RESNA Annual Conference - 2025

Feasibility and effectiveness of pre-operative rehabilitation training and education on occupational performance in people with lower limb amputation – a scoping review

Hongwu Wang1, Yuan Li1, Raghu Chandrashekhar1

1University of Florida

ABSTRACT

Lower-limb amputation poses significant challenges, including residual limb pain, phantom limb sensation, and difficulty adapting to post-amputation life, which can reduce the quality of life. Pre-operative rehabilitation training and education have been proposed to enhance post-operative outcomes, but evidence remains limited. This systematic scoping review examines the impact of pre-operative programs on postoperative outcomes for individuals undergoing lower-limb amputation. A search across PubMed, CINAHL, and Web of Science identified studies published between 2014 and 2024. Five studies met the inclusion criteria, demonstrating that pre-operative interventions can improve functional outcomes, reduce hospital stays, and increase prosthetic use. However, the evidence was limited by methodological weaknesses, with studies rated at Levels III and IV and showing moderate to serious risks of bias. While concerns about feasibility persist—such as short pre-surgical timelines and patient comorbidities—the findings suggest pre-operative rehabilitation is both practical and beneficial when integrated into care. Further research is needed to develop standardized, evidence-based protocols accessible across settings. A multidisciplinary approach involving prosthetists and therapists is essential to optimize patient outcomes and support meaningful occupational performance post-amputation.

INTRODUCTION

People with lower limb amputations face many challenges ... Pre-operative training and education may possibly better prepare patients anticipating an amputation for what is ahead of them.

METHODS

Literature search and screening criteria

Three databases were searched during June 2024: PubMed, CINAHL, and Web of Science... Articles not written in English and review articles were excluded from this review.

Literature screening procedure

A flowchart illustrates the study selection process for a systematic review, divided into three main phases: Identification, Screening, and Inclusion. For the Identification, a total of 446 records were identified through databases: PubMed (308), CINAHL (115), and Web of Science (23). An additional 8 records were identified from other sources: Citation searching (4) and grey literature (4). 70 references were removed: 2 duplicates manually, 68 duplicates via Covidence, 0 removed by automation tools or for other reasons. For Screening, 384 studies were screened, 346 were excluded, and 38 studies were sought for retrieval. All 38 were successfully retrieved, and 38 studies were assessed for eligibility. 33 were excluded for the following reasons: Wrong outcomes (2), Wrong intervention (11), Wrong study design (19), and Wrong patient population (1). 5 studies were included in the final review.
Figure 1. PRISMA diagram flow of the search results. Alternative text: A flowchart illustrates the study selection process for a systematic review, divided into three main phases: Identification, Screening, and Inclusion. For the Identification, a total of 446 records were identified through databases: PubMed (308), CINAHL (115), and Web of Science (23). An additional 8 records were identified from other sources: Citation searching (4) and grey literature (4). 70 references were removed. For Screening, 384 studies were screened, 346 were excluded, and 38 studies were sought for retrieval. All 38 were successfully retrieved, and 38 studies were assessed for eligibility. 33 were excluded for wrong outcomes (2), wrong intervention (11), wrong study design (19), and wrong patient population (1). 5 studies were included in the final review.

The literature screening process was conducted using the Covidence software... Reasons for exclusion at this phase were recorded.

Data extraction, methodology, rating, and synthesis

Article information was extracted in standard form... Results were tabulated and expanded on from the qualitative data reviewed.

RESULTS

Five studies (Figure 1) were included in the final synthesis ... Matheny et al. (2023) also reported an increased likelihood of receiving a prosthesis if participants engaged in their pre-operative training and education program.

Table 1. The study design and key findings of the five included articles.

Authors Year Design Key Findings
Bowrey, S., Naylor, H., Russell, P., & Thompson, J. [6] 2018 Retrospective Review Developed the BLARt score to predict functional outcomes in lower limb amputees, aiding preoperative expectations.
Daso, G., Chen, A.J., Yeh, S., O'Connell, J.B., Rigberg, D.A., Virgilio, D.C., Gelabert, H.A., Ulloa, J.G. [7] 2022 Retrospective Review Examined ambulatory outcomes and survival in veterans post-lower extremity amputation, with potential improvements noted.
Fulton, S., Baird, T., Naik, S., Stiller, K. [8] 2022 Retrospective, Matched, Case-Controlled Pilot Service Evaluation Prehabilitation-plus reduced acute and total hospital length of stay for major lower limb amputation patients.
Matheny, H., Woo, K., Siada, S., Qumsiyeh, Y., Aparicio, C., Borashan, C., & O'Banion, L. A. [4] 2023 Retrospective matched cohort design Demonstrated community-wide feasibility of the Lower Extremity Amputation Protocol for vascular amputees.
Silva, A. D. M., Furtado, G., Dos Santos, I. P., da Silva, C. B., Caldas, L. R., Bernardes, K. O., & Ferraz, D. D. [5] 2021 Longitudinal Study Showed improved functional capacity in elderly lower-limb amputees after prosthesis rehabilitation.

