Quality of life in individuals with lower limb amputation: an integrative review

INTRODUCTION

Lower limb amputation (LLA) is a life-altering disorder with serious physical, psychological and social outcomes. LLA is rising significantly in the world as a result of the following factors: diabetes mellitus, peripheral arterial disease, infections and traumatic injuries, especially in the low- and middle-income countries.¹ There is a strong focus of the World Health Organization (WHO) that rehabilitation and reintegration into society is an important part of the care provided to amputees, particularly where the aim is to improve their quality of life.² Quality of life (QOL) is a multidimensional notion that will include physical health, psychological well-being, social relationships and functional capacity.³ In LLA individuals, QOL tends to be severely reduced because of chronic pain, limited mobility, phantom limb pain, emotional distress and difficulties with activities of daily living. In addition, social stigma, joblessness, and poor interpersonal relations can also decrease the perceived QOL of amputees.^4,5 Knowledge of the QOL in the case of lower limb amputees is crucial in developing holistic rehabilitation interventions, supportive interventions and policy frameworks to meet their special needs. Most researchers have explored various facets of QOL in this population, but the results of most studies are inconsistent with regard to the environment, amputation type, cause and postoperative period. An integrative review gives a synthesis of the available empirical and theoretical literature to make inferences and determine gaps in the available knowledge.⁶ The overall purpose of this integrative review is to critically review and synthesize existing knowledge on the quality of life in lower limb amputees. It examines the physical, psychological and social aspects of the QOL, determines the factors that influence it and provides implications on clinical practice and future studies.

METHODS

The review was an integrative review that sought to search and synthesize the available literature on the QoL in patients with lower limb amputation (LLA).

Literature search strategy

The systematic and extensive search of the following electronic databases was carried out: PubMed, CINAHL, Scopus, Embase and Google Scholar. Articles that were published in the last thirteen years (the period between January 2013 and March 2025) were taken into account.

The keywords and Medical Subject Headings (MeSH) that were used were lower limb amputation, below-knee amputation and above-knee amputation; amputees; quality of life; rehabilitation and psychosocial impact. Keywords were effectively combined by use of Boolean operators (AND, OR).

Study selection

Retrieved studies were imported into Rayyan where duplicates were removed.

Titles and abstracts were screened for relevance and irrelevant articles were removed. Shortlisted full text articles were assessed by two authors independently for eligibility based on the predefined inclusion and exclusion criteria. An adapted PRISMA flowchart revealed the studies selection processes (Figure 1).

Inclusion criteria

In the review, studies were included based on the following criteria: they were peer-reviewed original research articles published in English, cross-sectional studies involving adult patients aged over 18 years who had undergone lower-limb amputation and research studies that assessed quality of life using standardized measurement tools such as the SF-36 or WHOQOL-BREF.

Exclusion criteria

Studies were excluded from the review if they were published in languages other than English, were case reports, editorials, or review articles, or if they focused exclusively on upper-limb amputation.

Search selection

Database searching yielded a total of 860 records. After removing the 160 duplicate records, 700 records were remained. Thereafter screening of title and abstract, 640 records were eliminated as irrelevant, and 60 articles were selected for full-text assessment. Full-text eligibility was evaluated, resulting in the exclusion of 50 articles due to non-English (n=12), Review/editorial (n=15), Upper limb amputation (n=10), No QOL tool (n=13). Finally, ten studies met the inclusion criteria and were included in the review. The process of study selection is shown in Figure 1.

Study characteristics

The characteristics of included study are outlined in Table 1. This integrative review incorporated ten articles published between 2014 and 2025 in various countries, such as Nigeria, Brazil, India, Iraq, Turkey, Pakistan, Egypt and Egypt. All the included studies incorporated the cross-sectional design. The researchers examined the quality of life (QoL) in persons with lower limb amputation (LLA) through the use of standardized measures like the SF-36, SF-12 and WHOQOL-BREF. The total sample size in this review was 3864 ranging between 23 and 450 (mean ages were 36.4,57.8).

Risk of bias assessment

All the articles retrieved were filtered with respect to title and abstract. The inclusion criteria were reviewed full-text articles potentially of interest. Methodological quality of the chosen studies was evaluated with the help of Joanna Briggs Institute (JBI) critical appraisal tools that is relevant to the study design.⁷ The studies were assessed by two independent reviewers to reduce bias. The disagreements were addressed by discussing or consulting with a third reviewer (Table 1).

