp OR ‘1 on 1’:ti,ab,kw OR‘amputee support*’ OR ‘emotional* support*’ OR ‘group therap*’ OR ((group* OR
peer*) NEXT/2 (counsel* OR therap* OR support*)) OR interpersonal:ti,ab,kw OR
mentor*:ti,ab,kw OR (mutual NEXT/2 (group* OR help* OR support*)) OR ((mutual OR
communit* OR peer*) NEAR/3 (help* OR group* OR support* OR aid OR led OR
assist*)) OR ‘one on one’:ti,ab,kw OR peer*:ti,ab OR (support* NEAR/2 group*) OR‘wounded warrior’#4

Additionalcounseling andtherapy‘acceptance and commitment therapy’/exp OR ‘behavioral counseling’/de OR‘behavior therapy'/exp OR ‘case manager’/de OR ‘case management’/de OR‘cognitive behavioral therapy’/exp OR ‘counseling’/exp OR ‘mental health care’/exp
OR ‘mindfulness based cognitive therapy’/exp OR ‘mindfulness based therapy’/exp
OR ‘motivational enhancement therapy’/de OR ‘motivational intervention’/de OR‘motivational interviewing’/de OR ‘motivational therapy’/de OR ‘patient
counseling’/de OR ‘patient guidance’/de OR ‘psychological counseling’/de OR‘psychosocial care’/de OR ‘psychotherapy’/exp OR ‘social medicine’/de OR ‘social
work’/de OR ‘social psychiatry’/de OR ((acceptance OR commitment) NEAR/3
therap*) OR ACT:ti OR ((behavior* OR cognitiv* OR famil* OR motivation* OR
psychological OR social*) NEAR/2 (counsel* OR intervent* OR management OR
service* OR support* OR therap*)) OR ‘case manage*’:ti,ab,kw OR CBT:ti OR
counseling:ti,ab,kw OR ‘mental health care’:ti,ab,kw OR (mindful* NEXT/2 therap*)
OR motivational:ti,ab,kw OR (motivation* NEAR/2 (enhancement* OR intervention*
OR interview* OR support*)) OR (psychodynamic NEAR/2 therap*) OR
psychotherap*:ti,ab,kw OR ((social OR interpersonal) NEAR/2 (support* OR train*))OR ‘social work*’:ti,ab,kw OR ‘social service*’:ti,ab,kw#5

Education andtechniques'education program'/de OR ‘meditation’/exp OR ‘mindfulness’/exp OR ‘mindfulness
based stress reduction’/de OR ‘pain education’/de OR ‘patient education’/de OR‘psychoeducation’/de OR (breathing NEAR/2 (deep OR exercise*)) OR ‘client
education’:ti,ab,kw OR hakomi:ti,ab OR MBSR:ti,ab OR meditat*:ti,ab,kw OR
mindfulness:ti,ab,kw OR (mindful* NEAR/2 ‘stress reduc*’) OR morita:ti,ab OR‘neuroscience education’ OR ‘neuroscience therap*’ OR ‘pain education’ OR ‘patientdischarge education’ OR ‘patient education’:ti,ab,kw OR PNE:ti,ab OR
psychoeducation* OR ‘self help’:ti,ab OR TNE:ti,ab#6Combineintervention sets

#2 OR #3 OR #4 OR #5#7

Combinepopulation andintervention sets

#1 AND #6#8

Apply limits,
remove unwanted
publication types,
limit to SRs, metaanalyses (MAs),
RCTs,
nonrandomized
controlled trials(non-RCTs), andcomparative
studies

See limits and hedges at the end of this table

KQ 2(cont.)March 2022

Strategy

Page 102 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

General terms‘health care delivery’/exp/mj OR ‘health care facility’/exp OR ‘postoperative care’/mj
OR ‘rehabilitation’/mj OR ‘rehabilitation care’/de OR ‘rehabilitation nursing’/de OR‘kinesiotherapy’/exp OR (amput* NEAR/2 rehab*):ti,ab,kw OR ((care NEAR/2
deliver*):ti,ab,kw) OR ((duration* OR frequenc* OR intensity) NEAR/5 outcome*) OR(frequenc* NEAR/5 (duration* OR intensit*)) OR (intensit* NEAR/5 (duration* OR
frequenc*)) OR (outcome* NEAR/2 improv*):ti OR (postoperative OR ‘post
operative’ OR postsurgical OR ‘post surgical’ OR ‘post surgery’ OR posttreatment OR‘post treatment’):ti OR ((rehab* NEAR/3 (nursing OR program* OR setting*)):ti,ab)
OR (service* NEAR/3 deliver*) OR (((appointment* OR treatment* OR visit*) NEAR/2(deliver* OR duration* OR frequen* OR intensit* OR length* OR service* OR setting*
OR time OR timing)):ti,ab,kw) OR (day* AND month* AND week*):ti,ab#3

Settings/ locations‘ambulatory care’/exp OR ‘hospital patient’/de OR ‘inpatient care’/de OR ‘inpatient
rehabilitation’/de OR ‘inpatient rehabilitation facility’/de OR ‘outpatient’/de OR‘outpatient care’/de OR ‘outpatient department’/de OR ‘rehabilitation center’/de OR‘residential care’/de OR ‘residential home’/de OR ‘acute care’:ti,ab,kw OR ‘acuterehab*’:ti,ab,kw OR (ambulatory NEXT/2 (care OR center* OR facilit* OR
rehab*)):ti,ab,kw OR ‘care facilit*’:ti,ab,kw OR clinic:ti OR clinics:ti OR ‘day*rehab*’:ti,ab,kw OR hospitalis*:ti OR hospitaliz*:ti OR ‘in hospital’:ti,ab OR((inpatient* OR outpatient*) NEAR/3 (care OR clinic* OR department* OR facilit* OR
hospital* OR rehab* OR therap* OR treat*)) OR (rehab* NEAR/2 (center* OR
hospital*)):ti,ab,kw OR ‘residential rehab*’:ti,ab,kw OR ‘skilled nursing’ OR‘UEAcenter*’ OR ('upper limb' NEAR/2 center*)

KQ 3

March 2022

Strategy

Page 103 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

Strategy#4Telehealth/virtual/
digital‘computer simulation’/exp OR ‘digital health’/de OR ‘digital health intervention’/deOR ‘digital health technology’/de OR ‘digital technology’/de OR ‘mhealth’/de OR'mobile application'/de OR ‘mobile health’/de OR ‘mobile health application’/de OR‘mobile health technology’/de OR 'mobile phone'/exp OR 'online monitoring'/de OR‘technology based intervention’/de OR 'telecommunication'/exp OR'teleconference'/de OR 'teleconsultation'/de OR ‘telehealth’/exp OR‘telemedicine’/exp OR 'telemonitoring'/de OR 'telephone'/de OR 'telephoneinterview'/exp OR 'telepsychiatry'/de OR 'telepsychotherapy'/de OR'videoconferencing'/de OR ‘video game’/de OR ‘virtual care’/de OR 'virtual
reality'/de OR (android OR camera* OR cellphone OR ‘cell phone’ OR computer* OR
distan* OR electronic OR email OR ‘e-mail’ OR game OR gaming OR facetime OR‘face time’ OR ipad OR ‘i pad’ OR iphone OR ‘i phone’ OR internet OR laptop OR
mobile OR online OR phone* OR remote* OR smart* OR tablet* OR telephone* ORvideo* OR virtual OR ‘web based’ OR wireless OR zoom):ti OR ((android OR camera*
OR cellphone OR ‘cell phone’ OR computer* OR digital OR distan* OR electronic OR
email OR ‘e-mail’ OR facetime OR ‘face time’ OR ipad OR ‘i pad’ OR iphone OR ‘iphone’ OR internet OR laptop OR mobile OR online OR remote* OR tablet* OR
telephone OR video* OR virtual OR ‘web based’ OR zoom) NEAR/2 (care OR
conference* OR consult* OR monitor* OR health* OR medicine OR psychiatr* OR
psycholog* OR psychotherap* OR therap* OR treatment* OR visit*)) OR ‘augmented
reality’ OR bluetooth OR ‘blue tooth’ OR ‘digital technolog*’ OR ‘e care’ OR ‘econsult*’ OR ehealth OR ‘e health’ OR emedicine OR ‘e medicine’ OR etherapy OR ‘etherapy’ OR ((game OR gaming) NEAR/5 (rehab* OR treatment*)) OR ‘game based’OR ‘gaming based’ OR mhealth OR ‘m health’ OR ((mobile OR wireless OR smart)
NEAR/5 (health* OR device* OR application* OR app OR apps)) OR ((phone* OR
telephone*) NEAR/3 (consult* OR interview* OR visit*)) OR ((‘real time’ OR realtime
OR real-time) AND (care OR communicat* OR consult* OR mentor* OR rehab* ORtherap* OR treatment*)) OR ((remote OR remotely) NEAR/5 (consult* OR game* OR
gaming OR health* OR visit*)) OR smartphone* OR ‘smart technolog*’ OR‘technology based’ OR telecare OR ‘tele care’ OR teleconsult* OR ‘tele consult*’ ORtelehealth OR ‘tele health’ OR telemanagement OR ‘tele management’ OR
telemedicine OR ‘tele medicine’ OR telemonitor* OR ‘tele monitor*’ OR telenursing
OR ‘tele nursing’ OR telerehab* OR ‘tele rehab*’ OR teletreatment* OR ‘tele
treatment*’ OR televideo OR ‘tele video’ OR videoconferenc* OR ‘virtual reality’#5

Combineintervention sets

#2 OR #3 OR #4#6

Combinepopulation andintervention sets

#1 AND #5#7

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

KQ 3(cont.)March 2022

Page 104 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

UE prostheses
population((‘arm prosthesis’/exp OR ‘finger implant’/exp OR ((‘bionics’/de OR ‘electric limb
prosthesis’/exp OR ‘limb prosthesis’/de OR ‘myoelectric control'/de OR ‘orthopedic
prosthesis’/de OR ‘prosthesis fixation’/de) AND 'upper limb'/exp)) OR ‘artificial
hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands OR
upper)):ti,ab OR (((bionic* OR ‘man-machine’ OR myoelectric* OR ‘myo electric*’ ORneuroprosth* OR prosthes* OR prosthet* OR ‘robot* manipulat*’) NEAR/2 (arm OR
arms OR carpal OR digit OR digits OR elbow* OR finger* OR forearm* OR forequarter
OR hand OR hands OR humeral OR humerus OR metacarp* OR palm OR palms OR
phalang* OR phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal
OR transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper
limb*’)):ti,ab) OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR arms
OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab,kw OR ((((artificial*OR ‘body power*’ OR bionic* OR electric* OR electronic OR ‘external* power*’ OR‘man-machine’ OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robot*) NEAR/3 (extremit* OR limb*)):ti,ab OR ('body power*' OR bionic* OR'external* power*' OR ‘man-machine’ OR myoelectric* OR neuroprosth* OR
prosthes* OR prosthet*):ti) AND (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ‘trans radial’ OR ulnar OR ‘upper arm*’ OR ‘upper limb*’ OR‘upper extremit*’ OR ‘upper or lower’):ti,ab))#3

Dexterity tests‘box and block test’/exp OR ‘jebsen taylor hand function test’/exp OR ‘nine hole peg
test’/exp OR ‘southampton hand assessment procedure’/exp OR ‘9 hole peg’ OR(assess* NEAR/5 myoelectric*):ti,ab,kw OR ‘assessment of capacity’ OR ACMC:ti,abOR ‘box & block*’ OR ‘box AND block*’ OR BBT:ti OR ((clothespin* OR ‘clothes pin’)
NEAR/2 relocat*) OR ((dexterity OR dexterous*) NEAR/4 (assess* OR evaluat* OR
measur* OR test*)):ti,ab,kw OR ‘hand assessment*’:ti,ab OR (‘hand function*’ AND(assess* OR evaluat* OR measur* OR score* OR scoring OR test*)):ti,ab OR
jebsentaylor OR ‘jebsen taylor’ OR (jebsen NEAR/4 test*) OR JTHF:ti,ab,kw OR ‘ninehole peg’ OR NHP:ti OR ‘relocation test*’ OR ‘southampton hand’ OR SHAP:ti#4

Activity/function
tests‘patient specific functional scale’/exp OR ‘quickdash’/exp OR ‘quickdash score’/exp
OR ‘quickdash questionnaire’/exp OR (‘physical activity, capacity and performance’/
exp AND (assess* OR evaluat* OR measure* OR rate OR rating OR test*):ti) OR(activit* NEAR/5 (assess* OR evaluat* OR measure* OR test*)):ti,ab OR (activit*
NEAR/5 ('daily life' OR 'daily living')):ti OR ‘activit* perform*’:ti,ab OR
AMULA:ti,ab,kw OR ‘AM ULA’:ti,ab OR ((assist* OR help*) NEAR/3 (activit* OR adl
OR daily OR life OR living)):ti,ab OR ‘BAM ULA’:ti,ab OR DASH:ti,ab,kw OR (function*
NEAR/2 (assess* OR evaluat* OR measur* OR test*)):ti OR ‘functional scale*’:ti,abOR (hand NEAR/2 score*) OR PSFS:ti,ab,kw OR ((perform* OR skill*) NEAR/2 (activit*
OR assess* OR measur* OR test*)):ti OR (‘prosthetic function*’ AND (asses* OR
evaluat* OR test*)):ti,ab OR quickdash OR ‘quick dash’ OR ‘test of prosthetic*’:ti,abOR ‘timed activit*’:ti,ab,kw OR ‘T MAP’:ti OR (‘university of new brunswick’ NEAR/3
test*) OR ‘UNB test*’

KQ 4

March 2022

Strategy

Page 105 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

Strategy#5

Psychological tests‘checklist’/de OR ‘cognitive test’/de OR ‘general anxiety disorder 7’/de OR ‘generalanxiety disorder scale’/de OR ‘general anxiety disorder scale 7’/de OR ‘patient healthquestionnaire’/exp OR ‘psychologic test’/exp OR ‘psychometry’/exp OR'questionnaire'/mj OR (‘questionnaire’/exp/mj AND (activit* OR adjustment* OR
anxiety OR behavior* OR cognition OR cognitive OR mental OR neuropsych* OR
performance OR psych* OR satisfaction)) OR ((anxiety OR ‘anxiety disorder*’ ORbehavior* OR cognitive* OR cognition OR mental OR psych* OR psychophysical* OR
neuropsych*) NEAR/4 (checklist* OR evaluat* OR measur* OR scale* ORquestionnaire* OR scale* OR score* OR test*)):ti,ab OR ‘GAD 7’:ti,ab OR ‘experience
scale*’ OR ‘patient health questionnaire*’ OR ‘PHQ 9’:ti,ab OR ‘PCL 5’:ti,ab OR ((ptsd
OR posttraumatic OR 'post traumatic') NEAR/3 checklist*) OR psychometric* OR
psychoprosthetic* OR TAPES OR (‘prosthesis experience*' NEAR/3 scale*) OR ‘trinity
activity’ OR ‘trinity amputation’#6

Other tests‘community reintegration’/exp OR 'mental component summary'/exp OR ‘nasa task
load index’/exp OR ‘physical component summary’/exp OR ‘upper extremity
function’/exp OR ‘upper extremity functional index’/exp OR ‘upper extremity
functional scale’/exp OR ‘veterans rand 12 item health survey’/de OR ‘client
satisfaction’ OR ((reintegrat* OR 're integrat*') AND (‘active duty’ OR army OR
combat OR deployed OR deployment OR marine* OR military OR navy OR 'service
member*' OR servicemen OR servicewomen OR soldier* OR veteran*)) OR ‘CRIS
CAT’:ti,ab,kw OR CRISCAT:ti,ab,kw OR ‘health survey*’:ti,ab OR ('mental
component*' NEAR/3 summar*) OR MCS:ti,ab,kw OR ‘nasa task load’ OR ‘OPUS
CSD’:ti,ab,kw OR ‘OPUS UE’:ti,ab,kw OR ((orthotic* OR prosthes* OR prosthetic*)
AND 'user* survey*') OR ‘patient satisfaction’:ti OR ((prosthes* OR prosthetic*) AND
survey*):ti,ab OR (‘physical component*’ NEAR/3 summar*) OR ((physical OR
mental) AND 'component score*') OR PCS:ti,ab,kw OR ‘prosthetic* perform*’:ti,abOR ‘RAND 12 item’ OR ‘RAND twelve item’ OR ‘scoring guide*’ OR ‘task load index*’
OR TLX:ti,ab,kw OR (‘upper extremit*’ AND ‘functional status’):ti,ab OR ((use OR
user*) NEAR/10 (questionnaire* OR survey*)):ti,ab OR ‘veteran* RAND*’ OR
VR12:ti,ab,kw OR ‘VR 12’:ti,ab,kw#7

General terms((assess* OR outcome*) NEAR/2 measur*):ti OR ((independen* OR ‘quality of life’OR ‘quality of living’) NEAR/2 (evaluat* OR measur* OR score OR scoring OR
test*)):ti,ab OR (identif* NEAR/3 (difficult* OR improv* OR worse*)):ti,ab OR((evaluat* OR improv* OR worse*) AND function*):ti OR ‘national survey’ OR((prosthes* OR prosthet*) AND (candidate* OR candidac* OR prescription*)):ti,abOR ((prosthes* OR prosthet*) NEAR/2 (experience* OR need OR needs OR required
OR requirement*)):ti,ab OR ((prosthes* OR prosthet*):ti,ab AND (determin* OR
need OR needs OR required OR requirement*):ti) OR ((prosthe* NEAR/2 (accept* OR
satisf*)):ti,ab AND (checklist* OR questionnaire* OR survey OR test*):ti,ab) OR(prosthe* AND (use OR usage) AND (assess* OR evaluat* OR questionnaire* OR
survey* OR test*)):ti OR (therap* NEAR/3 (evaluat* OR need OR needs OR required
OR requirement*)):ti,ab#8Combinepopulation sets

#1 OR #2

#9

Combineintervention sets

#3 OR #4 OR #5 OR #6 OR #7#10

Combinepopulation andintervention sets

#8 AND #9#11

Apply limits,
remove unwanted
publication types

See limits and hedges at the end of this table

KQ 4(cont.)March 2022

Page 106 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

UE prostheses
population((‘arm prosthesis’/exp OR ‘finger implant’/exp OR ((‘bionics’/de OR ‘electric limb
prosthesis’/exp OR ‘limb prosthesis’/de OR ‘myoelectric control'/de OR ‘orthopedic
prosthesis’/de OR ‘prosthesis fixation’/de) AND 'upper limb'/exp)) OR ‘artificial
hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands OR
upper)):ti,ab OR (((bionic* OR ‘man-machine’ OR myoelectric* OR ‘myo electric*’ ORneuroprosth* OR prosthes* OR prosthet* OR ‘robot* manipulat*’) NEAR/2 (arm OR
arms OR carpal OR digit OR digits OR elbow* OR finger* OR forearm* OR forequarter
OR hand OR hands OR humeral OR humerus OR metacarp* OR palm OR palms OR
phalang* OR phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal
OR transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper
limb*’)):ti,ab) OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR arms
OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab,kw OR ((((artificial*OR ‘body power*’ OR bionic* OR electric* OR electronic OR ‘external* power*’ OR‘man-machine’ OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robot*) NEAR/3 (extremit* OR limb*)):ti,ab OR ('body power*' OR bionic* OR'external* power*' OR ‘man-machine’ OR myoelectric* OR neuroprosth* OR
prosthes* OR prosthet*):ti) AND (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ‘trans radial’ OR ulnar OR ‘upper arm*’ OR ‘upper limb*’ OR‘upper extremit*’ OR ‘upper or lower’):ti,ab))#3

