Physiotherapy Interventions for Adults with Lower-Limb Amputation: Systematic Review of Effects on Quality of Life and Functional Outcomes

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Physiotherapy interventions aim to restore function, improve gait, reduce falls, and manage pain. Objective: To systematically review randomized controlled trials (RCTs) evaluating the effectiveness of physiotherapy interventions on QoL and secondary functional outcomes in adults with lower-limb amputation. Methods: A systematic search was conducted in PubMed, Embase, Cochrane, and PEDro from 2015 to 2025, following PRISMA 2020 guidelines, yielding 302 records. Eligible RCTs involving physiotherapy interventions for adults with lower-limb amputation were included. Risk of bias was assessed using the PEDro scale and Cochrane tools, and the certainty of evidence for QoL outcomes was evaluated using GRADE methodology. The review was prospectively registered in PROSPERO (ID: 1128315). Due to heterogeneity in interventions, outcomes, and study designs, a narrative synthesis was performed. Results: Seven RCTs (n = 185) met inclusion criteria. Interventions included back school programs, Wii Fit exercises, personalized exercise programs, low-cost physiotherapy programs, Hull Early Walking Aid, phantom exercises, and prosthetic knee training. Evidence indicates that physiotherapy interventions improve QoL and secondary outcomes, including walking speed, balance, gait biomechanics, pain management, and prosthesis adaptation. Conclusion: Physiotherapy interventions are effective in enhancing QoL and functional outcomes in adults with lower-limb amputation. Implementation of individualized, multi-component rehabilitation programs is recommended. Further large-scale RCTs with standardized protocols and long-term follow-up are needed to strengthen the evidence base and guide clinical practice. Lower-limb amputation Physiotherapy Rehabilitation Quality of life Functional outcomes Gait training Balance training Prosthetic adaptation Figures Figure 1 Figure 2 Introduction Lower-limb amputation is a life-altering event that results in significant physical, functional, and psychological consequences. Individuals experience reduced gait efficiency, impaired balance, altered weight-bearing mechanics, and decreased muscle strength, which collectively increase the risk of falls and limit functional mobility[1, 2, 3, 5] .Phantom limb pain, residual limb pain, and joint pain are prevalent complications that further impair mobility and daily function [6, 7] . Moreover, the psychological impact—including depression, anxiety, and social isolation—can substantially reduce quality of life (QoL) and participation in social and occupational activities[8, 9, 10] . The consequences of amputation are particularly pronounced among older adults, individuals with vascular comorbidities such as peripheral arterial disease or diabetes, and those with traumatic or dysvascular causes, where the residual limb and overall health status may limit rehabilitation potential [11, 12, 13] . Functional limitations may also persist due to inadequate prosthetic use or delayed prosthesis fitting, compounding mobility restrictions and decreasing independence in activities of daily living[14,15] . Physiotherapy interventions play a pivotal role in mitigating these consequences, aiming to restore functional independence, enhance mobility, and improve overall well-being. Evidence-based strategies include task-specific and strength exercises, gait training, prosthetic adaptation, balance and postural control programs, virtual reality-assisted therapy, back school programs, and structured home-based interventions[16,17,5, 3, 18, 19] . These interventions target multiple domains: optimizing gait mechanics, increasing walking speed, improving postural stability, reducing falls, alleviating pain, and enhancing psychosocial outcomes including self-efficacy and quality of life[20, 21, 22] Despite a growing body of literature, the available evidence is fragmented, with considerable heterogeneity in study designs, sample sizes, intervention types, duration, outcome measures, and follow-up periods [23,24,25] . Such variability hinders the ability to draw robust conclusions regarding the effectiveness of physiotherapy interventions in this population. To date, no systematic review has synthesized RCT-only evidence of physiotherapy interventions on quality of life in adults with lower-limb amputation. This highlights the novelty and rationale for the current review. The review aims to evaluate the effectiveness of physiotherapy interventions on QoL and secondary functional outcomes in adults with lower-limb amputation, providing evidence to inform rehabilitation strategies and optimize recovery. Methods Search Strategy: A systematic search was conducted in PubMed, Embase, Cochrane, and PEDro databases up to August 2025, following PRISMA 2020 guidelines [26] . Keywords included “lower-limb amputation,” “physiotherapy,” “rehabilitation,” “exercise,” “gait training,” and “quality of life.” A total of 302 records were retrieved: PubMed (n=122), Embase (n=80), Cochrane (n=70), PEDro (n=30). Registration: This systematic review was conducted following PRISMA 2020 guidelines and is registered in PROSPERO (ID: 1128315). Eligibility Criteria: Population: Adults ≥18 years with lower-limb amputation Intervention: Any physiotherapy or rehabilitation program Comparator: Usual care, standard care, or no intervention Outcomes: Primary – QoL; Secondary – walking speed, gait, balance, pain, prosthesis adaptation Study Design: Randomized controlled trials (RCTs) Screening and Data Extraction: Titles, abstracts, and full-texts were screened independently by two reviewers. Discrepancies were resolved through discussion and consensus. Data were extracted into a structured table (See Table 1), including study characteristics, sample size, amputation type, intervention, comparator, duration, and outcomes. Table. 