Of the five studies, two articles had Level III of evidence... The Bias of the three-level IV studies [6-8] was specified in Table 2.

Table 2. Cochrane Risk of Bias tool of the included Level IV studies

Domain Bowrey et al., 2018 [6] Daso et al., 2022 [7] Fulton et al., 2022 [8]
Bias due to confounding Moderate Risk Moderate Risk Moderate Risk
Bias in the selection of participants for the study Low Risk Serious Risk Low Risk
Bias in the measurement of interventions Low Risk Low Risk No Information
Bias due to departures from intended interventions Moderate Risk No Information Serious Risk
Bias due to missing data No Information No Information No Information
Bias in the measurement of outcomes Low Risk Low Risk Low Risk
Bias in the selection of the reported result Low Risk Moderate Risk No Information

DISCUSSION

Our review highlighted the feasibility [4-7] of pre-operation rehabilitation training and the positive impact on postoperative functional outcomes [4-8] in patients with lower limb amputation, even though some healthcare professionals and researchers working with the amputation population were concerned that preoperative rehabilitation was not feasible due to the short time window before surgery, older age, multiple comorbidities, and lack of motivation for behavioral change [8]. This finding agreed with studies in other populations that pre-operative rehabilitation programs are feasible and can be integrated into existing pre-surgical protocols and/or programs [9-11].

The strength of the evidence for using rehabilitation prior to amputation to improve functional outcomes following amputation is low because of the limited evidence and the poor methodological quality rating. More evidence is required to support preoperative rehabilitation for patients receiving lower limb amputation. In addition, no standardized pre-operative programs and/or protocols can be delivered across various settings. A more accessible and evidence-based pre-operation rehabilitation program is needed in future work. Furthermore, prosthetists and therapists, such as occupational and physical therapists, should advocate for a pre-rehabilitative team for patients needing to receive a lower limb amputation to promote occupational performance following the amputation.

REFERENCES

  1. Hanyu-Deutmeyer, A. A., Cascella M., & Varacallo M. (2024) Phantom limb pain. [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448188/
  2. Hijmans, J.M, Dekker, R., & Geertzen, J.H.B. (2020). Pre-operative rehabilitation in lower-limb amputation patients and its effect on post-operative outcomes. Medical Hypotheses. 143:1-9. https://doi.org/10.1016/j.mehy.2020.110134
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  4. Matheny, H., Woo, K., Siada, S., Qumsiyeh, Y., Aparicio, C., Borashan, C., & O'Banion, L. A. (2023). Community-wide feasibility of the Lower Extremity Amputation Protocol amongst vascular amputees. Journal of vascular surgery, 78(4), 1057–1063. https://doi.org/10.1016/j.jvs.2023.06.001
  5. Silva, A. D. M., Furtado, G., Dos Santos, I. P., da Silva, C. B., Caldas, L. R., Bernardes, K. O., & Ferraz, D. D. (2021). Functional capacity of elderly with lower-limb amputation after prosthesis rehabilitation: a longitudinal study. Disability and rehabilitation. Assistive technology, 16(5), 556–560. https://doi.org/10.1080/17483107.2019.1684581
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  7. Daso, G., Chen, A.J., Yeh, S., O'Connell, J.B., Rigberg, D.A., Virgilio, D.C., Gelabert, H.A., Ulloa, J.G. (2022). Lower extremity amputations among veterans: Have ambulatory outcomes and survival improved. Annals of Vascular Surgery, 87:311-320. https://doi.org/10.1016/j.avsg.2022.06.007
  8. Fulton, S., Baird, T., Naik, S., Stiller, K. (2022). Prehabilitation-plus for patients undergoing major lower limb amputation may reduce acute hospital and total hospital length of stay: A retrospective, matched, case-controlled pilot service evaluation. International Journal of Therapy and Rehabilitation, 29:1741-1645. http://doi.org/10.12968/ijtr.2020.0156
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