Targeted/narrow
UEA population (tobe paired withbroad amputation,
patient-related etc
interventions)((arm OR arms OR carpal OR digit OR digits OR digital OR elbow* OR finger* OR
forearm* OR forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR radial OR radius OR
shoulder* OR thumb* OR transcarpal OR transhumeral OR transradial OR ulnar OR‘upper or lower’ OR ‘upper extremit*’ OR ‘upper limb*’ OR wrist*) NEAR/4(amputat* OR amputee* OR postamputation* OR reamputat*)):ti,ab,kw OR (‘upper
limb’/exp/mj AND (‘amputation’/mj OR ‘amputation stump’/mj OR ‘amputee’/de OR‘disarticulation’/de OR ‘traumatic amputation’/de))#4

Targeted/narrow
UE prostheses
population (to bepaired with broad
prostheses-related
interventions)(('bionics'/mj OR 'electric limb prosthesis'/mj OR 'limb prosthesis'/mj OR'myoelectric control'/mj OR 'orthopedic prosthesis'/mj) AND 'upper limb'/exp/mj)
OR ‘artificial hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands
OR upper)):ti,ab OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR
arms OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab#5Amputation factors ‘amputation level’/de OR ‘hemispheric dominance’/de OR ‘injury severity’/de OR
bilateral*:ti,ab OR ‘bi lateral*’:ti,ab OR ((cause* OR delay* OR etiolog* OR factor*
OR level* OR reason* OR severity OR time) NEAR/3 amput*) OR ((cause* OR
etiolog* OR factor* OR level* OR reason* OR severity OR time) AND amput*):ti OR
laterality:ti,ab OR unilateral*:ti,ab

KQ 5March 2022

Strategy

Page 107 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#6

Personal factors‘age’/exp/mj OR attitude/exp/mj OR ‘caregiver support’/de OR ‘cognition’/exp/mj
OR ‘ethnicity’/exp/mj OR ‘economic status’/de OR ‘gender’/exp/mj OR ‘gender
identity’/exp/mj OR ‘identity’/exp/mj OR ‘motivation’/exp/mj OR ‘sensory
dysfunction’/de OR ‘social support’/de OR ‘self concept’/exp/mj OR ‘psychologicaladjustment’/exp/mj OR ‘range of motion’/mj OR ‘strength’/exp/mj OR ((amputee*
OR client* OR patient*) NEAR/3 (age* OR attitude* OR characteristic* OR factor* OR
related OR satisfaction*)):ti,ab,kw OR ‘body image*’:ti,ab,kw OR (caregiver* NEAR/2
status*):ti,ab,kw OR coping:ti,ab,kw OR cognition:ti,ab OR cognitive:ti,ab OR
demograph*:ti,ab,kw OR ‘economic status*’ OR ethnicit*:ti,ab,kw OR ‘emotional
adjust*’:ti,ab,kw OR gender*:ti,ab,kw OR goals:ti,ab,kw OR identit*:ti,ab,kw OR‘low* income*’ OR ‘marital status*’:ti,ab,kw OR ‘mental health’:ti,ab,kw OR
motivation*:ti,ab,kw OR ‘psychological* adjust*’:ti,ab,kw OR race:ti,ab OR ‘range*of motion’:ti,ab OR resilience:ti,ab,kw OR (self NEXT/2 (care OR competenc* OR
concept* OR efficac*)) OR ‘sensory deficit*’ OR ‘sensory dysfunction*’ OR ‘social
class*’ OR (social* NEAR/2 support*) OR (strength NEAR/3 (arm OR determin* OR
hand OR limb* OR muscle* OR patient* OR measure*)):ti,ab OR
transgender*:ti,ab,kw OR vision*:ti,ab OR ‘well being’:ti,ab#7

Psychologicalissues, disorders,pain, injuries'acute stress disorder'/de OR ‘battle injury’/de OR ‘blast injury’/de OR‘comorbidity’/de OR ‘depression’/exp/mj OR ‘missile wound’/de OR ‘pain’/de OR‘personality disorder’/exp/mj OR ‘posttraumatic stress disorder’/exp/mj OR‘psychotrauma’/exp/mj OR ‘sleep disorder’/exp/mj OR ‘stump pain’/de OR‘substance abuse’/de OR ‘traumatic brain injury’/exp/mj OR alcohol*:ti,ab OR‘associated injur*’:ti,ab,kw OR ‘brain damage*’:ti,ab OR ‘brain injur*’:ti,ab,kw OR‘combat disorder*’:ti,ab,kw OR ‘combat stress’:ti,ab,kw OR comorbid*:ti,ab,kw OR‘co morbid*’:ti,ab,kw OR cooccur*:ti,ab,kw OR ‘co occur*’:ti,ab,kw OR (depression
OR depressive):ti,ab OR ((drug* OR substance*) NEAR/2 (abuse OR addict* ORuse*)):ti,ab,kw OR ((mood* OR personality OR stress) NEAR/3 disorder*):ti,ab,kw OR
mTBI:ti,ab OR ‘operational stress*’:ti,ab,kw OR ‘neurologic* disease*’:ti,ab,kw OR
pain:ti,ab OR posttrauma*:ti,ab,kw OR ‘post trauma*’:ti,ab,kw OR (psychologic*
NEXT/2 (disorder* OR stress* OR trauma*)):ti,ab,kw OR PTSD:ti,ab OR (sleep*
NEAR/3 (disorder* OR issue* OR problem*)):ti,ab,kw OR ‘trauma*disorder*’:ti,ab,kw OR ‘trauma* syndrome*’:ti,ab,kw OR TBI:ti,ab OR ‘traumaticstress*’:ti,ab,kw#8

Prostheses factors((‘comfort’/exp OR ‘cosmesis’/de OR ‘cosmetic’/de OR ‘function’/de OR‘usability’/de) AND (‘artificial limb*’ OR device* OR prosthes* OR prosthet*):ti,ab)
OR ((artificial OR device* OR prosthes* OR prosthet*) NEAR/3 (aesthetic* OR
comfort* OR cosmetic* OR ease OR mobility OR train* OR usage OR usability OR
satisf*)):ti,ab,kw OR cosmesis OR ‘device use’:ti,ab,kw OR ‘ease of use’ OR‘prosthetic* function*’ OR ‘prosthe* use’:ti,ab,kw OR ‘use of device*’:ti,ab,kw OR
weight:ti,ab#9Rehabilitation
outcomes‘outcome’/de OR ‘outcome assessment’/exp OR ‘outcomes’/de OR ‘patient
outcomes’/de OR ‘treatment outcome’/exp OR (amputee* NEAR/5 outcome*) OR
effectiveness*:ti OR function*:ti OR improved:ti OR improvement:ti OR
independence:ti,ab OR 'long term':ti OR outcome*:ti OR ‘patient outcome*’ OR‘patient rehab*’ OR ‘quality of life’:ti,ab,kw OR ((recover* OR rehab*) NEAR/3(effectiveness OR outcome*)):ti,ab,kw OR reintegration*:ti,ab,kw OR (treatment*
NEXT/2 (effective* OR outcome*)):ti,ab,kw OR ((client* OR patient* OR rehab* OR‘service member*’ OR treatment* OR veteran*) AND (associated OR association* OR
efficac* OR effective* OR factor* OR outcome* OR perform* OR predict* OR prognos*
OR recover* OR symptom*)):ti

KQ 5(cont.)March 2022

Strategy

Page 108 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #KQ 5(cont.)March 2022

Concept

Strategy#10

Focusedamputation,
patient, cooccurring andprostheses factors
search((amputat* AND (cause* OR delay* OR etiolog* OR level* OR reason* OR severity
OR time)) OR alcohol* OR adjustment* OR bilateral OR (injur* AND severity) OR
laterality OR unilateral* OR age OR attitude* OR ((amputee* OR client* OR personal
OR patient*) AND (characteristic* OR factor* OR related)) OR ‘body image*’ OR‘caregiver status*’ OR coping OR cognition OR cognitive OR demograph* OR‘economic status’ OR ethnicit* OR gender* OR goals OR identit* OR income OR'marital status*' OR men OR ‘mental health’ OR motivation* OR race OR ‘range* of
motion’ OR resilience OR satisfaction OR (self AND (care OR competenc* OR
concept* OR efficac*)) OR ‘sensory deficit*’ OR ‘sensory dysfunction’ OR sex OR‘social class*’ OR ‘social support*’ OR ‘sensory deficit*’ OR ‘sensory dysfunction*’ ORstrength OR transgender* OR vision* OR ‘well being’ OR women OR ((associat* OR
brain) AND (injur* OR trauma*)) OR (brain AND damage*) OR (combat AND(disorder* OR stress*)) OR comorbid* OR ‘co morbid*’ OR cooccur* OR ‘co occur*’
OR depression OR depressive OR ((drug OR substance*) AND (abuse OR addict* ORuse)) OR ((mood* OR personality OR stress) AND disorder*) OR mTBI OR ‘operational
stress*’ OR ((neurologic* OR psychologic*) AND (disease* OR disorder* OR stress*
OR trauma*)) OR pain OR posttrauma* OR ‘post trauma*’ OR PTSD OR (sleep* AND(disorder* OR issue* OR problem*)) OR (trauma* AND (disorder* OR syndrome* OR
stress*)) OR TBI OR ((aesthetic* OR comfort* OR cosmesis OR cosmetic OR ease OR
mobility OR train* OR use OR usability OR satisfaction OR weight) AND (artificial OR
bionic OR device* OR prosthes* OR prosthet*)) OR (function* NEAR/3 (artificial OR
prosthes* OR prosthet*))):ti#11

Combine broad
population sets

#1 OR #2

#12

Combine(#5 OR #6 OR #7 OR #8) AND #9
amputation, patient
factors andrehabilitation
outcomes#13

Combine broad
population withfactors andoutcomes#14

Combine broad#10 AND #11
population withfocusedamputation, patient
etc search#15

Combine narrow
populations withbroad amputation,
patient etc
searches(#3 AND (#5 OR #6 OR #7 OR #8)) OR (#4 AND #8)#16

Combine sets

#13 OR #14 OR #15#17

Apply limits,
remove unwanted
publication types

See limits and hedges at the end of this table#11 AND #12

Page 109 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

UE prostheses
population((‘arm prosthesis’/exp OR ‘finger implant’/exp OR ((‘bionics’/de OR ‘electric limb
prosthesis’/exp OR ‘limb prosthesis’/de OR ‘myoelectric control'/de OR ‘orthopedic
prosthesis’/de OR ‘prosthesis fixation’/de) AND 'upper limb'/exp)) OR ‘artificial
hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands OR
upper)):ti,ab OR (((bionic* OR ‘man-machine’ OR myoelectric* OR ‘myo electric*’ ORneuroprosth* OR prosthes* OR prosthet* OR ‘robot* manipulat*’) NEAR/2 (arm OR
arms OR carpal OR digit OR digits OR elbow* OR finger* OR forearm* OR forequarter
OR hand OR hands OR humeral OR humerus OR metacarp* OR palm OR palms OR
phalang* OR phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal
OR transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper
limb*’)):ti,ab) OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR arms
OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab,kw OR ((((artificial*OR ‘body power*’ OR bionic* OR electric* OR electronic OR ‘external* power*’ OR‘man-machine’ OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robot*) NEAR/3 (extremit* OR limb*)):ti,ab OR ('body power*' OR bionic* OR'external* power*' OR ‘man-machine’ OR myoelectric* OR neuroprosth* OR
prosthes* OR prosthet*):ti) AND (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ‘trans radial’ OR ulnar OR ‘upper arm*’ OR ‘upper limb*’ OR‘upper extremit*’ OR ‘upper or lower’):ti,ab))#3

Terminal devices‘degree of freedom’/de OR ‘hand prosthesis’/exp/mj OR ‘hook’/exp OR ‘voluntary
movement’/de OR ((‘body power*’ OR motor* OR passive OR sensor*) NEAR/3(hand* OR prosthe*)) OR ‘degree* of freedom’:ti,ab,kw OR DOF:ti,ab,kw OR ‘DOF
hand*’ OR greifer* OR hook* OR hosmer:ti,ab,kw OR ‘hosmer hook*’ OR ‘ilimb*’ OR‘i limb*’ OR motorized OR motorised OR multiarticulating OR ‘multi articulat*’ ORterminal* OR (voluntar* NEAR/5 (close OR closing OR movement* OR open*))#4

Control strategies‘automated pattern recognition’/de OR ‘brain computer interface’/exp OR‘computer interface’/de OR ‘control strategy’/de OR ‘control system’/de OR ‘patternrecognition’/exp OR ‘body power*’:ti,ab OR ‘bodily power*’:ti,ab OR (control*
NEAR/3 (crisp* OR device* OR flexible OR machine* OR strateg* OR system*)) OR‘finite state*’ OR interface*:ti,ab,kw OR microcontrol* OR ((movement* OR
motion*) NEAR/3 (detect* OR onset)) OR ‘on-off’ OR ((on OR off) NEAR/2 control*)OR ‘onset analysis’ OR (pattern* NEAR/3 recogn*) OR ((proportion* OR recognition*
OR regression*) NEAR/5 control*) OR ‘prosthes* control*’ OR ‘prosthet* control*’

KQ 6

March 2022

Strategy

Page 110 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#5

Prosthesis type‘myoelectrically controlled prosthesis’/exp OR ((‘artificial intelligence’/exp OR‘artificial neural network’/exp OR 'computer system'/de OR ‘cosmetic’/de OR'electromyogram'/de OR ‘electrotactile stimulation’/de OR 'functional electricalstimulation'/de OR ‘myoelectric control’/de OR ‘sensory feedback’/exp OR ‘signal
processing’/exp OR ‘signal processor’/exp) AND ('artificial hand*' OR 'artificial limb*'
OR device* OR prosthes* OR prosthet*)) OR ‘body powered’ OR (component*
NEAR/5 select*) OR ((cosmetic* OR hybrid) AND (artificial OR device* OR prosthes*
OR prosthet* OR robotic*)) OR DEKA OR ‘electric* power*’ OR (‘electric* stimulat*’
AND prosthe*) OR ((electrode* OR electromyogram* OR EMG OR 'functional
electric*' OR intraneural OR ‘intra neural’ OR microelectrode* OR ‘nerve stimulat*’OR ‘neural network*’ OR sEMG) AND (prosthes* OR prosthet*)):ti,ab,kw OR
electrotactile OR ‘electro tactile’ OR eOPRA OR ‘e-OPRA’ OR ‘external* power*’ OR‘LUKE arm*’ OR (modular NEAR/3 (limb* OR prosthe*)) OR MPL:ti,ab,kw OR((myoelectric* OR ‘myo electric*’) AND (artificial OR device* OR prosthes* OR
prosthet*)) OR neurointegrat* OR ‘neuro integrat*’ OR neuroprosth* OR ‘neuro
prosth*’ OR ((prosthes OR prosthet*) NEAR/3 (component* OR electric* OR
electronic* OR feedback OR outcome* OR passive* OR power* OR pressure OR
select* OR type*)):ti,ab,kw OR ((sensor* OR signal*) NEAR/3 (feedback OR integrat*
OR process*)):ti,ab OR ‘wrist rotator*’#6

Socket design
and/or suspension
method‘biomechanics’/mj OR 'harness'/de OR 'lamination'/de OR ‘mechanics’/exp/mj OR'pressure'/exp OR ‘prosthesis fixation’/de OR ‘prosthetic socket’/de OR‘suspension’/de OR ‘torque’/de OR 21A35 OR 21A36 OR ‘active transhumeral’ OR(anatomical NEAR/3 socket*) OR flexible:ti,ab,kw OR ‘compression release*’ OR
flexibilit*:ti,ab,kw OR gel:ti,ab,kw OR (gel* NEAR/2 insert*) OR harness* OR ‘highfidelity’ OR laminat* OR monolithic OR muenster:ti,ab,kw OR
osseointegrat*:ti,ab,kw OR ((pin OR sleeve) NEAR/3 (artificial* OR device* OR limb*
OR prosthe*)) OR ((pressure* OR vacuum*) NEAR/5 suspen*) OR rigid*:ti,ab OR
sauter:ti,ab,kw OR ‘self suspen*’ OR ‘shuttle lock*’ OR socket*:ti,ab OR ‘supracondylar’ OR supracondylar OR (suction* NEAR/5 (socket OR suspension)) OR
suspension*:ti,ab OR torque:ti,ab OR vacuum:ti,ab#7Combinepopulation sets

#1 OR #2

#8

Combineintervention sets

#3 OR #4 OR #5 OR #6#9

Combinepopulation andintervention sets

#7 AND #8#10

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

KQ 6(cont.)March 2022

Strategy

Page 111 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

Phantom/residual
limb pain‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb pain’/de OR ‘stumppain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast injury’/de OR ‘chronic
pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile wound’/de OR‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR ‘posttraumatic
pain’/de OR pain OR pains OR painful) AND (((missing NEAR/4 (perception* OR
perceive*)):ti,ab OR phantom* OR ‘remaining limb*’ OR ‘residual limb*’)) OR ‘pain
perceived’:ti,ab OR ‘perceived pain’:ti,ab OR (pain* NEAR/3 stump*))#3

Narrower upper
extremity terms
paired withphantom andresidual limb pain
terms(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb
pain’/de OR ‘stump pain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast
injury’/de OR ‘chronic pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile
wound’/de OR ‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR‘posttraumatic pain’/de OR pain OR pains OR painful) AND ((pain* NEAR/3 stump*)
OR (phantom* OR ‘remaining limb*’ OR ‘residual limb*’))))KQ 7