1 Characteristic of all included studies Study Country Design Sample Size Amputation Level / Cause Intervention Comparator Duration QoL Outcome Secondary Outcomes Mazari et al., 2010[29] UK RCT 29 Transtibial / Various Hull Early Walking Aid Standard rehab 6 weeks Improved mobility & QoL Walking speed, balance Imam et al., 2017[19] Australia RCT 39 Lower-limb / Older adults Wii Fit Exercise Program Usual care 6 weeks QoL (SF-36) Walking performance, balance Schafer et al., 2018[20] Australia Block RCT 15 Lower-limb / Various Personalized Exercise Program Usual care 6 weeks QoL (SF-36) Falls, gait biomechanics Hafner & Askew, 2015[14] USA Randomized crossover 12 Transfemoral / Unilateral Passive, Adaptive, Active Prosthetic Knees Each participant as own control 8 weeks Self-reported QoL Physical performance measures Anaforoğlu et al., 2016[18] Turkey RCT 40 Lower-limb / Various Back School Program Control (No intervention) 6 weeks QoL (SF-36) Pain, functional mobility Almeida et al., 2021[15] Brazil RCT 26 Lower-limb / Various Low-cost Physiotherapy Program Usual care 4 weeks QoL (SF-36) Gait adaptation to prosthesis Zaheer et al., 2021[21] Pakistan RCT 24 Lower-limb / Various Phantom Exercises Usual care 4 weeks QoL (SF-36) Pain, mobility QoL = Quality of Life; SF-36 = Short Form-36 questionnaire; RCT = Randomized Controlled Trial. Risk of Bias Assessment: PEDro scale and Cochrane Risk of Bias tools were applied[27, 28). Most studies scored 7/10 on PEDro, indicating good quality. Blinding of participants and therapists was consistently challenging. Table 2 PEDro scale assessment of included studies Study Random Allocation Allocation Concealment Baseline Similarity Blinding Subjects Blinding Therapists Blinding Assessors Outcome >85% Intention-to-Treat Between-Group Comparisons Point Measures & Variability Total Score Quality Mazari et al., 2010[29] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Imam et al., 2017[19] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Schafer et al., 2018[20] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Hafner & Askew, 2015 [14] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Anaforoğlu et al., 2016[18] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Almeida et al., 2021[15] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good Zaheer et al., 2021[21] ✓ ✗ ✓ ✗ ✗ ✓ ✓ ✓ ✓ ✓ 7 Good ✓ = Criterion met; ✗ = Criterion not met. PEDro score range: 0–10. Scores 6–8 = Good quality, 9–10 = Excellent, 4–5 = Fair, <4 = Poor. [27] Certainty of Evidence: GRADE methodology assessed primary outcome (QoL). Certainty was moderate due to small sample sizes and imprecision in effect estimates. Additional Analyses: Due to heterogeneity in interventions, outcomes, and study designs, a narrative synthesis was performed, structured by intervention type. Studies with high risk of bias were analyzed separately in sensitivity analyses. Results Study Selection Of 302 records retrieved, 25 full-text articles were assessed for eligibility, and 7 RCTs (n = 185) met inclusion criteria (Figure 1, PRISMA flowchart). Interventions Included physiotherapy interventions were: Back School Program [18] Wii Fit Exercise Program [19] Personalized Exercise Program [20] Low-Cost Physiotherapy Program [15] Hull Early Walking Aid[29] Phantom Exercises[21] Prosthetic Knee Interventions [14] Primary Outcome: Quality of Life All studies reported improvements in QoL after physiotherapy interventions. Quality of life outcomes were measured using validated questionnaires, including the Short Form-36 Health Survey (SF-36)[29] , the Short Form-12 Health Survey (SF-12) [30] , the World Health Organization Quality of Life – BREF (WHOQOL-BREF) [31] , and the Prosthesis Evaluation Questionnaire (PEQ) [32] . Narrative synthesis indicated moderate improvements in physical functioning, psychosocial well-being, and social participation. GRADE assessment rated certainty of evidence as moderate due to small sample sizes and imprecision[30] (Table 4). Table 4 – GRADE Summary of Findings (QoL) [30] Certainty assessment Impact Certainty Importance № of studies Study design Risk of bias Inconsistency Indirectness Imprecision Other considerations Quality of Life (follow-up: range 4 weeks to 12 weeks; assessed with: SF-36, SF-12, WHOQOL-BREF, Prosthesis Evaluation Questionnaire (PEQ)) 7 randomised trials not serious not serious not serious serious a none Physiotherapy interventions probably improve quality of life in adults with lower-limb amputation. ⨁⨁⨁◯ Moderate a CRITICAL CI: confidence interval Explanations a. due to small sample sizes in several studies (n = 12–24) and wide confidence intervals, which increases uncertainty in the effect estimate. Certainty ratings based on GRADE approach: High, Moderate, Low, Very Low Secondary Outcomes Walking and Gait: Improvements in walking speed, step length, gait symmetry, and functional mobility. Falls and Safety: Personalized exercise programs and prosthetic interventions reduced falls. Pain and Psychological Wellbeing: Back school programs and phantom exercises reduced pain and enhanced psychological wellbeing. Prosthesis Adaptation: Low-cost physiotherapy programs and Hull Early Walking Aid improved prosthesis adaptation and user satisfaction Table 3: Secondary Outcomes Summary Study Secondary Outcomes Mazari