Data analysis

An extraction table (Table 2) was formed to analyse the all findings. Data that were extracted were author(s), year of publication, country, study design, sample size, assessment tools and important findings on QoL domains.

Presentation of findings

Findings were reported using narrative form and structured them into key areas that have an impact on quality of life in LLA patients: physical and mental health outcomes, gender and level of amputation, use of prosthesis and social support, perceptions of quality of life. The summary of the characteristics and results of the included studies was summarized in Table 1.

Physical and mental health outcomes

A number of studies proved that LLA has a great influence on physical and mental health and two studies explained it in detail. A study in Nigeria identified statistically significant relationships between LLA and the physical and mental aspects of QoL.⁹ On the same note another study also found that stump and phantom pain were linked to much lower physical (PCS) and mental (MCS) component scores.¹⁵

Gender and level of amputation

It is documented by 3 studies. A study conducted in Egypt found that males scored higher in physical functioning and emotional roles than females.¹⁷ Another study also found the same thing that physical functioning and general health scores of males were higher as compared to female scores.¹¹ In the same line one more study also reported better result in male amputee compared to female.

Moreover, the amputation level below the knee was discovered to score higher on QoL compared to above-knee amputation.¹³ Same findings found in another study also that above-knee amputees and comorbid patients reported much lower scores on the QoL scale than below-knee amputees or without comorbidities.¹⁵

Prosthesis and social support use

Prostheses use became a positive factor that affected QoL and explained by two studies. A study found that mobility, physical and environmental domain scores of the prosthesis users were significantly higher than those of non-users.¹³ Another study also indicated that more than half of the sample had good social support, which was positively associated with improved physical, psychological, and social QoL.¹⁰ The relationship between social support and QoL was found to be statistically significant (r=0.250, p=0.000).

Quality of life perceptions

Perception of QoL explained in detailed by 4 studies among all the included studies. In a study carried out in India, it was found that the perceptions of quality of life were usually low among amputees. A small proportion of amputees (17 percent) valued their QoL as good, whereas most of them rated their quality of life as average or poor.¹² On the same note, a study conducted in Baghdad revealed that more than three-quarters of the participants indicated having poor QoL and very few rated it as good.⁸ Contrast findings found in one study that observed a greater total QoL score, with the highest mean score of the environmental domain and the lowest score of the social domain.¹⁶

A study in Brazil found that functional capacity and vitality had the lowest scoring QoL domains, and the social aspect had the highest score.¹⁴ Conversely, investigations of WHOQOL-BREF instruments often revealed reduced scores in the social and psychological fields, particularly in the occurrence of pain, absence of prosthetic devices or insufficient support networks. On the whole, this review has shown that QoL of LLA patients is determined by a multifactorial combination of such factors as gender, pain, the use of the prosthesis, level of amputation, comorbid conditions, and social support. Physical domains are generally rated more than psychological and social ones, which indicates that there is a strong necessity to implement a holistic approach to rehabilitation including physical and psychosocial dimensions of the post-amputation life.

DISCUSSION

The study was an integrative review of ten studies that investigated the QoL of persons who have undergone LLA. The results of the study are uniform that LLA has a considerable adverse effect on physical, psychological, social and environmental spheres of QoL. Although the extent to which it affects them depends on their gender, the degree of amputation, comorbidity and the use of prostheses, the general tendency is that this population has lower life satisfaction and functionality.

Physical and psychological effect

The majority of the reviewed studies showed decreased physical functioning and vitality in LLA patients. An example is that Matros et al reported the lowest scores in functional capacity and vitality domains with SF-36, which was also found in the another research, who linked lower physical and mental components scores to stump pain, phantom pain and higher-level amputations.^14,15 These results are consistent with previous research that emphasized chronic pain and mobility as the main predictors of low QoL in amputees.¹⁸ Such a correlation between physical constraints and mental distress also echoes the results of another previous who found out that depression and anxiety are common among amputated individuals and closely related to perceived physical inability.¹⁹

Gender differences in QoL

Several studies in this review, have indicated that male amputees recorded a higher QoL in both physical and mental domains as compared to females.^9,11,17 This difference can be explained by social cultural roles, coping strategies, and different social support of both sexes. In line with these results, a previous study also indicated that women who undergo amputation are more likely to have poorer body image and emotional distress, which lead to poorer psychological outcomes.²⁰

Impact of prosthesis use and rehabilitation

Prosthesis usage was found to have a positive effect on QoL, particularly in terms of mobility and physical independence. According to the report by Hashim et al the scores of mobility and the environment were significantly higher in the case of users of the prosthesis.¹³ It conforms by another study which discovered that the use of prostheses was linked to positive self-esteem levels and social reintegration among LLA patients.²¹ Nevertheless, the functionality and fit limitations can still occur even in the case of prosthesis users, and thus extensive rehabilitation programs are needed to maximize the benefits.