March 2022

Strategy

Page 112 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#4

Pharmacologic#5Non-pharmacologic ‘acceptance and commitment therapy’/de OR ‘acupuncture’/exp OR ‘behavior
therapy’/exp OR ‘biofeedback’/exp OR 'biofeedback training'/de OR ‘biofeedback
therapy’/de OR ‘cognitive behavioral therapy’/exp OR ‘desensitization’/de OR‘graded motor imagery’/de OR ‘meditation’/exp OR ‘mindfulness’/exp OR‘mindfulness based cognitive therapy’/de OR ‘mindfulness based stress
reduction’/de OR ‘mindfulness based stress reduction program’/de OR ‘mindfulness
based therapy’/de OR ‘mirror therapy’/de OR ‘motor imagery’/de OR 'motor
imagery training'/de OR ‘nerve stimulation’/exp OR ‘nerve stimulator’/exp OR‘nonpharmaceutical intervention’/de OR 'neurofeedback training'/de OR'neurofeedback therapy'/de OR ‘neuromodulation’/de OR ‘pain neuroscienceeducation’/de OR ‘psychotherapy’/exp OR ‘radiofrequency ablation’/exp OR‘radiofrequency therapy’/de OR ‘reinnervation’/exp OR ‘rehabilitation’/exp OR‘relaxation training’/de OR ‘spinal cord stimulation’/de OR ‘spinal cord
stimulator’/de OR ‘transcutaneous electrical nerve stimulation’/de OR (accept*
NEAR/4 (commitment OR therap*)) OR ACT:ti,ab OR acupuncture OR biofeedback*OR ‘bio feedback’ OR ((behavior* OR cognit*) NEAR/5 therap*) OR ‘cognitive
behavioral’ OR CBT:ti,ab OR desensitiz* OR desensitis* OR ((dorsal OR spine OR
spinal) NEAR/6 stimulat*) OR ‘electric* stimulat*’ OR ‘electric* nerve stimulat*’ OR
feedback OR (implant* NEAR/5 stimulat*) OR MBSR:ti,ab OR meditat* OR ‘mental
health’ OR ‘mental therap*’ OR mindful* OR ‘mirror box’ OR ‘mirror therap*’ OR‘mirror visual’ OR MVF:ti,ab OR ‘motor imag*’ OR ‘motor execution’ OR ‘motor
sequenc*’ OR myobiofeedback* OR myofeedback* OR ‘nerve stimulat*’ ORneurofeedback* OR neuromodulat* OR ‘neuro* modulat*’ OR nonpharma* OR ‘non
pharma*’ OR ‘pain neuroscience’ OR PNE:ti,ab OR (‘peripheral nerve*’ NEAR/4
stimulat*) OR PNS:ti,ab OR prevent*:ti,ab OR ‘neuroscience educat*’ OR
psychotherap* OR radiofrequenc* OR ‘radio frequenc*’ OR reinnervat* OR (relax*
NEXT/4 (technique* OR therap* OR treatment*)) OR ‘RF ablation’ OR SCS:ti,ab OR‘self care’ OR ‘stress reduc*’ OR ‘transcutaneous electric*’ OR TENS

KQ 7(cont.)March 2022

Strategy‘analgesia’/exp OR ‘analgesic agent’/exp OR ‘anticonvulsive agent’/exp OR‘antidepressant agent’/exp OR ‘benzodiazepine derivative’/exp OR'benzatropine'/exp OR ‘beta adrenergic receptor blocking agent’/exp OR‘bupivacaine’/de OR ‘calcitonin’/de OR 'capsaicin'/de OR ‘carbamazepine’/de OR‘codeine’/de OR ‘dronabinol’/de OR ‘drug therapy’/exp OR ‘fentanyl’/de OR‘dronabinol’/de OR ‘gabapentin’/de OR ‘ketamine’/de OR ‘lidocaine’/de OR‘menthol’/de OR ‘muscle relaxant agent’/exp OR ‘muscle relaxants’/exp OR ‘muscle
relaxants therapeutic use’/de OR ‘morphine’/de OR 'narcotic analgesic agent'/exp
OR ‘n methyl dextro aspartic acid receptor stimulating agent’/exp OR ‘nonsteroid
antiinflammatory agent’/exp OR 'opiate'/de OR ‘opiate agonist’/exp OR ‘opiate
receptor affecting agent’/exp OR ‘paracetamol’/de OR ‘tramadol’/de OR ‘vitaminD’/exp OR ('acetylsalicylic acid' OR advil* OR aleve* OR anacin* OR aspirin OR
diclofenac OR ibuprofen OR motrin* OR naproxen OR salicylate*):ti,ab,kw OR(((arnica OR aspercreme* OR bengay* OR biofreeze* OR camphor* OR capsicum OR‘deep relief*’ OR diclofenac) NEAR/3 (gel OR patch OR topical)):ti,ab,kw) OR
amitriptyline OR antidepressant* OR ‘anti depressant*’ OR anticonvulsant* OR
anticonvulsive* OR antiepileptic* OR APAP:ti,ab,kw OR benzodiaz* OR benztropine
OR ‘beta adrenergic’ OR ‘beta blocker*’ OR bupivacaine OR buprenorphine OR
calcitonin OR capsaicin* OR carbamazepine OR codeine OR (drug* OR medication*
OR medicine* OR pharmac*):ti,ab OR ((drug* OR medication* OR medicine* OR
pharmac*) NEAR/5 (pain OR prevent*)) OR dronabinol OR gabapentin OR (ibuleve*
OR ‘icy hot*’ OR lidocaine OR ‘methyl salicylate’ OR 'methylsalicylate' OR pennsaid*
OR powergel* OR voltarol):ti,ab,kw OR ketamine OR lidocaine OR marinol OR
mirtazapine OR ‘muscl* relaxant*’ OR ‘muscular relax*’ OR ‘muscle relax*’ ORmorphine OR ((‘non steroid*’ OR nonsteroid*) NEXT/2 (anti-inflammator* OR
antiinflammator*)) OR NMDA:ti,ab,kw OR ‘n methyl d’ OR nsaid*:ti,ab,kw OR nsaid*:ti,ab,kw OR nortriptyline OR opioid* OR paracetamol OR pregabalin OR‘serotonin nonepinephrine’ OR SNRI*:ti,ab OR tapentadol OR TCA*:ti,ab OR (topical
NEAR/2 pain*) OR tramadol OR ‘vitamin d’Page 113 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #KQ 7(cont.)

Concept#6

Combine main
population withphantom/residual
limb pain terms#1 AND #2#7

Combinepopulation sets

#3 OR #6

#8

Combineintervention sets

#4 OR #5

#9

Combinepopulation andintervention sets

#7 AND #8#10

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
and RCTs

See limits and hedges at the end of this table#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

Phantom/residual
limb pain‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb pain’/de OR ‘stumppain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast injury’/de OR ‘chronic
pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile wound’/de OR‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR ‘posttraumatic
pain’/de OR pain OR pains OR painful) AND (((missing NEAR/4 (perception* OR
perceive*)):ti,ab OR phantom* OR ‘remaining limb*’ OR ‘residual limb*’)) OR ‘pain
perceived’:ti,ab OR ‘perceived pain’:ti,ab OR (pain* NEAR/3 stump*))#3

Narrower upper
extremity terms
paired withphantom andresidual limb pain
terms(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb
pain’/de OR ‘stump pain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast
injury’/de OR ‘chronic pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile
wound’/de OR ‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR‘posttraumatic pain’/de OR pain OR pains OR painful) AND ((pain* NEAR/3 stump*)
OR (phantom* OR ‘remaining limb*’ OR ‘residual limb*’))))KQ 8

March 2022

Strategy

Page 114 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#4

Pharmacologic‘analgesia’/exp OR ‘analgesic agent’/exp OR ‘anticonvulsive agent’/exp OR‘antidepressant agent’/exp OR ‘benzodiazepine derivative’/exp OR'benzatropine'/exp OR ‘botulinum toxin A’/de OR ‘bupivacaine’/de OR ‘cannabis’/deOR 'capsaicin'/de OR ‘carbamazepine’/de OR ‘codeine’/de OR ‘dronabinol’/de OR‘drug therapy’/exp OR ‘fentanyl’/de OR ‘dronabinol’/de OR ‘gabapentin’/de OR‘ketamine’/de OR ‘lidocaine’/de OR ‘medical cannabis’/de OR ‘menthol’/de OR‘muscle relaxant agent’/exp OR ‘muscle relaxants’/exp OR ‘muscle relaxants
therapeutic use’/de OR ‘morphine’/de OR 'narcotic analgesic agent'/exp OR ‘nmethyl dextro aspartic acid receptor stimulating agent’/exp OR ‘nonsteroid
antiinflammatory agent’/exp OR 'opiate'/de OR ‘opiate agonist’/exp OR ‘opiate
receptor affecting agent’/exp OR ‘paracetamol’/de OR ‘tramadol’/de OR ‘vitaminD’/exp OR ('acetylsalicylic acid' OR advil* OR aleve* OR anacin* OR aspirin OR
diclofenac OR ibuprofen OR motrin* OR naproxen OR salicylate*):ti,ab,kw OR(((arnica OR aspercreme* OR bengay* OR biofreeze* OR camphor* OR capsicum OR‘deep relief*’ OR diclofenac) NEAR/3 (gel OR patch OR topical)):ti,ab,kw) OR
amitriptyline OR antidepressant* OR ‘anti depressant*’ OR anticonvulsant* OR
anticonvulsive* OR antiepileptic* OR APAP:ti,ab,kw OR benzodiaz* OR benztropine
OR botox OR botulinum OR bupivacaine OR cannabis OR cannabidiol OR capsaicin*
OR carbamazepine OR codeine OR (drug* OR medication* OR medicin* OR
pharmac*):ti,ab OR ((drug* OR medication* OR medicin* OR pharmac*) NEAR/5(pain OR manag*)) OR dronabinol OR epidiolex OR gabapentin OR (ibuleve* OR ‘icy
hot*’ OR lidocaine OR ‘methyl salicylate’ OR 'methylsalicylate' OR pennsaid* OR
powergel* OR voltarol):ti,ab,kw OR keppra OR ketamine OR lacosamide OR lidocaine
OR marinol OR (medic* NEAR/4 marijuana) OR mirtazapine OR ‘muscl* relaxant*’ OR‘muscular relax*’ OR ‘muscle relax*’ OR morphine OR ((‘non steroid*’ OR
nonsteroid*) NEXT/2 (anti-inflammator* OR antiinflammator*)) OR NMDA:ti,ab,kw
OR ‘n methyl d’ OR nsaid* OR n-said*:ti,ab,kw OR nortriptyline OR opioid* ORparacetamol OR pregabalin OR ‘serotonin nonepinephrine’ OR SNRI*:ti,ab OR
TCA*:ti,ab OR (topical NEAR/2 pain*) OR tramadol OR ‘vitamin d’#5

Combine main
population withphantom/residual
limb pain terms#1 AND #2#6

Combinepopulation sets

#3 OR #5

#7

Combinepopulation andintervention sets

#4 AND #6#8

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
and RCTs

See limits and hedges at the end of this table

KQ 8(cont.)March 2022

Strategy

Page 115 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

Phantom/residual
limb pain‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb pain’/de OR ‘stumppain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast injury’/de OR ‘chronic
pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile wound’/de OR‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR ‘posttraumatic
pain’/de OR pain OR pains OR painful) AND (((missing NEAR/4 (perception* OR
perceive*)):ti,ab OR phantom* OR ‘remaining limb*’ OR ‘residual limb*’)) OR ‘pain
perceived’:ti,ab OR ‘perceived pain’:ti,ab OR (pain* NEAR/3 stump*))#3

Narrower upper
extremity terms
paired withphantom andresidual limb pain
terms(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘phantom limb’/exp OR ‘phantom pain’/de OR ‘residual limb
pain’/de OR ‘stump pain’/de OR ((‘arm pain’/de OR ‘battle injury’/de OR ‘blast
injury’/de OR ‘chronic pain’/de OR ‘intractable pain’/de OR ‘limb pain’/de OR ‘missile
wound’/de OR ‘neuropathic pain’/de OR ‘pain’/de OR ‘postoperative pain’/de OR‘posttraumatic pain’/de OR pain OR pains OR painful) AND ((pain* NEAR/3 stump*)
OR (phantom* OR ‘remaining limb*’ OR ‘residual limb*’))))KQ 9

March 2022

Strategy

Page 116 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Strategy#4Non-pharmacologic ‘acceptance and commitment therapy’/de OR ‘acupuncture’/exp OR ‘augmented
interventions
reality’/de OR ‘augmented reality system’/de OR ‘behavior therapy’/exp OR‘biofeedback’/exp OR 'biofeedback training'/de OR ‘biofeedback therapy’/de OR‘cognitive behavioral therapy’/exp OR ‘desensitization’/de OR ‘graded motor
imagery’/de OR ‘meditation’/exp OR ‘mindfulness’/exp OR ‘mindfulness based
cognitive therapy’/de OR ‘mindfulness based stress reduction’/de OR ‘mindfulness
based stress reduction program’/de OR ‘mindfulness based therapy’/de OR ‘mirror
therapy’/de OR ‘motor imagery’/de OR 'motor imagery training'/de OR ‘nerve
stimulation’/exp OR ‘nerve stimulator’/exp OR ‘nonpharmaceutical intervention’/deOR 'neurofeedback training'/de OR 'neurofeedback therapy'/de OR‘neuromodulation’/de OR ‘pain neuroscience education’/de OR ‘psychotherapy’/exp
OR ‘radiofrequency ablation’/exp OR ‘radiofrequency therapy’/de OR‘reinnervation’/exp OR ‘rehabilitation’/exp OR ‘relaxation training’/de OR ‘spinal cord
stimulation’/de OR ‘spinal cord stimulator’/de OR ‘transcutaneous electrical nerve
stimulation’/de OR ‘virtual reality’/de OR ‘virtual reality system’/de OR ‘virtual reality
simulator’/exp OR ‘virtual reality exposure therapy’/de OR (ameliorat* OR manag* OR
reduc* OR eliminat* OR treat* OR treatment*):ti OR (accept* NEAR/4 (commitment
OR therap*)) OR ACT:ti,ab OR acupuncture OR ‘augmented reality’ OR biofeedback*OR ‘bio feedback’ OR ((behavior* OR cognit*) NEAR/5 therap*) OR ‘cognitive
behavioral’ OR CBT:ti,ab OR desensitiz* OR desensitis* OR ((dorsal OR spine OR spinal)
NEAR/6 stimulat*) OR ‘electric* stimulat*’ OR feedback OR (implant* NEAR/5
stimulat*) OR managing:ti,ab,kw OR management:ti,ab,kw OR MBSR:ti,ab OR
meditat* OR ‘mental health*’ OR ‘mental therap*’ OR mindful* OR ‘mirror box’ OR‘mirror therap*’ OR ‘mirror visual’ OR MVF:ti,ab OR ‘motor imag*’ OR ‘motor
execution’ OR ‘motor sequenc*’ OR myobiofeedback* OR myofeedback* OR ‘nerve
stimulat*’ OR neurofeedback* OR neuromodulat* OR ‘neuro* modulat*’ ORnonpharma* OR ‘non pharma*’ OR ‘pain neuroscience’ OR PNE:ti,ab OR (‘peripheral
nerve*’ NEAR/4 stimulat*) OR PNS:ti,ab OR ‘neuroscience educat*’ OR psychotherap*
OR radiofrequenc* OR ‘radio frequenc*’ OR reinnervat* OR (relax* NEAR/4(technique* OR therap* OR treatment*)) OR ‘RF ablation’ OR SCS:ti,ab OR ‘self care’OR ‘stress reduc*’ OR ‘transcutaneous electric*’ OR TENS OR ‘virtual reality’#5

Combine main
population withphantom/ residual
limb pain terms#1 AND #2#6

Combinepopulation sets

#3 OR #5

#7

Combinepopulation andintervention sets

#4 AND #6#8

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

KQ 9(cont.)March 2022

Concept

Page 117 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

Strategy#1

Adults who are
candidates for UE
surgery(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR preamputat* OR preprosthe* OR ‘pre prosthe*’ ORreamputat* OR ‘remaining limb*’ OR ‘residual limb*’ OR stump*):ti,ab,kw) OR ‘arm
amputation’/de OR ‘finger amputation’/de OR ‘forearm amputation’/de OR‘forequarter amputation'/de OR ‘hand amputation’/de OR ‘shoulder amputation’/deOR ‘thumb amputation’/de OR ‘transhumeral amputation’/de OR (loss* NEAR/2('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

Level ofamputations'amputation level'/de OR (amputat* NEAR/3 level*):ti,ab,kw OR ‘amputation
method’ OR ((above OR at OR below) NEXT/3 (elbow* OR shoulder* OR wrist*)):ti,abOR ‘method* of amputation*’ OR ‘partial digit*’:ti,ab,kw OR ‘partial finger’:ti,ab,kw
OR ‘partial hand’:ti,ab,kw OR ‘partial thumb’:ti,ab,kw OR ((elbow* OR shoulder* OR
wrist*) NEAR/2 disarticulat*):ti,ab OR ((level* OR method* OR technique*) AND(forequarter OR transcarpal OR transhumeral OR transradial)):ti,ab#3Surgical procedure‘myoplasty’/de OR ‘peripheral nerve stimulator’/de OR ‘osseointegration’/de OR‘revision surgery’/de OR ‘spinal cord stimulation’/de OR ‘targeted muscle
reinnervation’/de OR ((amputation/exp/mj OR ‘surgical approach’/de OR ‘surgical
technique’/exp OR ‘surgical approach*’ OR ‘surgical technique*’) AND (approach*OR level* OR method* OR procedure* OR technique):ti) OR ((operative OR surgery
OR surgical) NEXT/2 (approach* OR method* OR procedure* OR technique*)):ti,ab
OR (amputation* NEAR/3 (approach* OR method* OR procedure* ORtechnique*)):ti,ab OR (myodesis OR myoplast* OR osseointegrat* OR ‘osseo
integrat*’ OR ‘targeted muscle reinnervation’ OR ‘revision surger*’ OR ertl OR‘peripheral nerve stimulat*’ OR ‘spinal cord stimulation’):ti,ab,kw#4

Patient outcomeswith amputationlevel/surgicalprocedure(('amputation level'/de OR ‘surgical approach’/de OR ‘surgical technique’/exp OR‘amputation level*’ OR ‘amputation method*’ OR ‘operative technique*’ OR‘surgical approach*’ OR ‘surgical technique*’) AND ‘patient outcome*’) OR((‘amputation level*’ OR ‘amputation method*’ OR ‘operative technique*’ OR‘surgical approach*’ OR ‘surgical technique*’) AND outcome*:ti) OR ((‘surgicaloutcome’/de OR (amputation* NEAR/2 outcome*)) AND (approach* OR level* OR
method* OR procedure* OR technique*):ti) OR (amputat*:ti,ab AND ((operative OR
surgery OR surgical OR ‘surgical procedure*’) NEAR/2 outcome*))#5

Combineintervention sets

#2 OR #3 OR #4#6

Combinepopulation andintervention sets

#1 AND #5#7

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

KQ 10

March 2022

Page 118 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

Strategy#1

Adults who are
candidates for UE
surgery(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR preamputat* OR preprosthe* OR ‘pre prosthe*’ ORreamputat* OR ‘remaining limb*’ OR ‘residual limb*’ OR stump*):ti,ab,kw) OR ‘arm
amputation’/de OR ‘finger amputation’/de OR ‘forearm amputation’/de OR‘forequarter amputation'/de OR ‘hand amputation’/de OR ‘shoulder amputation’/deOR ‘thumb amputation’/de OR ‘transhumeral amputation’/de OR (loss* NEAR/2('upper limb*' OR 'upper extremit*')):ti,ab,kw#2Skin condition,‘blood flow’/exp OR ‘circulation’/exp OR ‘heterotopic ossification’/de OR
infection, pain, etc. ‘infection’/exp/mj OR ‘limb ischemia’/exp/mj OR ‘muscle ischemia’/de OR‘neuroma’/exp/mj OR ‘pain’/exp/mj OR 'palpation'/exp OR ‘skin infection’/exp OR‘skin ischemia’/exp/mj OR ‘skin perfusion pressure’/exp OR (angiograph* NEAR/3
score*) OR (blood NEAR/2 (flow* OR supply)) OR circulation:ti,ab,kw OR
dermatitis:ti,ab,kw OR edema*:ti,ab,kw OR ‘heterotopic ossification’ OR
infected:ti,ab OR infection*:ti,ab OR ischemic:ti,ab,kw OR (amput* AND (muscle*
NEAR/3 (condition* OR strength OR weak*)):ti,ab,kw) OR pain*:ti,ab OR
neuroma*:ti,ab OR oedema*:ti,ab,kw OR ‘patency score*’ OR ‘palpable pulse*’ ORpalpitation*:ti,ab,kw OR scintigraphic OR (skin NEAR/3 (breakdown* OR care OR
cleaning OR condition* OR disease* OR infection* OR integrity)):ti,ab,kw OR ‘skin
perfusion pressure’ OR SPP:ti,ab,kw OR ‘vascular insufficienc*’:ti,ab,kw#3