et al., 2010 [29] Walking speed, balance, gait symmetry, prosthesis satisfaction, adverse events Imam et al., 2017 [19] Step length, walking distance, balance confidence, adherence to Wii Fit program Schafer et al., 2018 [20] Number of falls, lower-limb strength, gait biomechanics, functional mobility tests Hafner & Askew, 2015 [14] Prosthetic knee function, energy expenditure, user satisfaction, functional mobility Anaforoğlu et al., 2016 [18] Back pain severity, lumbar flexibility, posture, functional disability scores Almeida et al., 2021 [15] Gait symmetry, walking speed, step length, balance, adaptation to prosthesis Zaheer et al., 2021 [21] Phantom limb pain intensity, mobility (TUG test), psychological wellbeing, adherence to exercises Reported outcomes include walking speed, balance, gait symmetry, falls, pain, psychological wellbeing, and prosthesis adaptation. Discussion This systematic review synthesized evidence from seven RCTs assessing physiotherapy interventions in adults with lower-limb amputation. The findings indicate that structured physiotherapy programs improve quality of life (QoL), functional mobility, balance, pain management, and prosthesis adaptation. [18, 15,31] Quality of Life and Functional Outcomes Physiotherapy interventions consistently improved QoL across included studies, with moderate certainty according to GRADE assessment. Improvements in physical functioning, psychosocial well-being, and social participation were particularly notable[18, 15,31] . These findings align with prior systematic reviews indicating that task-specific exercises, virtual reality-assisted therapy, and home-based rehabilitation can enhance both physical and mental components of QoL in amputees[16, 9, 23, 24,17] Secondary outcomes such as walking speed, gait symmetry, balance, and prosthesis use also improved following physiotherapy interventions. Personalized exercise programs and gait training reduced fall incidence and enhanced mobility[20,14, 5]. Back school programs, phantom exercises, and mirror therapy alleviated residual limb and phantom limb pain, promoting better psychological well-being and functional engagement[6,10,7, 8,9] Low-cost physiotherapy programs and early mobilization interventions (e.g., Hull Early Walking Aid) improved prosthesis adaptation and satisfaction, particularly in resource-limited settings[29,15,11] . These findings are supported by evidence showing that early and task-specific rehabilitation facilitates neuroplasticity, improves gait mechanics, and reduces compensatory movement patterns[25,32] Clinical Implications The results emphasize the importance of structured, patient-centered physiotherapy programs in the rehabilitation of adults with lower-limb amputation. Clinicians should tailor interventions to the individual’s level of amputation, comorbidities, and functional goals. For example, virtual reality-assisted exercises may be particularly effective in younger, traumatic amputees, whereas home-based programs may provide accessible solutions for older or dysvascular populations[33,11,12] . Early mobilization and prosthetic training, including use of aids such as the Hull Early Walking Aid, facilitate adaptation and improve mobility outcomes[29,15,13] In resource-limited settings such as Ethiopia, low-cost, community-based physiotherapy programs can be especially valuable to enhance QoL and functional outcomes. Methodological Considerations Despite promising outcomes, the overall quality of evidence is limited by small sample sizes, short follow-up periods, and heterogeneity in interventions and outcome measures. Blinding of participants and therapists was consistently challenging, contributing to potential performance bias (PEDro Scale Assessment; Cochrane Risk of Bias Summary). The diversity of QoL instruments used (SF-36, SF-12, WHOQOL-BREF, PEQ) complicates cross-study comparisons. Future trials should adopt standardized protocols, longer follow-up durations, and consistent outcome measures to strengthen evidence[34,25,31, 12] Research and Policy Implications This review highlights gaps in current research, including limited representation of older adults, dysvascular amputees, and low-resource settings. High-quality, multicenter RCTs are needed to validate intervention efficacy and inform evidence-based guidelines[24, 22, 17] Policymakers should consider integrating physiotherapy into post-amputation care pathways, including early inpatient rehabilitation, community-based programs, and access to affordable prosthetic training[12, 11] . Registration of systematic reviews in PROSPERO, as conducted in this study (ID: 1128315), ensures transparency and reproducibility, strengthening the credibility of evidence synthesis. Limitations This review is limited by the small number of RCTs available and potential publication bias. Only English-language studies were included, which may introduce language bias. Additionally, heterogeneity in interventions, outcome measures, and QoL assessment tools restricted the feasibility of meta-analysis, necessitating a narrative synthesis. Despite these limitations, the findings provide a comprehensive overview of the current evidence base and practical guidance for clinicians and researchers. Conclusion Structured physiotherapy interventions significantly improve quality of life, functional outcomes, balance, pain management, and prosthesis adaptation in adults with lower-limb amputation. Implementation of individualized, multi-component rehabilitation programs is recommended to optimize recovery, functional independence, and community reintegration. Future research should focus on large-scale, multicenter RCTs with standardized intervention protocols, consistent outcome measures, long-term follow-up, and inclusion of diverse populations to strengthen the evidence base and inform clinical practice and policy. Declarations Ethics approval and consent to participate Not applicable. This systematic review did not involve direct human participants, animals, or personal data. Consent for publication Not applicable. The manuscript does not contain any individual person’s data or identifying information. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary information files. Competing interests The authors declare that they have no competing interests. Funding This work did not receive any funding from public, commercial, or not-for-profit sources. Author Contributions Moges Baye (¹²): Conceptualization, protocol development, literature search, data extraction, risk of bias assessment, manuscript drafting, supervision, and final approval. Jenber Ayalew (³): Critical appraisal, data analysis, interpretation, discussion writing, and manuscript revision. Eldana Solomon (⁴): Assistance with literature search, data extraction, table compilation, and manuscript formatting. Mihret Dejen Takele (¹): Data extraction, compilation of tables and figures, risk of bias assessment, formatting, and review. Acknowledgements Not applicable References Hills AJ, Shalhoub J, Shepherd AC, Davies AH. Peripheral arterial disease. Br J Hosp Med. 2009;70(10):560–5. Presern-Strukelj M, Poredos P. The influence of electrostimulation on the circulation of the remaining leg in patients with one-sided amputation. Angiology. 2002;53(3):329–35. Ülger Ö, Yıldırım Şahan T, Çelik SE. 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Games Health J. 2024 Aug;13(4):245–51. Godlwana L, Stewart A, Musenge E. The effect of a home exercise intervention on persons with lower limb amputations: a randomized controlled trial. Clin Rehabil. 2020 Jan;34(1):99–110. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFiles1.docx SupplementaryFiles2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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17:01:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1741643,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7434620/v1/b1972fa7-fb98-4e2c-97ef-6d0659d6b38a.pdf"},{"id":90783339,"identity":"c67e97be-451a-438f-96c7-d40a8ff5d792","added_by":"auto","created_at":"2025-09-08 06:10:21","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":288197,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiles1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7434620/v1/741b1f53b04f48e14f9bed82.docx"},{"id":90783338,"identity":"10369573-6fb1-4d97-9bbd-9eda01faaa52","added_by":"auto","created_at":"2025-09-08 06:10:21","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":12921,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFiles2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7434620/v1/67df0e82c42041043bbc3b83.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Physiotherapy Interventions for Adults with Lower-Limb Amputation: Systematic Review of Effects on Quality of Life and Functional Outcomes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLower-limb amputation is a life-altering event that results in significant physical, functional, and psychological consequences. Individuals experience reduced gait efficiency, impaired balance, altered weight-bearing mechanics, and decreased muscle strength, which collectively increase the risk of falls and limit functional mobility[1, 2, 3, 5] .Phantom limb pain, residual limb pain, and joint pain are prevalent complications that further impair mobility and daily function [6, 7] . Moreover, the psychological impact\u0026mdash;including depression, anxiety, and social isolation\u0026mdash;can substantially reduce quality of life (QoL) and participation in social and occupational activities[8, 9, 10] .\u003c/p\u003e\n\u003cp\u003eThe consequences of amputation are particularly pronounced among older adults, individuals with vascular comorbidities such as peripheral arterial disease or diabetes, and those with traumatic or dysvascular causes, where the residual limb and overall health status may limit rehabilitation potential [11, 12, 13] . Functional limitations may also persist due to inadequate prosthetic use or delayed prosthesis fitting, compounding mobility restrictions and decreasing independence in activities of daily living[14,15] .\u003c/p\u003e\n\u003cp\u003ePhysiotherapy interventions play a pivotal role in mitigating these consequences, aiming to restore functional independence, enhance mobility, and improve overall well-being. Evidence-based strategies include task-specific and strength exercises, gait training, prosthetic adaptation, balance and postural control programs, virtual reality-assisted therapy, back school programs, and structured home-based interventions[16,17,5, 3, 18, 19] . These interventions target multiple domains: optimizing gait mechanics, increasing walking speed, improving postural stability, reducing falls, alleviating pain, and enhancing psychosocial outcomes including self-efficacy and quality of life[20, 21, 22]\u0026nbsp; Despite a growing body of literature, the available evidence is fragmented, with considerable heterogeneity in study designs, sample sizes, intervention types, duration, outcome measures, and follow-up periods [23,24,25] . Such variability hinders the ability to draw robust conclusions regarding the effectiveness of physiotherapy interventions in this population.