Social support as a protective factor

Social support was continuously identified as a predictor of improved QoL. Al-Jubori et al study discovered that social support had significant, positive correlations with all domains of QoL.¹⁰ Through the existing literature, social connectedness has been found to reduce psychological distress and facilitates the process of adjusting after amputation.²² Peer support programs and community-based rehabilitation might be effective interventions given the psychosocial challenges amputees are exposed to.

Quality of life perception and cross-setting variability

Surprisingly, there was a difference in the perception of QoL across the regions and settings. The studies by Indian researchers in Baghdad have shown that most amputees had poor or average QoL.¹² The unhealthy attitude may be caused by cultural beliefs, stigma, access to healthcare and economic instability. On the other hand, another study in Brazil found comparatively higher scores in the social domain, which means that under certain conditions, cultural and systemic aspects may help to cushion the psychological effects of amputation.¹⁴

Comparison with global literature

The findings are in agreement with world literature which shows that LLA results in lowering QoL. This review study revealed that amputees were lower rated in comparison to the general populations in all domains of QoL, especially physical functioning and mental well-being. The review has also highlighted the long-term effect of amputation on independence and employment which were not directly measured in all studies included in this review but are also relevant outcomes.²³

Practical implications

The review highlights the significance of a multidisciplinary approach to post-amputation care, which involves physical rehabilitation, the installation of prostheses, psychological counselling and social support. Intervention needs to be specific and should be offered depending on patient-specific factors, including gender, amputation level, pain management and social context.

Limitations

The limited number of studies (n=10), focus on English-language literature, heterogeneity in QoL tools and lack of meta-analysis are all limitations of this review. Also, the generalizability and strength of the conclusions can be impacted by the potential publication bias and moderate risk of bias in some of the included studies.

CONCLUSION

This type of integrative review demonstrates that LLA produces a significant effect on the QoL of patients, especially in the sphere of physical, psychological and social domains. The reviewed studies are in agreement on the fact that pain, amputation level, gender, prosthesis use, comorbid conditions, as well as social support are factors that affect QoL outcomes. The males, users of prostheses, below-knee amputation, and those with robust social support systems are likely to report an improved QoL.

In spite of the improvements in the field of prosthetics and rehabilitation, the percentage of LLA patients with poor QoL remains high, particularly in psychological and social spheres. These results highlight the multidimensional issues of persons living with LLA.

Although the physical rehabilitation is essential, the emotional, social and environmental aspects of recovery must be addressed using a holistic and patient-centered approach. Mental health services, social integration strategy and personalized rehabilitation plan are important components of holistic care models that can be used to enhance overall QoL among this population.

Recommendations to improve the quality of life among patients with received lower limb amputation

Multidisciplinary rehabilitation programs

The healthcare systems have to adopt the multidisciplinary rehabilitation programs which include physical therapy, psychological counselling and prosthetic training and the vocational assistance since the LLA patients are faced with a wide spectrum of problems.

Periodic QoL assessment

Standardized questionnaires based on questionnaires (e.g., SF-36, WHOQOL-BREF) sought to be implemented in clinical practice and allow tracking the progress, identifying the specific needs and adjusting the care plan.

Enhance prosthetic availability and education

Easy access to well-fitting, functional prostheses should be improved and widely trained on their use, especially in the low-resource regions.

Psychosocial interventions

Emotional distress and development of coping skills should be minimized by providing individualized psychosocial support which may include peer counselling, support groups and community re-entry programs.

Gender-sensitive approaches

Since female amputees are more likely to experience poor QoL, there is a need to develop gender-sensitive interventions that will support the physical and psychological requirements of the latter.

Public health and policy support

The policymakers are required to come up with supportive pieces of legislation and funding models that make rehabilitation services, provision of prosthetics and community-based care of amputees affordable.

Future investigation

There should be an evaluation of long-term QoL outcomes, and additional cross-cultural research is necessary to understand the efficacy of different rehabilitation techniques on specific groups of amputees.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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