Wound healing,
prostheses fitting,need for revision
surgery‘outcome’/de OR ‘outcome assessment’/exp/mj OR ‘outcomes’/de OR ‘patient
outcomes’/de OR ‘postoperative complication’/exp/mj OR ‘prosthesis fixation’/deOR ‘prosthetic fitting’/de OR ‘reoperation’/de OR ‘revision surgery’/de OR‘treatment outcome’/exp/mj OR ‘wound healing’/exp OR ((postsurg* OR ‘post
surg*’) AND (‘adverse event*’ OR complicat*)) OR ((adverse OR complicat* OR
qualit* OR speed*) AND wound* AND (heal OR healing)) OR (wound* NEAR/3(complicat* OR heal OR healing)) OR (prosthe* NEAR/3 fit*) OR ‘revision surger*’ OR‘re amputat*’:ti,ab,kw OR reoperat*:ti,ab,kw OR (revision* NEAR/4 amputat*)#4

Targeted terms(amput* AND (‘adverse event*’ OR complicat* OR outcome* OR readmit* OR ‘readmit*’ OR readmission* OR ‘re admission*’ OR revision*)):ti OR (amput* ANDcomplicat* AND ‘prosthe* fiting’):ti,ab OR (amput* NEAR/3 outcome*):ti,ab OR((amput* OR skin OR surger* OR surgical OR wound*) AND (factor* OR complicat*
OR predict*)):ti OR (complicat* NEAR/4 (factor* OR healing OR wound*)):ti,ab OR((factor* OR predict* OR need* OR requir*) AND (revision* NEAR/4 (amputat* OR
surger*))):ti,ab OR (‘prosthe* fit*’ OR reoperat* OR ‘revision amput*’ OR ‘revision
surger*’ OR ‘wound healing’):ti OR ((preamputat* OR ‘pre amputat*’ ORpreprosthe* OR ‘pre prosthe*’ OR presurgical OR ‘pre surgical’ OR 'prosthe* fit*' OR'wound healing') NEAR/5 (factor* OR predict* OR outcome*)) OR ((amput* NEAR/3
infect*) OR (angiograph* NEAR/3 score*) OR (blood NEAR/2 (flow* OR supply)) OR
circulation OR dermatitis OR edema* OR ‘heterotopic ossification’ OR (amput* AND(muscle* NEAR/3 (condition* OR strength OR weak*))) OR oedema* OR ‘patency
score*’ OR ‘palpable pulse*’ OR palpitation* OR scintigraphic OR (skin NEAR/3(breakdown* OR care OR cleaning OR condition* OR disease* OR infection* OR
integrity)) OR ‘skin perfusion pressure’ OR SPP OR ‘vascular insufficienc*’ OR((ischemic OR infected OR infection* OR neuroma* OR pain) NEAR/3 (effect* OR
factor* OR fitting* OR healing OR outcome*))):ti,ab OR ((ischemic OR infected OR
infection* OR neuroma* OR pain) AND (effect* OR factor* OR fitting* OR healing OR
outcome* OR revision)):ti#5

Combineintervention sets(#2 AND #3) OR #4

KQ 11

March 2022

Page 119 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #KQ 11(cont.)KQ 12

March 2022

Concept

Strategy#6

Combinepopulation andintervention sets

#1 AND #5#7

Apply limits,
remove unwanted
publication types

See limits and hedges at the end of this table#1

Adults with UE
amputation(‘arm injury’/exp OR ‘upper limb’/exp OR (arm OR arms OR carpal OR digit OR digits
OR digital OR elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR interscapulothoracic OR metacarp* OR palm OR palms OR((phalang* OR phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR
thumb*)) OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’ ORwrist*):ti,ab,kw) AND (‘amputation’/de OR ‘amputation stump’/de OR ‘amputee’/deOR ‘disarticulation’/de OR ‘traumatic amputation’/de OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR ‘limb loss*’ OR ‘loss of limb*’ ORpostamputation* OR reamputat* OR ‘remaining limb*’ OR ‘residual limb*’ ORstump*):ti,ab,kw) OR ‘arm amputation’/de OR ‘finger amputation’/de OR ‘forearm
amputation’/de OR ‘forequarter amputation'/de OR ‘hand amputation’/de OR‘shoulder amputation’/de OR ‘thumb amputation’/de OR ‘transhumeral
amputation’/de OR (loss* NEAR/2 ('upper limb*' OR 'upper extremit*')):ti,ab,kw#2

UE prostheses
population((‘arm prosthesis’/exp OR ‘finger implant’/exp OR ((‘bionics’/de OR ‘electric limb
prosthesis’/exp OR ‘limb prosthesis’/de OR ‘myoelectric control'/de OR ‘orthopedic
prosthesis’/de OR ‘prosthesis fixation’/de) AND 'upper limb'/exp)) OR ‘artificial
hand*’:ti,ab OR ('artificial limb*' AND (arm OR arms OR hand OR hands OR
upper)):ti,ab OR (((bionic* OR ‘man-machine’ OR myoelectric* OR ‘myo electric*’ ORneuroprosth* OR prosthes* OR prosthet* OR ‘robot* manipulat*’) NEAR/2 (arm OR
arms OR carpal OR digit OR digits OR elbow* OR finger* OR forearm* OR forequarter
OR hand OR hands OR humeral OR humerus OR metacarp* OR palm OR palms OR
phalang* OR phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal
OR transhumeral OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper
limb*’)):ti,ab) OR ((neuroprosth* OR prosthes* OR prosthet*) NEAR/4 (arm OR arms
OR hand OR hands OR ‘upper extremit*’ OR ‘upper limb*’)):ti,ab,kw OR ((((artificial*OR ‘body power*’ OR bionic* OR electric* OR electronic OR ‘external* power*’ OR‘man-machine’ OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robot*) NEAR/3 (extremit* OR limb*)):ti,ab OR ('body power*' OR bionic* OR'external* power*' OR ‘man-machine’ OR myoelectric* OR neuroprosth* OR
prosthes* OR prosthet*):ti) AND (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ‘trans radial’ OR ulnar OR ‘upper arm*’ OR ‘upper limb*’ OR‘upper extremit*’ OR ‘upper or lower’):ti,ab))Page 120 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #KQ 12(cont.)March 2022

Concept

Strategy#3Physical andoccupational
therapies‘athletic rehabilitation’/de OR ‘core stability exercise’/de OR 'exercise'/exp/mj OR‘functional training’/de OR ‘kinesiotherapy’/exp OR ‘occupational therapy’/de OR‘physiotherapy’/exp OR ‘manipulative medicine’/exp OR ‘manual therapist’/exp OR‘muscle training’/de OR ‘occupational therapist’/de OR ‘physical medicine’/de OR‘physical rehabilitation’/de OR ‘physiotherapist’/de OR ‘range of motion’/exp/mj OR‘range of motion exercise’/de OR ‘rehabilitation medicine’/de OR ‘resistancetraining’/de OR ‘return to sport’/de OR 'return to work'/de OR ‘strengthening
exercise’/de OR ‘vocational rehabilitation’/de OR ((‘amputee’/de OR‘amputation’/de OR ‘arm amputation’/exp) AND ‘range of motion’/exp) OR ‘adaptive
sport*’:ti,ab,kw OR (chang* NEAR/5 dominan*) OR exercise*:ti OR ((exercise* OR
recreation* OR physical OR occupation* OR vocation*) NEAR/4 (rehab* ORtherap*)):ti,ab,kw OR ‘functional training’ OR kinesiotherap*:ti,ab,kw OR ‘manual
therap*’:ti,ab,kw OR ‘manipulative medicine’:ti,ab OR physiatrist*:ti,ab,kw OR'physical medicine':ti,ab,kw OR ((physical OR occupation* OR vocation*) AND
protocol*):ti,ab OR physiotherap*:ti,ab,kw OR ‘physio therap*’:ti,ab,kw OR((exercise* OR rehab* OR therap* OR train*) NEAR/5 ‘range* of motion*’):ti,ab OR‘rehab* therap*’:ti,ab,kw OR relearn*:ti,ab OR ‘resistance training’:ti,ab,kw OR
retrain*:ti,ab,kw OR (return* NEXT/2 (duty OR play OR sport* OR work)):ti,ab OR(scar* NEAR/2 massage*) OR strengthen*:ti,ab OR ‘sport* train*’:ti,ab,kw OR(strengthen* AND (‘residual limb*’ OR ‘intact limb*’)) OR (core NEAR/3 strength*)
OR (preserv* NEAR/5 (contralateral OR intact))#4

Prostheses/equipm ‘assistive technology’/de OR ‘assistive technology device’/de OR ‘physical therapy
ent specificdevice’/de OR ‘rehabilitation equipment’/de OR ((adaptive OR assistive OR rehab*)
NEXT/4 (technolog* OR equipment)):ti,ab,kw OR ((device* OR prosthes* OR
prosthet*) NEAR/4 (educat* OR provision* OR rehab* OR teach* OR train*)) OR‘durable medical equipment’:ti,ab,kw OR DME:ti OR (efficien* NEAR/5 train*)#5Intervention timing, ‘biofeedback’/exp OR 'biofeedback training'/de OR ‘biofeedback therapy’/de OR
additional‘community reintegration’/de OR ‘desensitization’/de OR ‘mirror box therapy’/de OR
therapies, and‘mirror therapy’/de OR ‘patient education’/de OR ‘psychosocial rehabilitation’/de OR
interventions‘wound care’/exp/mj OR ‘wound management’/de OR (activit* NEAR/4 analy*) OR
biofeedback* OR ‘bio feedback*’ OR (communit* NEAR/2 reintegrat*) OR desensitiz*
OR desensitis* OR ((frequency OR number*) NEAR/4 (course OR exercise* ORintervention* OR practice* OR rehab* OR session* OR therap* OR train* OR
treatment* OR visit*)) OR ‘mirror box*’ OR ‘mirror therap*’ OR ‘mirror visual’ OR
MVF:ti OR ‘neuromuscular educat*’ OR ‘neuro muscular educat*’ OR ‘patientdischarge education’:ti,ab,kw OR ‘patient education’:ti,ab,kw OR ((course OR exercise*
OR intervention* OR practice* OR rehab* OR session* OR timing OR therap* OR train*
OR treatment* OR visit*) AND (per NEAR/2 (day* OR hour* OR minute* OR month*
OR week*))) OR ((physician* OR therap*) AND (‘patient reported’ NEAR/3 (information
OR outcome* OR symptom*))):ti,ab OR ‘practice pattern*’ OR ((schedule* OR stage*
OR time OR visit*) NEAR/5 (course OR intervention* OR rehab* OR therap* OR
training*)) OR ‘stage* of care’ OR (timing AND (intervention* OR rehab* OR therap*))
OR ‘therap* protocol*’ OR ‘wound care’:ti,ab OR ‘wound management*’:ti,ab#6Combinepopulation sets

#1 OR #2

#7

Combineintervention sets

#3 OR #4 OR #5#8

Combinepopulation andintervention sets

#6 AND #7

Page 121 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #
#9

KQ 12
(cont.)

Limits andhedgesapplied toeachsearchstrategy

Concept

Strategy

Apply limits,
remove unwanted
publication types,
limit to SRs, MAs,
RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

Hedge to identify
RCTs'random sample'/de OR 'randomized controlled trial'/de OR randomization/de OR(random* OR RCT):ti,abHedge to identify
meta-analyses andsystematic reviews'meta analysis'/exp OR 'systematic review'/de OR [cochrane review]/lim OR
systematic*:ti OR (cochrane OR metaanaly* OR “meta analy*” OR (search* AND(databases OR electronic OR methodolog* OR embase* OR ebsco* OR medline* OR
ovid* OR sciencedirect* OR scopus* OR systematic OR web)) OR (systematic*
NEAR/2 review*)):ti,abHedge to identify
nonrandomized
controlled andcomparative
studies'case control study'/exp OR 'clinical trial'/exp OR 'cohort analysis'/de OR'comparative study'/exp OR 'control group'/de OR 'controlled study'/exp OR‘longitudinal study’/de OR 'major clinical study'/de OR ‘prospective study’/de OR‘retrospective study’/de OR (‘between groups’ OR 'case control*' OR cohort OR
compar* OR 'control group*' OR 'controlled study' OR 'controlled trial' OR 'crossover' OR crossover OR 'double blind' OR 'double blinded' OR longitudinal OR'matched controls' OR placebo* OR prospective OR retrospective OR sham):ti,ab OR(versus OR vs):ti

Limit to English
language
publications

AND [english]/lim

Exclude animal and NOT (([animals]/lim NOT [humans]/lim) OR (animal* OR cadaver* OR experimental
experimental
OR (vitro NOT vivo) OR canine OR dog OR dogs OR mouse OR mice OR murine OR pig
studies
OR pigs OR piglet* OR porcine OR rabbit* OR rat OR rats OR rodent* OR sheep OR
swine):ti)
Exclude studies
focusing onchildren

NOT ((adolescen* OR boys OR child* OR girls OR juvenile* OR paediatric* OR
pediatric* OR preschool* OR teen* OR toddler* OR youth*) NOT (adult* OR men OR
women)):ti

Remove unwanted
publication andstudy types(e.g., case reports,
conferences,
editorials)

NOT ('conference paper'/exp OR [conference abstract]/lim OR [conference
paper]/lim OR [conference review]/lim OR ('case report' OR book OR editorial OR
erratum OR letter OR note OR 'short survey')/de OR (book OR conference OR
editorial OR erratum OR letter OR note OR 'short survey'):it OR ‘a case’:ti,ab OR 'year
old':ti OR (book OR 'conference proceeding'):pt OR (‘case report’ OR comment OR((rationale OR study) NEAR/3 protocol)):ti)

Remove unrelated
studies

NOT ((((elbow OR hip OR joint OR knee OR shoulder) NEXT/1 (arthroscop* OR
arthroplast* OR replacement*)):ti) OR (arthroplast*:ti,ab,kw NOT amput*) OR
dental:ti OR denture*:ti OR laparoscopic*:ti OR maxillofacial:ti OR orthodontic*:ti
OR palmoplantar:ti OR parkinson*:ti OR poststroke*:ti OR prosthodontic*:ti OR
stroke:ti OR 'robotic assisted surg*':ti,ab OR 'robotic surg*':ti,ab OR 'surgicalrobot*':ti,ab OR teeth:ti OR tooth:ti OR ((robot* NEAR/2 surg*):ti))Limit to items
published 20132021

AND [2013-2021]/py

Limit to results
added to the
database between
February 1, 2013,
and April 30, 2021

AND [1-2-2013]/sd NOT [30-04-2021]/sd*For more information about the key question (KQ), see Table A-2.

March 2022

Page 122 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

B.

CINAHL in EBSCO Syntax (KQs 2, 3, 7, 8, 9, 12)

Question* Set #Concept

S1

Adults with UE
amputation(DE "arm injuries" OR DE "upper extremity" OR TX (arm OR arms OR carpal
OR digit OR digits OR digital OR elbow* OR finger* OR forearm* OR
forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*)) OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR "upper extremit*" OR "upper limb*" OR wrist*))AND (DE "amputation" OR DE "amputation stumps" OR DE "amputees" OR
DE "disarticulation" OR DE "amputation, traumatic" OR TX (amputat* OR
amputee* OR disarticulat* OR exarticulat* OR "limb loss*" OR "loss of limb*"
OR postamputation* OR reamputat* OR "remaining limb*" OR "residual
limb*" OR stump*)) OR TX (loss* N2 ("upper limb*" OR "upper extremit*"))S2

General terms

DE “behavioral medicine” OR DE “motivation” OR DE “psychosocial
intervention” OR DE “psychosocial functioning” OR DE “psychosocial support
systems” OR DE "social adjustment” OR DE “social behavior” OR DE “social
skills” OR TX “behavioral health OR TI communit* OR TX (communit* AND(assist* OR integrat* OR interact* OR live OR living OR particip* OR
reintegrat* OR relation* OR support*)) OR TX (“general communit*” ORhappiness OR “patient engagement*” OR psychosocial* OR “psycho social*”)OR TX (social* N3 (adapt* OR adjust* OR behavior* OR competent* OR
integrat* OR interact* OR particip* OR rehab* OR reintegrat* OR skill*))S3

Peer/group/mentor/
community

DE “community integration” OR DE “therapeutic community” OR DE“community participation” OR DE “community psychiatry” OR DE“psychotherapy, group” OR DE “mentors” OR DE “peer group” OR DE “peerinfluence” OR DE “social support” OR DE “self-help groups” OR TX (“1 on 1”
OR “amputee support*” OR “emotional* support*” OR “group therap*”) OR
TX ((group* OR peer*) W2 (counsel* OR therap* OR support*)) OR TX
interpersonal OR TX mentor* OR TX (mutual W2 (group* OR help* OR
support*)) OR TX ((mutual OR communit* OR peer*) N3 (help* OR group* OR
support* OR aid OR led OR assist*)) OR TX “one on one” OR TI peer* OR AB
peer* OR TX (support* N2 group*) OR TX “wounded warrior”

S4

Additional counselingand therapy

DE “acceptance and commitment therapy” OR DE “behavior therapy” OR DE“cognitive behavioral therapy” OR DE “case managers” OR DE “counseling”
OR DE “mental health services” OR DE “mindfulness” OR DE “psychotherapy”
OR DE “social medicine” OR TX ((acceptance OR commitment) N3 therap*)
OR TI ACT OR TX ((behavior* OR cognitiv* OR famil* OR motivation* OR
psychological OR social*) N2 (counsel* OR intervent* OR management OR
service* OR support* OR therap*)) OR TX “case manage*” OR TI CBT OR TX
counseling OR TX “mental health care” OR TX (mindful* W2 therap*) OR TX
motivational OR TX (motivation* N2 (enhancement* OR intervention* OR
interview* OR support*)) OR TX (psychodynamic N2 therap*) OR TX
psychotherap* OR TX ((social OR interpersonal) N2 (support* OR train*)) OR
TX “social work*” OR TX “social service*”

S5

Education andtechniques

DE “education” OR DE “meditation” OR DE “mindfulness” OR DE “patient
education as topic” OR TX (breathing N2 (deep* OR exercise*)) OR TX (“client
education” OR hakomi OR MBSR OR meditat* OR mindfulness) OR TX(mindful* N2 “stress reduc*”) OR TX (morita OR “neuroscience education”
OR “neuroscience therap*” OR “pain education” OR “patient discharge
education” OR “patient education”) OR TI PNE OR TX psychoeducation* OR
TX “self help” OR TI TNE