\u003c/p\u003e\n\u003cp\u003eTo date, no systematic review has synthesized RCT-only evidence of physiotherapy interventions on quality of life in adults with lower-limb amputation. This highlights the novelty and rationale for the current review.\u003c/p\u003e\n\u003cp\u003eThe review aims to evaluate the effectiveness of physiotherapy interventions on QoL and secondary functional outcomes in adults with lower-limb amputation, providing evidence to inform rehabilitation strategies and optimize recovery.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eSearch Strategy:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA systematic search was conducted in PubMed, Embase, Cochrane, and PEDro databases up to August 2025, following PRISMA 2020 guidelines\u003c/strong\u003e[26]\u003cstrong\u003e.\u003c/strong\u003e Keywords included \u0026ldquo;lower-limb amputation,\u0026rdquo; \u0026ldquo;physiotherapy,\u0026rdquo; \u0026ldquo;rehabilitation,\u0026rdquo; \u0026ldquo;exercise,\u0026rdquo; \u0026ldquo;gait training,\u0026rdquo; and \u0026ldquo;quality of life.\u0026rdquo; \u003cstrong\u003eA total of 302 records were retrieved: PubMed (n=122), Embase (n=80), Cochrane (n=70), PEDro (n=30).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegistration:\u0026nbsp;\u003c/strong\u003eThis systematic review was conducted following PRISMA 2020 guidelines and is registered in PROSPERO\u003cstrong\u003e\u0026nbsp;(ID: 1128315).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003ePopulation:\u003c/strong\u003e Adults \u0026ge;18 years with lower-limb amputation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIntervention:\u003c/strong\u003e Any physiotherapy or rehabilitation program\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eComparator:\u003c/strong\u003e Usual care, standard care, or no intervention\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eOutcomes:\u003c/strong\u003e Primary \u0026ndash; QoL; Secondary \u0026ndash; walking speed, gait, balance, pain, prosthesis adaptation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStudy Design:\u003c/strong\u003e Randomized controlled trials (RCTs)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eScreening and Data Extraction:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTitles, abstracts, and full-texts were screened independently by two reviewers. Discrepancies were resolved through discussion and consensus. Data were extracted into a structured table (See Table 1), including study characteristics, sample size, amputation type, intervention, comparator, duration, and outcomes. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable. 1 Characteristic of all included studies \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAmputation Level / Cause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDuration\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQoL Outcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMazari et al., 2010[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUK\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTranstibial / Various\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHull Early Walking Aid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStandard rehab\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImproved mobility \u0026amp; QoL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWalking speed, balance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImam et al., 2017[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower-limb / Older adults\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWii Fit Exercise Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQoL (SF-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWalking performance, balance\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSchafer et al., 2018[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAustralia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBlock RCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower-limb / Various\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePersonalized Exercise Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQoL (SF-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFalls, gait biomechanics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHafner \u0026amp; Askew, 2015[14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRandomized crossover\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTransfemoral / Unilateral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePassive, Adaptive, Active Prosthetic Knees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEach participant as own control\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSelf-reported QoL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysical performance measures\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnaforoğlu et al., 2016[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTurkey\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower-limb / Various\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBack School Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eControl (No intervention)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQoL (SF-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePain, functional mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlmeida et al., 2021[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBrazil\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower-limb / Various\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLow-cost Physiotherapy Program\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQoL (SF-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGait adaptation to prosthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZaheer et al., 2021[21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLower-limb / Various\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhantom Exercises\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUsual care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eQoL (SF-36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePain, mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eQoL = Quality of Life; SF-36 = Short Form-36 questionnaire; RCT = Randomized Controlled Trial.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRisk of Bias Assessment:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePEDro scale and Cochrane Risk of Bias tools were applied[27, 28). Most studies scored 7/10 on PEDro, indicating good quality. Blinding of participants and therapists was consistently challenging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 PEDro scale assessment of included studies\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRandom Allocation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAllocation Concealment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Similarity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlinding Subjects\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlinding Therapists\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBlinding Assessors\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome \u0026gt;85%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntention-to-Treat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBetween-Group Comparisons\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePoint Measures \u0026amp; Variability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMazari et al., 2010[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImam et al., 2017[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSchafer et al., 2018[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHafner \u0026amp; Askew, 2015 [14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAnaforoğlu et al., 2016[18]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAlmeida et al., 2021[15]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eZaheer et al., 2021[21]\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✗\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e✓\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGood\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e✓\u0026nbsp;= Criterion met;\u0026nbsp;✗\u0026nbsp;= Criterion not met.\u003cbr\u003ePEDro score range: 0\u0026ndash;10. Scores 6\u0026ndash;8 = Good quality, 9\u0026ndash;10 = Excellent, 4\u0026ndash;5 = Fair, \u0026lt;4 = Poor. [27]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCertainty of Evidence:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGRADE methodology assessed primary outcome (QoL). Certainty was moderate due to small sample sizes and imprecision in effect estimates.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional Analyses:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to heterogeneity in interventions, outcomes, and study designs, a narrative synthesis was performed, structured by intervention type. Studies with high risk of bias were analyzed separately in sensitivity analyses.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eStudy Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf 302 records retrieved, 25 full-text articles were assessed for eligibility, and 7 RCTs (n = 185) met inclusion criteria (Figure 1, PRISMA flowchart).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterventions\u003c/p\u003e\n\u003cp\u003eIncluded physiotherapy interventions were:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eBack School Program [18]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eWii Fit Exercise Program [19]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePersonalized Exercise Program [20]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eLow-Cost Physiotherapy Program [15]\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHull Early Walking Aid[29] \u0026nbsp;\u003c/li\u003e\n \u003cli\u003ePhantom Exercises[21] \u0026nbsp;\u003c/li\u003e\n \u003cli\u003eProsthetic Knee Interventions [14]\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcome: Quality of Life\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll studies reported improvements in QoL after physiotherapy interventions. Quality of life outcomes were measured using validated questionnaires, including the Short Form-36 Health Survey (SF-36)[29] , the Short Form-12 Health Survey (SF-12) [30] , the World Health Organization Quality of Life \u0026ndash; BREF (WHOQOL-BREF) [31] , and the Prosthesis Evaluation Questionnaire (PEQ) [32] . Narrative synthesis indicated moderate improvements in physical functioning, psychosocial well-being, and social participation. GRADE assessment rated certainty of evidence as moderate due to small sample sizes and imprecision[30] \u0026nbsp;(Table 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 \u0026ndash; GRADE Summary of Findings (QoL)\u003c/strong\u003e [30]\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eCertainty assessment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCertainty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eImportance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e№ of studies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRisk of bias\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInconsistency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndirectness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eImprecision\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOther considerations\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of Life (follow-up: range 4 weeks to 12 weeks; assessed with: SF-36, SF-12, WHOQOL-BREF, Prosthesis Evaluation Questionnaire (PEQ))\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003erandomised trials\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enot serious\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eserious\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003enone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePhysiotherapy interventions \u003cstrong\u003eprobably improve quality of life\u003c/strong\u003e in adults with lower-limb amputation.