S6Combine intervention
sets

S2 OR S3 OR S4 OR S5

S7

Combine populationand intervention sets

S1 AND S6

KQ 2

March 2022

Strategy

Page 123 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

S8

Apply limits, remove
unwanted publication
types, limit to SRs,
MAs, RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

S1

Adults with UE
amputation(DE "arm injuries" OR DE "upper extremity" OR TX (arm OR arms OR carpal
OR digit OR digits OR digital OR elbow* OR finger* OR forearm* OR
forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*)) OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR "upper extremit*" OR "upper limb*" OR wrist*))AND (DE "amputation" OR DE "amputation stumps" OR DE "amputees" OR
DE "disarticulation" OR DE "amputation, traumatic" OR TX (amputat* OR
amputee* OR disarticulat* OR exarticulat* OR "limb loss*" OR "loss of limb*"
OR postamputation* OR reamputat* OR "remaining limb*" OR "residual
limb*" OR stump*)) OR TX (loss* N2 ("upper limb*" OR "upper extremit*"))S2

General terms

DE “delivery of health care” OR DE “health facilities” OR TI (amput* N2
rehab*) OR AB (amput* N2 rehab*) OR TI (care N2 deliver*) OR AB (care N2
deliver*) OR TX ((duration* OR frequenc* OR intensity) N5 outcome*) OR TX(frequenc* N5 (duration* OR intensit*)) OR TX (intensit* N5 (duration* OR
frequenc*)) OR TI (outcome* N2 improv*) OR TI (postoperative OR “postoperative” OR postsurgical OR “post surgical” OR “post surgery” OR
posttreatment OR “post treatment”) OR TX ((rehab* N3 (nursing OR
program* OR setting*)) OR TX (service* N3 deliver*) OR TX (((appointment*
OR treatment* OR visit*) N2 (deliver* OR duration* OR frequen* OR
intensit* OR length* OR service* OR setting* OR time OR timing)) OR AB(day* AND month* AND week*)

S3

Settings/locations

DE “ambulatory care facilities” OR DE “inpatients” OR DE “hospitalization”
OR DE “outpatients” OR DE “outpatient clinics, hospital” OR DE“rehabilitation centers” OR DE “residential facilities” OR TX “acute care” OR
TX “acute rehab*” OR TX (ambulatory N2 (care OR center* OR facilit* OR
rehab*)) OR TX “care facilit*” OR TI clinic OR TI clinics OR TX “day* rehab*”
OR TI hospitalis* OR TI hospitaliz* OR TI “in hospital” OR AB “in hospital” OR
TX ((inpatient* OR outpatient*) N3 (care OR clinic* OR department* OR
facilit* OR hospital* OR rehab* OR therap* OR treat*)) OR TX (rehab* N2(center* OR hospital*)) OR TX “residential rehab*” OR TX “skilled nursing”
OR TX “UEAcenter*” OR TX (“upper limb” N2 center*)

KQ 2(cont.)KQ 3

March 2022

Strategy

Page 124 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

S4

Telehealth/virtual/
digitalDE “computer simulation” OR DE “digital technology” OR DE “telemedicine”
OR DE “telephone” OR DE “video games” OR DE “virtual reality” OR TI(android OR camera* OR cellphone OR “cell phone” OR computer* OR
distan* OR electronic OR email OR “e-mail” OR game OR gaming OR facetime
OR “face time” OR ipad OR “i pad” OR iphone OR “i phone” OR internet OR
laptop OR mobile OR online OR phone* OR remote* OR smart* OR tablet*
OR telephone* OR video* OR virtual OR “web based” OR wireless OR zoom)
OR TX ((android OR camera* OR cellphone OR “cell phone” OR computer*
OR digital OR distan* OR electronic OR email OR “e-mail” OR facetime OR“face time” OR ipad OR “i pad” OR iphone OR “i phone” OR internet OR
laptop OR mobile OR online OR remote* OR tablet* OR telephone OR video*
OR virtual OR “web based” OR zoom) N2 (care OR conference* OR consult*
OR monitor* OR health* OR medicine OR psychiatr* OR psycholog* OR
psychotherap* OR therap* OR treatment* OR visit*)) OR TX (“augmented
reality” OR bluetooth OR “blue tooth” OR “digital technolog*” OR “e care”
OR “e consult*” OR ehealth OR “e health” OR emedicine OR “e medicine” OR
etherapy OR “e therapy”) OR TX ((game OR gaming) N5 (rehab* OR
treatment*)) OR “game based” OR “gaming based” OR mhealth OR “mhealth” OR TX ((mobile OR wireless OR smart) N5 (health* OR device* ORapplication* OR app OR apps)) OR TX ((phone* OR telephone*) N3 (consult*
OR interview* OR visit*)) OR TX ((“real time” OR realtime OR real-time) AND(care OR communicat* OR consult* OR mentor* OR rehab* OR therap* OR
treatment*)) OR TX ((remote OR remotely) N5 (consult* OR game* OR
gaming OR health* OR visit*)) OR TX (smartphone* OR “smart technolog*”
OR “technology based” OR telecare OR “tele care” OR teleconsult* OR “teleconsult*” OR telehealth OR “tele health” OR telemanagement OR “telemanagement” OR telemedicine OR “tele medicine” OR telemonitor* OR “telemonitor*” OR telenursing OR “tele nursing” OR telerehab* OR “tele rehab*”
OR teletreatment* OR “tele treatment*” OR televideo OR “tele video” ORvideoconferenc* OR “virtual reality”)

S5

Combine intervention
sets

S2 OR S3 OR S4

S6

Combine populationand intervention sets

S1 AND S5

S7

Apply limits, remove
unwanted publication
types, limit to SRs,
MAs, RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

S1

Adults with UE
amputation(DE "arm injuries" OR DE "upper extremity" OR TX (arm OR arms OR carpal
OR digit OR digits OR digital OR elbow* OR finger* OR forearm* OR
forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*)) OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR "upper extremit*" OR "upper limb*" OR wrist*))AND (DE "amputation" OR DE "amputation stumps" OR DE "amputees" OR
DE "disarticulation" OR DE "amputation, traumatic" OR TX (amputat* OR
amputee* OR disarticulat* OR exarticulat* OR "limb loss*" OR "loss of limb*"
OR postamputation* OR reamputat* OR "remaining limb*" OR "residual
limb*" OR stump*)) OR TX (loss* N2 ("upper limb*" OR "upper extremit*"))S2Phantom/residual limb ((DE “chronic pain” OR DE “pain” OR DE “pain, postoperative” OR pain*) AND
pain(((missing N4 (perception* OR perceive*)) OR DE “phantom limb” ORphantom* OR “remaining limb*” OR “residual limb*”)) OR “pain perceived”
OR “perceived pain” OR (pain* N3 stump*)

KQ 3(cont.)

KQ 7
KQ 8
KQ 9

March 2022

Strategy

Page 125 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #

KQ 7
KQ 8
KQ 9
(cont.)KQ 12

March 2022

Concept

Strategy

S3

Narrower upper
extremity terms
paired with phantom
and residual limb pain
terms (to capture
studies not containing
amputation terms insearchable fields)((DE "arm injuries" OR DE "upper extremity" OR TX (arm OR arms OR carpal
OR digit OR digits OR digital OR elbow* OR finger* OR forearm* OR
forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*)) OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR "upper extremit*" OR "upper limb*" OR wrist*))AND (DE “chronic pain” OR DE “pain” OR DE “pain, postoperative” OR pain*)AND (DE “phantom limb” OR phantom* OR “remaining limb*” OR “residual
limb*” OR (pain* N3 stump*)))

S4

Combine population
S1 AND S2
and phantom limb sets

S5

Combine sets

S3 OR S4

S6

Apply limits, remove
unwanted publication
types, limit to SRs,
MAs, RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

S1

Adults with UE
amputation(DE "arm injuries" OR DE "upper extremity" OR TX (arm OR arms OR carpal
OR digit OR digits OR digital OR elbow* OR finger* OR forearm* OR
forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*)) OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR "upper extremit*" OR "upper limb*" OR wrist*))AND (DE "amputation" OR DE "amputation stumps" OR DE "amputees" OR
DE "disarticulation" OR DE "amputation, traumatic" OR TX (amputat* OR
amputee* OR disarticulat* OR exarticulat* OR "limb loss*" OR "loss of limb*"
OR postamputation* OR reamputat* OR "remaining limb*" OR "residual
limb*" OR stump*)) OR TX (loss* N2 ("upper limb*" OR "upper extremit*"))S2

UE prosthesis
population((DE “bionics” OR DE ”artificial limbs”) AND DE “upper extremity”) OR TX“artificial hand*” OR (TX (“artificial limb*” AND (arm OR arms OR hand OR
hands OR upper)) OR (TX ((bionic* OR “man-machine” OR myoelectric* OR“myo electric*” OR neuroprosth* OR prosthes* OR prosthet* OR “robot*
manipulat*”) N2 (arm OR arms OR carpal OR digit OR digits OR elbow* OR
finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR palm OR palms OR phalang* OR phalanx* OR
radial OR radius OR shoulder* OR thumb* OR transcarpal OR transhumeral
OR transradial OR ulnar OR ‘upper extremit*’ OR ‘upper limb*’))) OR (TX((neuroprosth* OR prosthes* OR prosthet*) N4 (arm OR arms OR hand OR
hands OR “upper extremit*” OR “upper limb*”))) OR (((TX ((artificial* OR“body power*” OR bionic* OR electric* OR electronic OR “external* power*”
OR “man-machine” OR myoelectric* OR myo-electric* OR neuroprosth* OR
prosthes* OR prosthet* OR robot*) N3 (extremit* OR limb*))) OR (TI (bionic
OR “body power*” OR "electric* powered" OR “external* power*” OR “manmachine” OR myoelectric* OR neuroprosth* OR prosthes* OR prosthet* OR
robotic*))) AND (TX (arm OR arms OR carpal OR digit OR digits OR elbow* OR
finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR “trans radial” OR ulnar OR “upper arm*” OR“upper limb*” OR “upper extremit*”)))

Page 126 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Strategy

S3Physical andDE “exercise” OR DE “occupational therapy” OR DE “physical therapy
occupational therapies modalities” OR DE “Osteopathic Medicine” OR DE “Range of Motion,
Articular” OR DE “Physical and Rehabilitation Medicine” OR DE “ResistanceTraining” OR DE “Return to sport” OR DE “Return to Work” OR DE“Rehabilitation, Vocational” OR TX “adaptive sport*” OR TX (chang* N5
dominan*) OR TI exercise* OR TX ((exercise* OR recreation* OR physical OR
occupation* OR vocation*) N4 (rehab* OR therap*)) OR TX (“functional
training” OR kinesiotherap* OR “manual therap*” OR “manipulative
medicine” OR physiatrist* OR “physical medicine”) OR TX ((physical OR
occupation* OR vocation*) AND protocol*) OR TX physiotherap* OR TX“physio therap*” OR TX ((exercise* OR rehab* OR therap* OR train*) N5“range* of motion*”) OR TX “rehab* therap*” OR TI relearn* OR AB relearn*
OR TX “resistance training” OR TI retrain* OR AB retrain* OR TX (return* W2(duty OR play OR sport* OR work)) OR TX (scar* N2 massage*) OR TI
strengthen* OR AB strengthen* OR TI “sport* train*”OR AB “sport* train*”
OR (strengthen* AND (“intact limb” OR “residual limb”)) OR (core N3
strength) OR (preserv* N5 (contralateral OR intact))

S4

Prostheses/equipment DE “self-help devices” OR TX ((adaptive OR assistive OR rehab*) W4
specific(technolog* OR equipment)) OR TX ((device* OR prosthes* OR prosthet*) N4(educat* OR provision* OR rehab* OR teach* OR train*)) OR TI “durable
medical equipment” OR AB “durable medical equipment” OR TI DME OR TX(efficien* N5 train*)

S5

Intervention timing,
additional therapies
and interventions

DE “biofeedback, psychology” OR DE “community integration” OR DE“desensitization, psychologic” OR DE “neurofeedback” OR DE “patient
education as topic” OR TX (activit* N4 analy*) OR TX biofeedback* OR TX“bio feedback*” OR TX (communit* N2 reintegrat*) OR TX desensitiz* OR TX
desensitis* OR TX ((frequency OR number*) N4 (course OR exercise* ORintervention* OR practice* OR rehab* OR session* OR therap* OR train* OR
treatment* OR visit*)) OR TX (“mirror box*” OR “mirror therap*” OR “mirror
visual”) OR TI MVF OR TX (“neuromuscular educat*” OR “neuro muscular
educat*” OR “patient discharge education” OR “patient education”) OR TX((course OR exercise* OR intervention* OR practice* OR rehab* OR session*
OR timing OR therap* OR train* OR treatment* OR visit*) AND (per N2 (day*OR hour* OR minute* OR month* OR week*))) OR TX ((physician* OR
therap*) AND (“patient reported” N3 (information OR outcome* OR
symptom*))) OR TX “practice pattern*” OR TX ((schedule* OR stage* OR time
OR visit*) N5 (course OR intervention* OR rehab* OR therap* OR training*))
OR TX “stage* of care” OR TX (timing AND (intervention* OR rehab* ORtherap*)) OR TX “therap* protocol*” OR TI (“wound care” OR “wound
management*”) OR AB (“wound care” OR “wound management*”)

S6

Combine populations

S1 OR S2

S7

Combine intervention
sets

S3 OR S4 OR S5

S8

Combine populationand intervention sets

S6 AND S7

S9

Apply limits, remove
unwanted publication
types, limit to SRs,
MAs, RCTs, non-RCTs,
and comparative
studies

See limits and hedges at the end of this table

KQ 12(cont.)March 2022

Concept

Page 127 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Concept

Strategy

Hedge to identify RCTs PT "randomized controlled trial" OR TI (random* OR RCT) OR AB (random*
OR RCT)

Limits andhedgesapplied toeachsearchstrategy

Hedge to identify
meta-analyses andsystematic reviews

PT "meta-analysis" OR PT "systematic review" OR "cochrane database syst
rev" OR TI systematic* OR TI "meta-analysis" OR AB (cochrane OR
metaanaly* OR "meta analy*" OR (search* AND (databases OR electronic OR
methodolog* OR embase* OR ebsco* OR medline* OR ovid* OR
sciencedirect* OR scopus* OR systematic OR web)) OR AB (systematic* N2
review*))

Hedge to identify
nonrandomized
controlled andcomparative studies

AB ("case control study" OR "clinical trial" OR "cohort analysis" OR"comparative study" OR "control group" OR "controlled study" OR"longitudinal study" OR "major clinical study" OR "prospective study" OR"retrospective study" OR "between groups" OR "case control*" OR cohort OR
compar* OR "control group*" OR "controlled study" OR "controlled trial" OR"cross over" OR crossover OR "double blind" OR "double blinded" OR
longitudinal OR "matched controls" OR placebo* OR prospective OR
retrospective OR sham) OR TI (versus OR vs)

Exclude animal andexperimental studies

NOT (TI (animal* OR cadaver* OR experimental OR (vitro NOT vivo) OR
canine OR dog OR dogs OR mouse OR mice OR murine OR pig OR pigs OR
piglet* OR rabbit* OR rat OR rats OR rodent* OR sheep OR swine))

Exclude studies
focusing on children

NOT (TI (adolescen* OR baby OR babies OR boys OR child* OR girls OR
infancy OR infant* OR juvenile* OR neonat* OR newborn* OR NICU OR
nurser* OR paediatric* OR pediatric* OR preschool* OR school OR schools
OR teen* OR toddler* OR youth*) NOT TI (adult* OR women OR men))

Remove unwanted
publication and study
types (e.g., casereports, conferences,
editorials)

NOT (TI ((elbow OR hip OR joint OR knee OR shoulder) N1 (arthroscop* OR
arthroplast* OR replacement*)) OR (arthroplast* NOT amput*) OR dental OR
denture* OR "foot ulcer*" OR laparoscopic* OR maxillofacial OR
orthodontic* OR palmoplantar OR parkinson* OR poststroke OR
prosthodontic* OR stroke OR "robotic assisted surg*" OR "robotic surg*" OR"surgical robot*" OR teeth OR tooth OR (robot* N2 surg*))

Limit to English
language publications

AND LA English

Limit to results with
abstracts

AND AA Y

Limit to results
published 2013-2021

AND PY 2013-2021

Date – ensure results
entered into
databases since 2014
review (February 1,
2013)

AND EM 201302-

Remove MEDLINE
results

limited by Menu option under Advanced Search*For more information about the key question (KQ), see Table A-2.

March 2022

Page 128 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation RehabilitationC.

PsycINFO with OVID syntax (KQs 2, 4, 5, 7, 8, 9, 12)

Question* Set #Concept1

Adults with UE
amputation(("arm (anatomy)"/ OR "elbow (anatomy)"/ OR exp "fingers (anatomy)"/ OR"palm (anatomy)"/ OR "shoulder (anatomy)"/ OR wrist/ OR (arm OR arms
OR carpal OR digit OR digits OR digital OR elbow* OR finger* OR forearm*
OR forequarter OR hand OR hands OR humeral OR humerus OR
interscapulothoracic OR metacarp* OR palm OR palms OR ((phalang* OR
phalanx*) AND (digit OR digits OR finger* OR hand OR hands OR thumb*))
OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR "upper extremit*" OR "upper
limb*" OR wrist*).ti,ab,id.) AND (amputation/ OR (amputat* OR amputee*
OR disarticulat* OR exarticulat* OR "limb loss*" OR "loss of limb*" ORpostamputation* OR reamputat* OR "remaining limb*" OR "residual limb*"
OR stump*).ti,ab,id.)) OR (loss* ADJ2 ("upper limb*" OR "upper
extremit*")).ti,ab,id.

2

Phantom/residual
limb pain"phantom limbs"/ OR "phantom limb*" OR (("remaining limb*" OR "residual
limb*" OR stump) ADJ3 pain)3

UE prostheses
population"artificial hand*".ti,ab. OR ("artificial limb*" AND (arm OR arms OR hand OR
hands OR upper)).ti,ab. OR ((bionic* OR "man-machine" OR myoelectric*
OR "myo electric*" OR neuroprosth* OR prosthes* OR prosthet* OR"robot* manipulat*") ADJ2 (arm OR arms OR carpal OR digit OR digits OR
elbow* OR finger* OR forearm* OR forequarter OR hand OR hands OR
humeral OR humerus OR metacarp* OR palm OR palms OR phalang* OR
phalanx* OR radial OR radius OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR ulnar OR "upper extremit*" OR "upper
limb*")).ti,ab. OR ((neuroprosth* OR prosthes* OR prosthet*) ADJ4 (arm OR
arms OR hand OR hands OR "upper extremit*" OR "upper limb*")).ti,ab,id.
OR ((artificial* OR "body power*" OR bionic* OR electric* OR electronic OR"external* power*" OR "man-machine" OR myoelectric* OR neuroprosth*
OR prosthes* OR prosthet* OR robot*) ADJ3 (extremit* OR limb*)).ti,ab. OR((prostheses/ OR ("body power*" OR bionic* OR "external* power*" OR"man-machine" OR myoelectric* OR neuroprosth* OR prosthes* OR
prosthet*).ti.) AND (arm OR arms OR carpal OR digit OR digits OR elbow* OR
finger* OR forearm* OR forequarter OR hand OR hands OR humeral OR
humerus OR metacarp* OR shoulder* OR thumb* OR transcarpal OR
transhumeral OR transradial OR "trans radial" OR ulnar OR "upper arm*" OR"upper limb*" OR "upper extremit*" OR "upper or lower").ti,ab.)