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e⨁⨁⨁◯\u003cbr\u003eModerate\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCRITICAL\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eCI:\u003c/strong\u003e confidence interval\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExplanations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea. due to small sample sizes in several studies (n = 12\u0026ndash;24) and wide confidence intervals, which increases uncertainty in the effect estimate.\u003c/p\u003e\n\u003cp\u003eCertainty ratings based on GRADE approach: High, Moderate, Low, Very Low\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eWalking and Gait:\u003c/strong\u003e Improvements in walking speed, step length, gait symmetry, and functional mobility.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eFalls and Safety:\u003c/strong\u003e Personalized exercise programs and prosthetic interventions reduced falls.\u003c/li\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003ePain and Psychological Wellbeing:\u003c/strong\u003e Back school programs and phantom exercises reduced pain and enhanced psychological wellbeing.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProsthesis Adaptation:\u003c/strong\u003e Low-cost physiotherapy programs and Hull Early Walking Aid improved prosthesis adaptation and user satisfaction\u003cbr\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Secondary Outcomes Summary\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary Outcomes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMazari et al., 2010\u003c/strong\u003e[29]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eWalking speed, balance, gait symmetry, prosthesis satisfaction, adverse events\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eImam et al., 2017\u003c/strong\u003e[19]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eStep length, walking distance, balance confidence, adherence to Wii Fit program\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSchafer et al., 2018\u003c/strong\u003e[20]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eNumber of falls, lower-limb strength, gait biomechanics, functional mobility tests\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHafner \u0026amp; Askew, 2015\u003c/strong\u003e[14]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eProsthetic knee function, energy expenditure, user satisfaction, functional mobility\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAnaforoğlu et al., 2016\u003c/strong\u003e[18]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eBack pain severity, lumbar flexibility, posture, functional disability scores\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlmeida et al., 2021\u003c/strong\u003e[15]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003eGait symmetry, walking speed, step length, balance, adaptation to prosthesis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eZaheer et al., 2021\u003c/strong\u003e[21]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 454px;\"\u003e\n \u003cp\u003ePhantom limb pain intensity, mobility (TUG test), psychological wellbeing, adherence to exercises\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eReported outcomes include walking speed, balance, gait symmetry, falls, pain, psychological wellbeing, and prosthesis adaptation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review synthesized evidence from seven RCTs assessing physiotherapy interventions in adults with lower-limb amputation. The findings indicate that structured physiotherapy programs improve quality of life (QoL), functional mobility, balance, pain management, and prosthesis adaptation. [18, 15,31]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality of Life and Functional Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhysiotherapy interventions consistently improved QoL across included studies, with moderate certainty according to GRADE assessment. Improvements in physical functioning, psychosocial well-being, and social participation were particularly notable[18, 15,31] . These findings align with prior systematic reviews indicating that task-specific exercises, virtual reality-assisted therapy, and home-based rehabilitation can enhance both physical and mental components of QoL in amputees[16,\u0026nbsp;9, 23, 24,17]\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondary outcomes such as walking speed, gait symmetry, balance, and prosthesis use also improved following physiotherapy interventions. Personalized exercise programs and gait training reduced fall incidence and enhanced mobility[20,14, 5]. Back school programs, phantom exercises, and mirror therapy alleviated residual limb and phantom limb pain, promoting better psychological well-being and functional engagement[6,10,7, 8,9]\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLow-cost physiotherapy programs and early mobilization interventions (e.g., Hull Early Walking