4

Combine populationsets

1 OR 2 OR 3

5

Apply limits, remove See limits and hedges at the end of this table
unwanted(Note that intervention search terms and study hedges were not included inpublication types and this PsycINFO strategy because the retrieval was very low)
off-topic results

KQ 2,
KQ 4,
KQ 5,
KQ 7,
KQ 8,
KQ 9,
KQ 12

March 2022

Strategy

Page 129 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Question* Set #Limits andhedgesapplied toeachsearchstrategy

Concept

Strategy

Limit to English
language
publications

limit to english language

Exclude animal andexperimental studies

NOT (animal* OR experimental OR (vitro NOT vivo) OR canine OR dog OR
dogs OR mouse OR mice OR murine OR pig OR pigs OR piglet* OR porcine
OR rabbit* OR rat OR rats OR rodent* OR sheep OR swine).ti.

Exclude studies
focusing on children

NOT ((adolescen* OR baby OR babies OR boys OR child* OR girls OR infancy
OR infant* OR juvenile* OR neonat* OR newborn* OR NICU OR nurser* OR
paediatric* OR pediatric* OR preschool* OR school OR schools OR teen* OR
toddler* OR youth*) NOT (adult* OR women OR woman OR pregnan*)).ti.

Remove unwanted
publication and study
types (e.g., casereports, conferences,
editorials)

NOT ((chapter OR "column/opinion" OR "comment/reply" OR dissertation
OR editorial OR letter OR review-book).dt. OR (book or encyclopedia OR"dissertation abstract").pt. OR ("case report" OR "a case" OR "yearold").ti,ab. OR ((rationale OR study) ADJ3 protocol).ti.)

Limit to results
published 2013-2021

limit to yr="2013 - 2021"

Limit to results
added to the
database between
February 1, 2013,
and April 30, 2021

limit to up=20130201-20210430

Remove MEDLINE
results (alreadycaptured by EMBASE
search)NOT (1* OR 2* OR 3* OR 4* OR 5* OR 6* OR 7* OR 8* OR 9*).pm.

*For more information about the key question (KQ), see Table A-2.

March 2022

Page 130 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix N: Alternative Text Descriptions of Algorithm
The following outline narratively describes the ULA algorithm. An explanation of the purpose of the algorithmand description of the various shapes used within the algorithm can be found in the Algorithm section. The
sidebars referenced within this outline can also be found in the Algorithm section.

Module A: Upper Limb Amputation Management
1. Module A starts with Box 1, in the shape of a rounded rectangle: “Patient presents with need for ULA
care”
2. Box 1 connects to Box 2, in the shape of a hexagon, asks the question: “Does the patient require
perioperative care?”a. If the answer is “Yes” to Box 2, then Box 3, in the shape of a rectangle: “Engage the amputation
care team to conduct a comprehensive interdisciplinary assessment; offer peer support* (seeRecommendation 14 and Sidebar 1)”
i. Box 3 has a footnote: “Peer support includes both peer visitors right after surgery andpeer support in an outpatient setting”
b. If the answer is “No” to Box 3, then Box 9, in the shape of a hexagon, asks the question: “Is thepatient a candidate for pre-prosthetic training?”
3. Box 3 connects to Box 4, in the shape of a hexagon, asks the question: “Is the patient ready for initiationof rehabilitation services?”
a. If the answer is “Yes” to Box 4, then Box 6, in the shape of a square: “Develop a patient-centeredrehabilitation care plan (see Sidebar 2)”
b. If the answer is “No” to Box 4, then Box 5, in the shape of a square: “Refer the patient toappropriate services for care and management”
4. Box 6 connects to Box 7, in the shape of a square: “Appropriate education regarding currently available
technology, surgical, rehabilitation procedures and peer support options should be provided to thepatient, family, and caregiver(s)”5. Box 7 connects to Box 8, in the shape of a square: “Ensure patient achieves highest level of functional
independence without a prosthesis”
6. Box 8 connects to Box 9, in the shape of a hexagon, asks the question: “Is the patient a candidate for preprosthetic training?”
a. If the answer is “Yes” to Box 9, then Box 10, in the shape of a square: “Engage the amputation
care team to administer pre-prosthetic training (see Sidebar 3)”
b. If the answer is “No” to Box 9, then Box 14, in the shape of a hexagon, asks the question: “Is thepatient a candidate for prosthetic training?”
i. If the answer is “Yes” to Box 14, then Box 15, in the shape of a square: “Engage theamputation care team to administer prosthetic training and education”
ii. If the answer is “No” to Box 14, then Box 19, in the shape of a square: “Ensure patientachieves highest level of functional independence without a prosthesis”
March 2022

Page 131 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

1. Box 19 connects to Box 20, in the shape of a square: “Recommend lifelong careand management of ULA”
7. Box 10 connects to Box 11, in the shape of a square: “Confirm prosthesis candidacy and determine mostappropriate prosthetic device(s)”a. Box 11 has a footnote: “May involve trials of various device components as appropriate andfeasible”
8. Box 11 connects to Box 12, in the shape of a square: “Write prosthetic device prescription including allnecessary components”
9. Box 12 connects to Box 13, in the shape of a square: “Initiate upper extremity prosthesis fitting”
10. Box 13 connects to Box 15, in the shape of a square: “Engage the amputation care team to administer
prosthetic training and education”
11. Box 15 connects to Box 16, in the shape of a hexagon, asks the question: “Does the prosthetic device
improve functional status and meet realistic patient goals?”a. If the answer is “Yes” to Box 16, then Box 17, in the shape of a square: “Conduct final prosthesis
check out including all appropriate members of the care team”
b. If the answer is “No” to Box 16, then Box 11, in the shape of a square: “Confirm prosthesis
candidacy and determine most appropriate prosthetic device(s)”12. Box 17 connects to Box 18, in the shape of a hexagon, asks the question: “Does the patient require
additional prostheses and/or terminal devices?
a. If the answer is “Yes” to Box 18, then Box 11, in the shape of a square: “Confirm prosthesis
candidacy and determine most appropriate prosthetic device(s)”b. If the answer is “No” to Box 18, then Box 20, in the shape of a square: “Recommend lifelong careand management of ULA”
13. Box 20 connects to Box 21, in the shape of a square: “Coordinate patient transition into lifelong care andmanagement (including patient transfer to new catchment area)”
14. Box 21 connects to Box 22, in the shape of a square: “Engage the amputation care team and provide
routine scheduled follow-up at least every 12 months (see Sidebar 2)”
15. Box 22 connects to Box 23, in the shape of a square: “Provide education on current management andpractices; refer patient as appropriate to address medical, prosthetic or rehabilitation needs (see Box 9)”

Module B: Upper Limb Amputation Management for Primary Care
1. Module B begins with Box 24, in the shape of a rounded rectangle: “Patient presents with need for ULA
care”
2. Above boxes 26, 28, 30, 32, and 34 says: “See Sidebar 4 for additional information”
3. Box 24 connects to Box 25, in the shape of a hexagon, asks the question: “Is this the patient’s initial visit?
March 2022

Page 132 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

a. If the answer is “Yes” to Box 25, then Box 26, in the shape of a square: “Offer mental healthreferral; referral to amputation care team”
b. If the answer is “No” to Box 25, then Box 27, in the shape of a hexagon, asks the question: “Isthere new or worsening pain that limits function; new or worsening residual limb condition; newor worsening non-amputated limb condition; or new risk factor for amputation progression?”
i. If the answer is “Yes” to Box 27, then Box 28, in the shape of a square: “Referral to
PM&R; referral to amputation care team”
ii. If the answer is “No” to Box 27, then Box 29, in the shape of a hexagon, asks thequestion: “Are there changes or new functional goals; need for new or replacement
equipment; need for home or work environmental modifications; or need for new or
replacement assistive technology?
iii. If the answer is “Yes” to Box 29, then Box 30, in the shape of a square: “Referral to OT;
referral to amputation care team”
1. If the answer is “No” to Box 30, then Box 31, in the shape of a hexagon, asks thequestion: “Are there new or worsening prosthesis fit or function issues; need for
replacement prosthetic components or supplies; or need for new prosthetic
componentry or technology to achieve functional goals?”a. If the answer is “Yes” to Box 31, then Box 32, in the shape of a square:“Referral to prosthetics; referral to amputation care team”
b. If the answer is “No” to Box 31, then Box 33, in the shape of a hexagon,
asks the question: “Are there changes in support system; newpsychosocial stressors; or new emotional, behavioral, or psychologicalconsiderations?”
i. If the answer is “Yes” to Box 33, then Box 34, in the shape of asquare: “Referral to mental health; referral to amputation careteam”
ii. If the answer is “No” to Box 33, then Box 35, in the shape of asquare: “Actively promote and facilitate annual follow-up with
amputation care team”

March 2022

Page 133 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Appendix O: Abbreviations
Abbreviation

Definition

ACT

acceptance and commitment therapy

AHRQ

Agency for Healthcare Research and Quality

AMI

agonist-antagonist myoneural interface

BMI

body mass index

CBT

cognitive behavioral therapy

CI

confidence interval

COI

conflict of interest

COR

contracting officer's representative

CPG

clinical practice guideline

DHA

Defense Health Agency

DoD

Department of Defense

EBPWG

Evidence-Based Practice Work GroupGRADE

Grading of Recommendations Assessment, Development and Evaluation

HBS

Hand Bionic Scale

HEC

Health Executive Committee

IMES

implantable myoelectric sensor system

KQ

key questionmAb

monoclonal antibodies

MBSR

mindfulness-based stress reduction

MHS

Military Health System

NAM

National Academy of Medicine

NIBS

noninvasive brain stimulation

NICE

National Institute for Health and Care Excellence

NRS

numeric rating scale

OI

osseointegration

OT

occupational therapy

PCP

primary care providers

PCS

Pain Catastrophizing Scale

PHP

personal health plan

PHQ

Patient Health Questionnaire

PICOTS

population, intervention, comparison, outcome, timing and setting

PLP

phantom limb pain

PM&R

physical medicine and rehabilitation

PNB

peripheral nerve blockPTphysical therapy

PTSD

post-traumatic stress disorder

QoL

quality of life

RCT

randomized controlled trial

RPNI

regenerative peripheral nerve interfaceSRsystematic review

March 2022

Page 134 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Abbreviation

Definition

SUD

substance use disorderTDterminal device

TENS

transcutaneous electrical nerve stimulation

TMR

target nerve reinnervation

U.S.

United States

UEA

upper extremity amputation

ULA

upper limb amputation

USPSTF

United States Preventive Services Task Force

VA

Department of Veterans Affairs

VAS

visual analog scale

VCA

vascularized composite allotransplantation

VHA

Veterans Health Administration

March 2022

Page 135 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

References
1.

U.S. Department of Veterans Affairs/Department of Defense Health Executive Committee (HEC). Evidence
Based Practice Work Group Charter [updated January 9, 2017]. Available from:www.healthquality.va.gov/documents/EvidenceBasedPracticeWGCharter123020161.pdf.

2.

Schuch CM, Pritham CH. International Standards Organization Terminology: Application to Prosthetics andOrthotics. Jpo Journal of Prosthetics and Orthotics. 1994;6:29-33.

3.

Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb
loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008;89(3):422-9. Epub 2008/02/26.
doi: 10.1016/j.apmr.2007.11.005. PubMed PMID: 18295618.

4.

National Limb Loss Information Center. Limb loss in the United States: Amputation statistics by cause. 2008.
Available from: https://www.amputee-coalition.org/resources/limb-loss-statistics/.

5.

VHA Amputee Data Repository. VHA Support Service Center.Aug 2021. Available from:https://vssc.med.va.gov.

6.

Military Health System. Military Health System Data Repository. Aug 2021. Available from:https://health.mil/Military-Health-Topics/Technology/Clinical-Support/Military-Health-System-DataRepository.

7.

U.S. Department of Veteran Affairs, Department of Defense. Guideline for Guidelines: Veterans HealthAdministration, Office of Quality & Performance, Evidence Review Subgroup; [updated January 29, 2019].
Available from: http://www.healthquality.va.gov/policy/index.asp.

8.

Ransohoff DF, Pignone M, Sox HC. How to decide whether a clinical practice guideline is trustworthy. Jama.
2013;309(2):139-40. Epub 2013/01/10. doi: 10.1001/jama.2012.156703. PubMed PMID: 23299601.

9.

Andrews JC, Schunemann HJ, Oxman AD, Pottie K, Meerpohl JJ, Coello PA, et al. GRADE guidelines: 15.
Going from evidence to recommendation-determinants of a recommendation's direction and strength.
Journal of clinical epidemiology. 2013;66(7):726-35. Epub 2013/04/11. doi: 10.1016/j.jclinepi.2013.02.003.
PubMed PMID: 23570745.

10.

Andrews J, Guyatt G, Oxman AD, Alderson P, Dahm P, Falck-Ytter Y, et al. GRADE guidelines: 14. Going fromevidence to recommendations: the significance and presentation of recommendations. Journal of clinicalepidemiology. 2013;66(7):719-25. Epub 2013/01/15. doi: 10.1016/j.jclinepi.2012.03.013. PubMed
PMID: 23312392.

11.

Schunemann HJ, Fretheim A, Oxman AD. Improving the use of research evidence in guideline development:
10. Integrating values and consumer involvement. Health research policy and systems / BioMed Central.
2006;4:22. Epub 2006/12/07. doi: 10.1186/1478-4505-4-22. PubMed PMID: 17147811; PubMed Central
PMCID: PMCPmc1697808.

12.

Guyatt GH, Oxman AD, Kunz R, Atkins D, Brozek J, Vist G, et al. GRADE guidelines: 2. Framing the questionand deciding on important outcomes. Journal of clinical epidemiology. 2011;64(4):395-400.
Epub 2011/01/05. doi: 10.1016/j.jclinepi.2010.09.012. PubMed PMID: 21194891.

13.

Newberry SJ, Ahmadzai N, Motala A, Tsertsvadze A, Maglione M, Ansari MT, et al. AHRQ Methods for
Effective Health Care. Surveillance and identification of signals for updating systematic reviews:
Implementation and early experience. Rockville (MD): Agency for Healthcare Research and Quality (US);
2013.

14.

U.S. Preventive Services Task Force. Standards for Guideline Development. June 2018.

March 2022

Page 136 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

15.

National Institute for Health and Care Excellence. The guidelines manual. London: National Institute for
Health and Care Excellence, 2012.

16.

Martinez Garcia L, McFarlane E, Barnes S, Sanabria AJ, Alonso-Coello P, Alderson P. Updated
recommendations: an assessment of NICE clinical guidelines. Implementation science : IS. 2014;9:72.
Epub 2014/06/13. doi: 10.1186/1748-5908-9-72. PubMed PMID: 24919856; PubMed Central
PMCID: PMCPmc4067507.

17.

Rush AJ, Fava M, Wisniewski SR, Lavori PW, Trivedi MH, Sackeim HA, et al. Sequenced treatment
alternatives to relieve depression (STAR*D): rationale and design. Control Clin Trials. 2004;25(1):119-42.
Epub 2004/04/06. PubMed PMID: 15061154.

18.

Clinical Practice Guidelines We Can Trust. Washington, DC: National Academies Press, 2011.

19.

Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centered care and adherence: Definitions andapplications to improve outcomes. Journal of the American Academy of Nurse Practitioners.
2008;20(12):600-7. Epub 2009/01/06. doi: 10.1111/j.1745-7599.2008.00360.x. PubMed PMID: 19120591.

20.

Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, et al. The impact of patient-centeredcare on outcomes. J Fam Pract. 2000;49(9):796-804. Epub 2000/10/14. PubMed PMID: 11032203.

21.

National Learning Consortium. Shared Decision Making 2013. Available from:https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf.

22.

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century.
Washington DC: National Academies Press, 2001.

23.

Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. Proposal forclinical algorithm standards. Medical decision making : an international journal of the Society for Medical
Decision Making. 1992;12(2):149-54. Epub 1992/04/01. PubMed PMID: 1573982.

24.

Yuan F, McGlinn EP, Giladi AM, Chung KC. A Systematic Review of Outcomes after Revision Amputation for
Treatment of Traumatic Finger Amputation. Plast Reconstr Surg. 2015;136(1):99-113. Epub 2015/06/26.
doi: 10.1097/prs.0000000000001487. PubMed PMID: 26111316; PubMed Central
PMCID: PMCPMC4481863.

25.

Ahmed A, Bhatnagar S, Mishra S, Khurana D, Joshi S, Ahmad SM. Prevalence of Phantom Limb Pain, Stump
Pain, and Phantom Limb Sensation among the Amputated Cancer Patients in India: A Prospective,
Observational Study. Indian J Palliat Care. 2017;23(1):24-35. Epub 2017/02/22. doi: 10.4103/09731075.197944. PubMed PMID: 28216859; PubMed Central PMCID: PMCPMC5294433.

26.

Resnik L, Borgia M. Responsiveness of outcome measures for upper limb prosthetic rehabilitation. Prosthet
Orthot Int. 2016;40(1):96-108. Epub 2014/10/23. doi: 10.1177/0309364614554032. PubMed
PMID: 25336051.

27.

Otto IA, Kon M, Schuurman AH, van Minnen LP. Replantation versus Prosthetic Fitting in Traumatic Arm
Amputations: A Systematic Review. PLoS One. 2015;10(9):e0137729. Epub 2015/09/05. doi: 10.1371/
journal.pone.0137729. PubMed PMID: 26340003; PubMed Central PMCID: PMCPMC4560425.

28.

Resnik L, Borgia M. Reliability, Validity, and Responsiveness of the QuickDASH in Patients With Upper Limb
Amputation. Arch Phys Med Rehabil. 2015;96(9):1676-83. Epub 2015/04/29. doi: 10.1016/j.apmr.
2015.03.023. PubMed PMID: 25912667.

29.

Resnik L, Borgia M, Cancio J, Heckman J, Highsmith J, Levy C, et al. Dexterity, activity performance,
disability, quality of life, and independence in upper limb Veteran prosthesis users: a normative study.
Disabil Rehabil. 2020:1-12. Epub 2020/10/20. doi: 10.1080/09638288.2020.1829106. PubMed
PMID: 33073621.

March 2022

Page 137 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

30.

Chinta MS, Wilkens SC, Vlot MA, Chen NC, Eberlin KR. Secondary Surgery following Initial
Replantation/Revascularization or Completion Amputation in the Hand or Digits. Plast Reconstr Surg.
2018;142(3):709-16. Epub 2018/06/22. doi: 10.1097/prs.0000000000004647. PubMed PMID: 29927836.

31.

Vlot MA, Wilkens SC, Chen NC, Eberlin KR. Symptomatic Neuroma Following Initial Amputation forTraumatic Digital Amputation. J Hand Surg Am. 2018;43(1):86.e1-.e8. Epub 2017/09/28. doi: 10.1016/j.jhsa.
2017.08.021. PubMed PMID: 28951100.

32.

Nygaard RM, Lacey AM, Lemere A, Dole M, Gayken JR, Lambert Wagner AL, et al. Time Matters in Severe
Frostbite: Assessment of Limb/Digit Salvage on the Individual Patient Level. J Burn Care Res. 2017;38(1):539. Epub 2016/09/09. doi: 10.1097/bcr.0000000000000426. PubMed PMID: 27606554.

33.

Rubin G, Orbach H, Rinott M, Wolovelsky A, Rozen N. The use of prophylactic antibiotics in treatment offingertip amputation: a randomized prospective trial. Am J Emerg Med. 2015;33(5):645-7.
Epub 2015/02/16. doi: 10.1016/j.ajem.2015.02.002. PubMed PMID: 25682579.

34.

Salminger S, Sturma A, Roche AD, Mayer JA, Gstoettner C, Aszmann OC. Outcomes, Challenges, and Pitfalls
after Targeted Muscle Reinnervation in High-Level Amputees: Is It Worth the Effort? Plast Reconstr Surg.
2019;144(6):1037e-43e. Epub 2019/11/26. doi: 10.1097/prs.0000000000006277. PubMed PMID: 31764652.

35.

Dumanian GA, Potter BK, Mioton LM, Ko JH, Cheesborough JE, Souza JM, et al. Targeted Muscle
Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees: A Randomized Clinical Trial.
Ann Surg. 2019;270(2):238-46. Epub 2018/10/30. doi: 10.1097/sla.0000000000003088. PubMed
PMID: 30371518.

36.

Mioton LM, Dumanian GA, Shah N, Qiu CS, Ertl WJ, Potter BK, et al. Targeted Muscle Reinnervation
Improves Residual Limb Pain, Phantom Limb Pain, and Limb Function: A Prospective Study of 33 Major Limb
Amputees. Clin Orthop Relat Res. 2020;478(9):2161-7. Epub 2020/05/27. doi: 10.1097/corr.
0000000000001323. PubMed PMID: 32452928; PubMed Central PMCID: PMCPMC7431223 Related
Research® editors and board members are on file with the publication and can be viewed on request.

37.

Bowen JB, Ruter D, Wee C, West J, Valerio IL. Targeted Muscle Reinnervation Technique in Below-Knee
Amputation. Plast Reconstr Surg. 2019;143(1):309-12. Epub 2018/12/28. doi: 10.1097/prs.
0000000000005133. PubMed PMID: 30589808.

38.

Cheesborough JE, Souza JM, Dumanian GA, Bueno RA, Jr. Targeted muscle reinnervation in the initialmanagement of traumatic upper extremity amputation injury. Hand (N Y). 2014;9(2):253-7.
Epub 2014/05/20. doi: 10.1007/s11552-014-9602-5. PubMed PMID: 24839430; PubMed Central
PMCID: PMCPMC4022965.

39.

Souza JM, Cheesborough JE, Ko JH, Cho MS, Kuiken TA, Dumanian GA. Targeted muscle reinnervation: anovel approach to postamputation neuroma pain. Clin Orthop Relat Res. 2014;472(10):2984-90.
Epub 2014/02/25. doi: 10.1007/s11999-014-3528-7. PubMed PMID: 24562875; PubMed Central
PMCID: PMCPMC4160494.

40.

Osborn LE, Moran CW, Johannes MS, Sutton EE, Wormley JM, Dohopolski C, et al. Extended home use of anadvanced osseointegrated prosthetic arm improves function, performance, and control efficiency. J NeuralEng. 2021;18(2). Epub 2021/02/02. doi: 10.1088/1741-2552/abe20d. PubMed PMID: 33524965.

41.

Harijee A, Thankappan K, Sharma M, NageswaraRao NN, Patel T, Bhaskaran R, et al. Estimation of HealthUtility and Quality Adjusted Life Years in Bilateral Hand Transplantation: A Time Trade-off Study. Ann Plast
Surg. 2021;86(3):345-50. Epub 2020/09/04. doi: 10.1097/sap.0000000000002544. PubMed
PMID: 32881744.

March 2022

Page 138 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

42.

Petruzzo P, Gazarian A, Kanitakis J, Parmentier H, Guigal V, Guillot M, et al. Outcomes after bilateral handallotransplantation: a risk/benefit ratio analysis. Ann Surg. 2015;261(1):213-20. Epub 2014/03/22.
doi: 10.1097/sla.0000000000000627. PubMed PMID: 24646555.

43.

Kwah LK, Green J, Butler J, Lam L. Quality of Clinical Practice Guidelines for Management of Limb
Amputations: A Systematic Review. Phys Ther. 2019;99(5):577-90. Epub 2019/02/05. doi: 10.1093/ptj/
pzz006. PubMed PMID: 30715480.

44.

Zayan NE, West JM, Schulz SA, Jordan SW, Valerio IL. Incisional Negative Pressure Wound Therapy: An
Effective Tool for Major Limb Amputation and Amputation Revision Site Closure. Adv Wound Care (New
Rochelle). 2019;8(8):368-73. Epub 2019/07/28. doi: 10.1089/wound.2018.0935. PubMed PMID: 31346491;
PubMed Central PMCID: PMCPMC6657297.

45.

Anderson F, Bischof WF. Augmented reality improves myoelectric prosthesis training. International Journal
on Disability and Human Development. 2014;13(3):349-54. doi: doi:10.1515/ijdhd-2014-0327.

46.

Soyer K, Unver B, Tamer S, Ulger O. The importance of rehabilitation concerning upper extremity amputees:
A Systematic review. Pak J Med Sci. 2016;32(5):1312-9. Epub 2016/11/25. doi: 10.12669/pjms.325.9922.
PubMed PMID: 27882044; PubMed Central PMCID: PMCPMC5103156.

47.

Barbin J, Seetha V, Casillas JM, Paysant J, Pérennou D. The effects of mirror therapy on pain and motor
control of phantom limb in amputees: A systematic review. Ann Phys Rehabil Med. 2016;59(4):270-5.
Epub 2016/06/04. doi: 10.1016/j.rehab.2016.04.001. PubMed PMID: 27256539.

48.

Kikkert S, Mezue M, O'Shea J, Henderson Slater D, Johansen-Berg H, Tracey I, et al. Neural basis of induced
phantom limb pain relief. Ann Neurol. 2019;85(1):59-73. Epub 2018/11/02. doi: 10.1002/ana.25371.
PubMed PMID: 30383312; PubMed Central PMCID: PMCPMC6492189.

49.

Bocci T, De Carolis G, Ferrucci R, Paroli M, Mansani F, Priori A, et al. Cerebellar Transcranial Direct Current
Stimulation (ctDCS) Ameliorates Phantom Limb Pain and Non-painful Phantom Limb Sensations.
Cerebellum. 2019;18(3):527-35. Epub 2019/03/05. doi: 10.1007/s12311-019-01020-w. PubMed
PMID: 30830672.

50.

Latour D. Unlimbited Wellness: Telehealth for Adults with Upper-Limb Difference. JPO: Journal of
Prosthetics and Orthotics. 2019;31(4):246-56. doi: 10.1097/jpo.0000000000000263. PubMed
PMID: 00008526-201910000-00003.

51.

Resnik L, Borgia M, Ekerholm S, Highsmith MJ, Randolph BJ, Webster J, et al. Amputation Care Quality andSatisfaction With Prosthetic Limb Services: A Longitudinal Study of Veterans With Upper Limb Amputation.
Fed Pract. 2021;38(3):110-20. Epub 2021/04/17. doi: 10.12788/fp.0096. PubMed PMID: 33859462; PubMed
Central PMCID: PMCPMC8040957 with regard to this article. This work was funded by the Office of theAssistant Secretary of Defense for Health Affairs, through the Orthotics and Prosthetics Outcomes Research
Program Prosthetics Outcomes Research Award (W81XWH-16-675 2-0065) and the U.S Department of
Veterans Affairs (VA RR&D, A2707-I and VA RR&D A9264A-S).

52.

Resnik L, Borgia M, Clark M. Function and Quality of Life of Unilateral Major Upper Limb Amputees: Effect of
Prosthesis Use and Type. Arch Phys Med Rehabil. 2020;101(8):1396-406. Epub 2020/05/22. doi: 10.1016/
j.apmr.2020.04.003. PubMed PMID: 32437692.

53.

Moradi-Hades A, Farmani F, Mardani MA, Bahramizadeh M, Heidarimoghadam R. The Comparative Effect of
Cosmetic and Mechanical Prosthesis on Quality of Life and Performance in People With Medium-Length
Below-Elbow Amputation. JPO: Journal of Prosthetics and Orthotics. 2019;31(2):89-94. doi: 10.1097/jpo.
0000000000000250. PubMed PMID: 00008526-201904000-00004.

March 2022

Page 139 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

54.

Resnik L, Acluche F, Borgia M, Latlief G, Phillips S. EMG Pattern Recognition Control of the DEKA Arm:
Impact on User Ratings of Satisfaction and Usability. IEEE J Transl Eng Health Med. 2019;7:2100113.
Epub 2019/01/27. doi: 10.1109/jtehm.2018.2883943. PubMed PMID: 30680253; PubMed Central PMCID:PMCPMC6331198.

55.

Resnik L, Borgia M, Heinemann AW, Clark MA. Prosthesis satisfaction in a national sample of Veterans withupper limb amputation. Prosthet Orthot Int. 2020;44(2):81-91. Epub 2020/01/22. doi: 10.1177/
0309364619895201. PubMed PMID: 31960734.

56.

Resnik L, Borgia M, Latlief G, Sasson N, Smurr-Walters L. Self-reported and performance-based outcomesusing DEKA Arm. J Rehabil Res Dev. 2014;51(3):351-62. Epub 2014/07/16. doi: 10.1682/jrrd.2013.08.0180.
PubMed PMID: 25019659.

57.

Resnik LJ, Borgia ML, Acluche F, Cancio JM, Latlief G, Sasson N. How do the outcomes of the DEKA Arm
compare to conventional prostheses? PLoS One. 2018;13(1):e0191326. Epub 2018/01/18. doi: 10.1371/
journal.pone.0191326. PubMed PMID: 29342217; PubMed Central PMCID: PMCPMC5771605.

58.

Valerio IL, Dumanian GA, Jordan SW, Mioton LM, Bowen JB, West JM, et al. Preemptive Treatment of
Phantom and Residual Limb Pain with Targeted Muscle Reinnervation at the Time of Major Limb
Amputation. J Am Coll Surg. 2019;228(3):217-26. Epub 2019/01/12. doi: 10.1016/j.jamcollsurg.2018.12.015.
PubMed PMID: 30634038.

59.

Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, et al. Ambulatory continuous
peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruplemasked, placebo-controlled clinical trial. Pain. 2021;162(3):938-55. Epub 2020/10/07. doi: 10.1097/j.pain.
0000000000002087. PubMed PMID: 33021563; PubMed Central PMCID: PMCPMC7920494 and B. Khatibi:
The University of California has received funding and product for other research projects from Myoscience(Fremont, CA), Epimed (Farmers Branch, TX), Infutronics (Natick, MA), Ferrosan Medical (Søborg, Denmark),
SPR Therapeutics (Cleveland, OH), and Heron Therapeutics (San Diego, CA). J.C. Eisenach: Consulting toAdynxx (San Francisco, CA). The remaining authors have no conflicts of interest to declare. A complete listof authors of the PAINfRE Investigators is provided in Appendix A, available at
http://links.lww.com/PAIN/B196. Sponsorships or competing interests that may be relevant to content are
disclosed at the end of this article.

60.

Alviar MJ, Hale T, Dungca M. Pharmacologic interventions for treating phantom limb pain. Cochrane
Database Syst Rev. 2016;10(10):Cd006380. Epub 2016/11/02. doi: 10.1002/14651858.CD006380.pub3.
PubMed PMID: 27737513; PubMed Central PMCID: PMCPMC6472447 Research in Orthopaedic
Rehabilitation. TAH: none known. TAH is a Rehabilitation physician and manages patients with amputations
and complications including phantom limb pain. MD: none known. MD is a Rehabilitation Medicine
specialist and manages both adult and paediatric patients with musculoskeletal and neurologic conditions
including patients with neuropathic pain.

61.

Sherman RA, Sherman CJ, Parker L. Chronic phantom and stump pain among American veterans: results of asurvey. Pain. 1984;18(1):83-95. Epub 1984/01/01. doi: 10.1016/0304-3959(84)90128-3. PubMed
PMID: 6709380.

62.

Werner D, Alawi SA. Hand Bionic Score: a clinical follow-up study of severe hand injuries and developmentof a recommendation score to supply bionic prosthesis. European Journal of Plastic Surgery. 2021;44(1):8196. doi: 10.1007/s00238-020-01679-z.

63.

Resnik L, Borgia M, Clark MA. The Prevalence and Impact of Back and Neck Pain in Veterans with Upper
Limb Amputation. Am J Phys Med Rehabil. 2021. Epub 2021/01/15. doi: 10.1097/phm.0000000000001694.
PubMed PMID: 33443850.

March 2022

Page 140 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

64.

Resnik L, Ekerholm S, Borgia M, Clark MA. A national study of Veterans with major upper limb amputation:
Survey methods, participants, and summary findings. PLoS One. 2019;14(3):e0213578. Epub 2019/03/15.
doi: 10.1371/journal.pone.0213578. PubMed PMID: 30870496; PubMed Central PMCID: PMCPMC6417699
and not necessarily endorsed by the Department of Defense. The authors have declared that no competinginterests exist.

65.

Resnik LJ, Borgia ML, Clark MA. A National Survey of Prosthesis Use in Veterans with Major Upper Limb
Amputation: Comparisons by Gender. Pm r. 2020;12(11):1086-98. Epub 2020/02/28. doi: 10.1002/pmrj.
12351. PubMed PMID: 32103626.

66.

Armstrong TW, Williamson MLC, Elliott TR, Jackson WT, Kearns NT, Ryan T. Psychological distress among
persons with upper extremity limb loss. Br J Health Psychol. 2019;24(4):746-63. Epub 2019/04/04.
doi: 10.1111/bjhp.12360. PubMed PMID: 30941874.

67.

Postema SG, Bongers RM, Brouwers MA, Burger H, Norling-Hermansson LM, Reneman MF, et al. Upper
Limb Absence: Predictors of Work Participation and Work Productivity. Arch Phys Med Rehabil. 2016;97(6):892-9. Epub 2016/01/23. doi: 10.1016/j.apmr.2015.12.022. PubMed PMID: 26792618.

68.

Hancock L, Correia S, Ahern D, Barredo J, Resnik L. Cognitive predictors of skilled performance with anadvanced upper limb multifunction prosthesis: a preliminary analysis. Disabil Rehabil Assist Technol. 2017;12(5):504-11. Epub 2016/04/07. doi: 10.3109/17483107.2016.1158326. PubMed PMID: 27049235.

69.

Kearns NT, Jackson WT, Elliott TR, Ryan T, Armstrong TW. Differences in level of upper limb loss onfunctional impairment, psychological well-being, and substance use. Rehabil Psychol. 2018;63(1):141-7.
Epub 2018/03/20. doi: 10.1037/rep0000192. PubMed PMID: 29553789.

70.

Walsh MV, Armstrong TW, Poritz J, Elliott TR, Jackson WT, Ryan T. Resilience, Pain Interference, and Upper
Limb Loss: Testing the Mediating Effects of Positive Emotion and Activity Restriction on Distress. Arch Phys
Med Rehabil. 2016;97(5):781-7. Epub 2016/02/09. doi: 10.1016/j.apmr.2016.01.016. PubMed
PMID: 26854856.

71.

Kuret Z, Burger H, Vidmar G. Influence of finger amputation on grip strength and objectively measured handfunction: a descriptive cross-sectional study. Int J Rehabil Res. 2015;38(2):181-8. Epub 2015/02/26.
doi: 10.1097/mrr.0000000000000110. PubMed PMID: 25715229.

72.

Lafo J, Correia S, Borgia M, Acluche F, Resnik L. Cognitive Characteristics Associated With Device Adoption,
Skill Retention, and Early Withdrawal From a Study of an Advanced Upper Limb Prosthesis. Am J Phys Med
Rehabil. 2019;98(10):879-87. Epub 2019/05/29. doi: 10.1097/phm.0000000000001220. PubMed PMID:
31135465; PubMed Central PMCID: PMCPMC6791518 have been reported by the authors or by any
individuals in control of the content of this article.

73.

Balakhanlou E, Webster J, Borgia M, Resnik L. Frequency and Severity of Phantom Limb Pain in Veteranswith Major Upper Limb Amputation: Results of a National Survey. Pm r. 2021;13(8):827-35.
Epub 2020/09/09. doi: 10.1002/pmrj.12485. PubMed PMID: 32896094.

74.

Wegener ST, Mackenzie EJ, Ephraim P, Ehde D, Williams R. Self-management improves outcomes in persons
with limb loss. Arch Phys Med Rehabil. 2009;90(3):373-80. Epub 2009/03/04. doi: 10.1016/j.apmr.
2008.08.222. PubMed PMID: 19254599.

75.

Turner AP, Wegener ST, Williams RM, Ehde DM, Norvell DC, Yanez ND, et al. Self-Management to Improve
Function After Amputation: A Randomized Controlled Trial of the VETPALS Intervention. Arch Phys Med
Rehabil. 2021;102(7):1274-82. Epub 2021/04/04. doi: 10.1016/j.apmr.2021.02.027. PubMed
PMID: 33811854.

March 2022

Page 141 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

76.

Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist forassessing the methodological quality of studies on measurement properties of health status measurement
instruments: an international Delphi study. Qual Life Res. 2010;19(4):539-49. Epub 2010/02/20.
doi: 10.1007/s11136-010-9606-8. PubMed PMID: 20169472; PubMed Central PMCID: PMCPMC2852520.

77.

Agency for Health Research and Quality. The Effective Health Care Program stakeholder guide Appendix D:
Research questions & PICO(TS) 2011. Available from:https://www.ahrq.gov/research/findings/evidence-based-reports/stakeholderguide/appendixc.html.

78.

World Health O. International classification of functioning, disability and health : ICF. Geneva: World HealthOrganization; 2001.

79.

Cieza A, Brockow T, Ewert T, Amman E, Kollerits B, Chatterji S, et al. Linking health-status measurements tothe international classification of functioning, disability and health. J Rehabil Med. 2002;34(5):205-10.
Epub 2002/10/24. doi: 10.1080/165019702760279189. PubMed PMID: 12392234.

80.

Cieza A, Geyh S, Chatterji S, Kostanjsek N, Ustün B, Stucki G. ICF linking rules: an update based on lessons
learned. J Rehabil Med. 2005;37(4):212-8. Epub 2005/07/19. doi: 10.1080/16501970510040263. PubMed
PMID: 16024476.

81.

Fayed N, Cieza A, Bickenbach JE. Linking health and health-related information to the ICF: a systematic
review of the literature from 2001 to 2008. Disabil Rehabil. 2011;33(21-22):1941-51. Epub 2011/02/10.
doi: 10.3109/09638288.2011.553704. PubMed PMID: 21303198.

82.

Hill W, Kyberd P, Norling Hermansson L, Hubbard S, Stavdahl Ø, Swanson S. Upper Limb Prosthetic Outcome
Measures (ULPOM): A Working Group and Their Findings. JPO: Journal of Prosthetics and Orthotics. 2009;21(9):P69-P82. doi: 10.1097/JPO.0b013e3181ae970b. PubMed PMID: 00008526-200910001-00004.

83.

Lindner HY, Nätterlund BS, Hermansson LM. Upper limb prosthetic outcome measures: review and content
comparison based on International Classification of Functioning, Disability and Health. Prosthet Orthot Int.
2010;34(2):109-28. Epub 2010/05/18. doi: 10.3109/03093641003776976. PubMed PMID: 20470058.

84.

Wright V. Prosthetic Outcome Measures for Use With Upper Limb Amputees: A Systematic Review of thePeer-Reviewed Literature, 1970 to 2009. JPO: Journal of Prosthetics and Orthotics. 2009;21(9):P3-P63.
doi: 10.1097/JPO.0b013e3181ae9637. PubMed PMID: 00008526-200910001-00002.

85.

Resnik L, Borgia M. Reliability and Validity of Outcome Measures for Upper Limb Amputation. JPO: Journalof Prosthetics and Orthotics. 2012;24(4):192-201. doi: 10.1097/JPO.0b013e31826ff91c. PubMed
PMID: 00008526-201210000-00005.

86.

England DL, Miller TA, Stevens PM, Campbell JH, Wurdeman SR. Assessment of a Nine-Item PatientReported Outcomes Measurement Information System Upper Extremity Instrument Among IndividualsWith Upper Limb Amputation. Am J Phys Med Rehabil. 2021;100(2):130-7. Epub 2020/07/18. doi: 10.1097/
phm.0000000000001531. PubMed PMID: 32675705.

87.

Postema SG, Bongers RM, Van der Sluis CK, Reneman MF. Repeatability and Safety of the Functional
Capacity Evaluation-One-Handed for Individuals with Upper Limb Reduction Deficiency and Amputation. J
Occup Rehabil. 2018;28(3):475-85. Epub 2017/09/22. doi: 10.1007/s10926-017-9723-0. PubMed
PMID: 28932940; PubMed Central PMCID: PMCPMC6096508.

88.

Resnik L, Borgia M, Acluche F. Brief activity performance measure for upper limb amputees: BAM-ULA.
Prosthet Orthot Int. 2018;42(1):75-83. Epub 2017/01/17. doi: 10.1177/0309364616684196. PubMed
PMID: 28091278.

89.

Kearns NT, Peterson JK, Smurr Walters L, Jackson WT, Miguelez JM, Ryan T. Development and Psychometric
Validation of Capacity Assessment of Prosthetic Performance for the Upper Limb (CAPPFUL). Arch Phys Med

March 2022

Page 142 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

Rehabil. 2018;99(9):1789-97. Epub 2018/05/20. doi: 10.1016/j.apmr.2018.04.021. PubMed
PMID: 29777713.
90.

Resnik L, Borgia M, Acluche F. Timed activity performance in persons with upper limb amputation: A
preliminary study. J Hand Ther. 2017;30(4):468-76. Epub 2017/05/11. doi: 10.1016/j.jht.2017.03.008.
PubMed PMID: 28487130.

91.

Resnik L, Borgia M, Cancio JM, Delikat J, Ni P. Psychometric evaluation of the Southampton handassessment procedure (SHAP) in a sample of upper limb prosthesis users. J Hand Ther. 2021.
Epub 2021/08/18. doi: 10.1016/j.jht.2021.07.003. PubMed PMID: 34400030.

92.

Light CM, Chappell PH, Kyberd PJ. Establishing a standardized clinical assessment tool of pathologic andprosthetic hand function: normative data, reliability, and validity. Arch Phys Med Rehabil. 2002;83(6):77683. Epub 2002/06/06. doi: 10.1053/apmr.2002.32737. PubMed PMID: 12048655.

93.

Vasluian E, Bongers RM, Reinders-Messelink HA, Burgerhof JG, Dijkstra PU, van der Sluis CK. Learning effects
of repetitive administration of the Southampton Hand Assessment Procedure in novice prosthetic users. J
Rehabil Med. 2014;46(8):788-97. Epub 2014/05/23. doi: 10.2340/16501977-1827. PubMed
PMID: 24850374.

94.

Head JS, Howard D, Hutchins SW, Kenney L, Heath GH, Aksenov AY. The use of an adjustable electrodehousing unit to compare electrode alignment and contact variation with myoelectric prosthesis
functionality: A pilot study. Prosthet Orthot Int. 2016;40(1):123-8. Epub 2014/08/20. doi: 10.1177/
0309364614545417. PubMed PMID: 25134531.

95.

Fougner AL, Stavdahl O, Kyberd PJ. System training and assessment in simultaneous proportional
myoelectric prosthesis control. J Neuroeng Rehabil. 2014;11:75. Epub 2014/04/30. doi: 10.1186/1743-000311-75. PubMed PMID: 24775602; PubMed Central PMCID: PMCPMC4041142.

96.

Bouwsema H, van der Sluis CK, Bongers RM. Changes in performance over time while learning to use amyoelectric prosthesis. J Neuroeng Rehabil. 2014;11:16. Epub 2014/02/27. doi: 10.1186/1743-0003-11-16.
PubMed PMID: 24568148; PubMed Central PMCID: PMCPMC3944783.

97.

van der Niet O, Bongers RM, van der Sluis CK. Functionality of i-LIMB and i-LIMB pulse hands: case report. J
Rehabil Res Dev. 2013;50(8):1123-8. Epub 2014/01/25. doi: 10.1682/jrrd.2012.08.0140. PubMed
PMID: 24458898.

98.

Dalley SA, Bennett DA, Goldfarb M. Preliminary functional assessment of a multigrasp myoelectric
prosthesis. Annu Int Conf IEEE Eng Med Biol Soc. 2012;2012:4172-5. Epub 2013/02/01. doi: 10.1109/embc.
2012.6346886. PubMed PMID: 23366847; PubMed Central PMCID: PMCPMC4474230.

99.

Bouwsema H, Kyberd PJ, Hill W, van der Sluis CK, Bongers RM. Determining skill level in myoelectric
prosthesis use with multiple outcome measures. J Rehabil Res Dev. 2012;49(9):1331-48. Epub 2013/02/15.
doi: 10.1682/jrrd.2011.09.0179. PubMed PMID: 23408215.

100.

Kyberd PJ. The influence of control format and hand design in single axis myoelectric hands: assessment offunctionality of prosthetic hands using the Southampton Hand Assessment Procedure. Prosthet Orthot Int.
2011;35(3):285-93. Epub 2011/09/23. doi: 10.1177/0309364611418554. PubMed PMID: 21937574.

101.

Ramirez IA, Lusk CP, Dubey R, Highsmith MJ, Maitland ME. Crossed four-bar mechanism for improved
prosthetic grasp. J Rehabil Res Dev. 2009;46(8):1011-20. Epub 2010/02/17. doi: 10.1682/jrrd.2009.01.0004.
PubMed PMID: 20157858.

102.

Agarwal R, Agarwal D, Agarwal M. Approach to mutilating hand injuries. J Clin Orthop Trauma. 2021;15:1725. Epub 2019/08/14. doi: 10.1016/j.jcot.2019.08.011. PubMed PMID: 33717934; PubMed Central
PMCID: PMCPMC7920121.

March 2022

Page 143 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

103.

Andersson G, Cocchiarella L. Guides to the evaluation of permanent impairment. 5th ed: American Medical
Association; 2000. 613 p.

104.

Lahiri A. Managing Mutilating Hand Injuries. Clin Plast Surg. 2019;46(3):351-7. Epub 2019/05/20.
doi: 10.1016/j.cps.2019.02.009. PubMed PMID: 31103080.

105.

Neumeister MW, Brown RE. Mutilating hand injuries: principles and management. Hand clinics. 2003;19(1):1-15, v. Epub 2003/04/10. PubMed PMID: 12683442.

106.

Moran SL, Berger RA. Biomechanics and hand trauma: what you need. Hand clinics. 2003;19(1):17-31.
Epub 2003/04/10. PubMed PMID: 12683443.

107.

Tooms RE. Amputation surgery in the upper extremity. The Orthopedic clinics of North America. 1972;3(2):383-95. Epub 1972/07/01. PubMed PMID: 5037524.

108.

Tintle SM, Baechler MF, Nanos GP, 3rd, Forsberg JA, Potter BK. Traumatic and trauma-related amputations:
Part II: Upper extremity and future directions. The Journal of bone and joint surgery American volume.
2010;92(18):2934-45. Epub 2010/12/17. doi: 10.2106/jbjs.j.00258. PubMed PMID: 21159994.

109.

Wright TW, Hagen AD, Wood MB. Prosthetic usage in major upper extremity amputations. J Hand Surg Am.
1995;20(4):619-22. Epub 1995/07/01. doi: 10.1016/s0363-5023(05)80278-3. PubMed PMID: 7594289.

110.

Krajbich JIP, Michael S.; Potter, Benjamin K.; Stevens, Phillip M. Atlas of amputations and limb deficiencies:
surgical, prosthetic, and rehabilitation principles. 4th ed. Rosemont, IL: American Academy of Orthopaedic
Surgeons; 2016.

111.

Pasquina PF, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee care. Arch Phys
Med Rehabil. 2006;87(3 Suppl 1):S34-43; quiz S4-5. Epub 2006/02/28. doi: 10.1016/j.apmr.2005.11.026.
PubMed PMID: 16500191.

112.

Shawen S, Doukas W, Shrout J, Ficke J, Potter B, Hayda R, et al. Care of the combat amputee.
Washington, DC: Dept. of the Army, Borden Institute; 2009.

113.

Cho MS. Elbow Disarticulation and Transhumeral Amputation: Surgical Management. 2016. In: Atlas of
Amputation and Limb Deficiencies: Surgical Prosthetic, and Rehabilitation Principles [Internet].
Rosemont, IL: American Academy of Orthopaedic Surgeons. 4th.

114.

Neusel E, Traub M, Blasius K, Marquardt E. Results of humeral stump angulation osteotomy. Archives oforthopaedic and trauma surgery. 1997;116(5):263-5. Epub 1997/01/01. PubMed PMID: 9177800.

115.

Baccarani A, Follmar KE, De Santis G, Adani R, Pinelli M, Innocenti M, et al. Free vascularized tissue transfer
to preserve upper extremity amputation levels. Plast Reconstr Surg. 2007;120(4):971-81. Epub 2007/09/07.
doi: 10.1097/01.prs.0000256479.54755.f6. PubMed PMID: 17805127.

116.

Tukiainen E, Barner-Rasmussen I, Popov P, Kaarela O. Forequarter Amputation and Reconstructive Options.
Ann Plast Surg. 2020;84(6):651-6. Epub 2020/03/10. doi: 10.1097/sap.0000000000002204. PubMed
PMID: 32149840.

117.

Elsner U, Henrichs M, Gosheger G, Dieckmann R, Nottrott M, Hardes J, et al. Forequarter amputation: a safe
rescue procedure in a curative and palliative setting in high-grade malignoma of the shoulder girdle. World J
Surg Oncol. 2016;14(1):216. Epub 2016/08/17. doi: 10.1186/s12957-016-0973-7. PubMed PMID: 27526689;
PubMed Central PMCID: PMCPMC4986170.

118.

Barry T, Herron T, Lorch S, Ciesla D. Complex reconstruction following traumatic forequarter amputation.
The Journal of Cardiothoracic Trauma. 2019;4(1):55-8. doi: 10.4103/jctt.jctt_15_19.

March 2022

Page 144 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

119.

Foong DP, Evriviades D, Jeffery SL. Integra permits early durable coverage of improvised explosive device(IED) amputation stumps. Journal of plastic, reconstructive & aesthetic surgery : JPRAS. 2013;66(12):171724. Epub 2013/08/07. doi: 10.1016/j.bjps.2013.07.007. PubMed PMID: 23916387.

120.

Helgeson MD, Potter BK, Evans KN, Shawen SB. Bioartificial dermal substitute: a preliminary report on its
use for the management of complex combat-related soft tissue wounds. Journal of orthopaedic trauma.
2007;21(6):394-9. Epub 2007/07/11. doi: 10.1097/BOT.0b013e318070c028. PubMed PMID: 17620998.

121.

Rohrich RJ, Ehrlichman RJ, May JW, Jr. Sensate palm of hand free flap for forearm length preservation in
nonreplantable forearm amputation: long-term follow-up. Ann Plast Surg. 1991;26(5):469-73.
Epub 1991/05/11. PubMed PMID: 1952722.

122.

Wood MR, Hunter GA, Millstein SG. The value of stump split skin grafting following amputation for trauma
in adult upper and lower limb amputees. Prosthet Orthot Int. 1987;11(2):71-4. Epub 1987/08/01. PubMed
PMID: 3309883.

123.

Zlotolow DA, Kozin SH. Advances in upper extremity prosthetics. Hand clinics. 2012;28(4):587-93.
Epub 2012/10/30. doi: 10.1016/j.hcl.2012.08.014. PubMed PMID: 23101609.

124.

Agrawal N, Gfrerer L, Heng M, Eberlin KR, Valerio I. Targeted Muscle Reinnervation as a Surgical Approachfor Phantom Limb Pain Management Following Amputation. Current Physical Medicine and Rehabilitation
Reports. 2021. doi: 10.1007/s40141-021-00329-0.

125.

Frost CM, Ursu DC, Flattery SM, Nedic A, Hassett CA, Moon JD, et al. Regenerative peripheral nerve
interfaces for real-time, proportional control of a Neuroprosthetic hand. J Neuroeng Rehabil. 2018;15(1):108. Epub 2018/11/22. doi: 10.1186/s12984-018-0452-1. PubMed PMID: 30458876; PubMed Central
PMCID: PMCPMC6245539.

126.

Srinivasan SS, Carty MJ, Calvaresi PW, Clites TR, Maimon BE, Taylor CR, et al. On prosthetic control: A
regenerative agonist-antagonist myoneural interface. Sci Robot. 2017;2(6). Epub 2017/05/31. doi: 10.1126/
scirobotics.aan2971. PubMed PMID: 33157872.

127.

Srinivasan SS, Diaz M, Carty M, Herr HM. Towards functional restoration for persons with limb amputation:
A dual-stage implementation of regenerative agonist-antagonist myoneural interfaces. Sci Rep.
2019;9(1):1981. Epub 2019/02/15. doi: 10.1038/s41598-018-38096-z. PubMed PMID: 30760764; PubMed
Central PMCID: PMCPMC6374452.

128.

Clites TR, Herr HM, Srinivasan SS, Zorzos AN, Carty MJ. The Ewing Amputation: The First Human
Implementation of the Agonist-Antagonist Myoneural Interface. Plast Reconstr Surg Glob Open.
2018;6(11):e1997. Epub 2019/03/19. doi: 10.1097/gox.0000000000001997. PubMed PMID: 30881798;
PubMed Central PMCID: PMCPMC6414116.

129.

Bates TJ, Fergason JR, Pierrie SN. Technological Advances in Prosthesis Design and Rehabilitation Following
Upper Extremity Limb Loss. Curr Rev Musculoskelet Med. 2020;13(4):485-93. Epub 2020/06/04.
doi: 10.1007/s12178-020-09656-6. PubMed PMID: 32488625; PubMed Central PMCID: PMCPMC7340716.

130.

Jonsson S, Caine-Winterberger K, Branemark R. Osseointegration amputation prostheses on the upper
limbs: methods, prosthetics and rehabilitation. Prosthet Orthot Int. 2011;35(2):190-200. Epub 2011/06/24.
doi: 10.1177/0309364611409003. PubMed PMID: 21697201.

131.

Sierakowski A, Watts C, Thomas K, Elliot D. Long-term outcomes of osseointegrated digital prostheses forproximal amputations. The Journal of hand surgery, European volume. 2011;36(2):116-25.
Epub 2010/09/03. doi: 10.1177/1753193410382720. PubMed PMID: 20807721.

132.

Sabharwal S, Shores JT, Forsberg JA. Osseointegration. Techniques in Orthopaedics. 2021;36(4):349-52.
doi: 10.1097/bto.0000000000000551. PubMed PMID: 00013611-202112000-00007.

March 2022

Page 145 of 146

VA/DoD Clinical Practice Guideline for the Management of Upper Limb Amputation Rehabilitation

133.

Gerzina C, Potter E, Haleem AM, Dabash S. The future of the amputees with osseointegration: A systematic
review of literature. J Clin Orthop Trauma. 2020;11(Suppl 1):S142-s8. Epub 2020/01/30. doi: 10.1016/j.jcot.
2019.05.025. PubMed PMID: 31992935; PubMed Central PMCID: PMCPMC6977164.

134.

Atkins D. Prosthetic training. Atlas of amputations and limb deficiencies: Surgical, prosthetic, andrehabilitation principles 3ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004. p. 275-84.

135.

Smurr L YK, Gulick K, et al. . Occupational therapy for polytrauma casualty with limb loss. Atlas of
amputations and limb deficiencies: Surgical, prosthetic, and rehabilitation principles. 3 ed. Rosemont, IL:
American Academy of Orthopaedic Surgeons; 2009. p. 275-84.

136.

Fletchall S. Upper Limb Prosthetic Training and Occupational Therapy. Atlas of amputations and limb
deficiencies: Surgical, prosthetic, and rehabilitation principles. 3 ed. Rosemont, IL: American Academy of
Orthopaedic Surgeons; 2016. p. 351-62.

137.

Myers H, Lu D, Gray SJ, Bruscino-Raiola F. Targeted muscle reinnervation to improve electromyography
signals for advanced myoelectric prosthetic limbs: a series of seven patients. ANZ J Surg. 2020;90(4):591-6.
Epub 2020/01/29. doi: 10.1111/ans.15664. PubMed PMID: 31989741.

138.

Hargrove LJ, Miller LA, Turner K, Kuiken TA. Myoelectric Pattern Recognition Outperforms Direct Control forTranshumeral Amputees with Targeted Muscle Reinnervation: A Randomized Clinical Trial. Sci Rep.
2017;7(1):13840. Epub 2017/10/25. doi: 10.1038/s41598-017-14386-w. PubMed PMID: 29062019; PubMed
Central PMCID: PMCPMC5653840 sells myoelectric control systems. No Coapt products or materials wereused in this study.

139.

Hargrove LJ, Lock BA, Simon AM. Pattern recognition control outperforms conventional myoelectric control
in upper limb patients with targeted muscle reinnervation. Annu Int Conf IEEE Eng Med Biol Soc. 2013;2013:
1599-602. Epub 2013/10/11. doi: 10.1109/embc.2013.6609821. PubMed PMID: 24110008.

140.

Phillips SL, Resnik L, Fantini C, Latlief G. Endpoint Control for a Powered Shoulder Prosthesis. JPO: Journal of
Prosthetics and Orthotics. 2013;25(4):193-200. doi: 10.1097/jpo.0000000000000006. PubMed
PMID: 00008526-201310000-00008.

March 2022

Page 146 of 146