Aid) improved prosthesis adaptation and satisfaction, particularly in resource-limited settings[29,15,11] . These findings are supported by evidence showing that early and task-specific rehabilitation facilitates neuroplasticity, improves gait mechanics, and reduces compensatory movement patterns[25,32]\u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results emphasize the importance of structured, patient-centered physiotherapy programs in the rehabilitation of adults with lower-limb amputation. Clinicians should tailor interventions to the individual’s level of amputation, comorbidities, and functional goals. For example, virtual reality-assisted exercises may be particularly effective in younger, traumatic amputees, whereas home-based programs may provide accessible solutions for older or dysvascular populations[33,11,12] . Early mobilization and prosthetic training, including use of aids such as the Hull Early Walking Aid, facilitate adaptation and improve mobility outcomes[29,15,13]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn resource-limited settings such as Ethiopia, low-cost, community-based physiotherapy programs can be especially valuable to enhance QoL and functional outcomes.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDespite promising outcomes, the overall quality of evidence is limited by small sample sizes, short follow-up periods, and heterogeneity in interventions and outcome measures. Blinding of participants and therapists was consistently challenging, contributing to potential performance bias (PEDro Scale Assessment; Cochrane Risk of Bias Summary). The diversity of QoL instruments used (SF-36, SF-12, WHOQOL-BREF, PEQ) complicates cross-study comparisons. Future trials should adopt standardized protocols, longer follow-up durations, and consistent outcome measures to strengthen evidence[34,25,31, 12]\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch and Policy Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review highlights gaps in current research, including limited representation of older adults, dysvascular amputees, and low-resource settings. High-quality, multicenter RCTs are needed to validate intervention efficacy and inform evidence-based guidelines[24, 22, 17]\u0026nbsp; Policymakers should consider integrating physiotherapy into post-amputation care pathways, including early inpatient rehabilitation, community-based programs, and access to affordable prosthetic training[12, 11] . Registration of systematic reviews in PROSPERO, as conducted in this study (ID: 1128315), ensures transparency and reproducibility, strengthening the credibility of evidence synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review is limited by the small number of RCTs available and potential publication bias. Only English-language studies were included, which may introduce language bias. Additionally, heterogeneity in interventions, outcome measures, and QoL assessment tools restricted the feasibility of meta-analysis, necessitating a narrative synthesis. Despite these limitations, the findings provide a comprehensive overview of the current evidence base and practical guidance for clinicians and researchers.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eStructured physiotherapy interventions significantly improve quality of life, functional outcomes, balance, pain management, and prosthesis adaptation in adults with lower-limb amputation. Implementation of individualized, multi-component rehabilitation programs is recommended to optimize recovery, functional independence, and community reintegration. Future research should focus on large-scale, multicenter RCTs with standardized intervention protocols, consistent outcome measures, long-term follow-up, and inclusion of diverse populations to strengthen the evidence base and inform clinical practice and policy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This systematic review did not involve direct human participants, animals, or personal data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data or identifying information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary information files.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work did not receive any funding from public, commercial, or not-for-profit sources.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eMoges Baye (\u0026sup1;\u0026sup2;):\u003c/strong\u003e Conceptualization, protocol development, literature search, data extraction, risk of bias assessment, manuscript drafting, supervision, and final approval.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eJenber Ayalew (\u0026sup3;):\u003c/strong\u003e Critical appraisal, data analysis, interpretation, discussion writing, and manuscript revision.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEldana Solomon (⁴):\u003c/strong\u003e Assistance with literature search, data extraction, table compilation, and manuscript formatting.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMihret Dejen Takele (\u0026sup1;):\u003c/strong\u003e Data extraction, compilation of tables and figures, risk of bias assessment, formatting, and review.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHills AJ, Shalhoub J, Shepherd AC, Davies AH. Peripheral arterial disease. Br J Hosp Med. 2009;70(10):560\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003ePresern-Strukelj M, Poredos P. The influence of electrostimulation on the circulation of the remaining leg in patients with one-sided amputation. Angiology. 2002;53(3):329\u0026ndash;35. \u003c/li\u003e\n\u003cli\u003e\u0026Uuml;lger \u0026Ouml;, Yıldırım Şahan T, \u0026Ccedil;elik SE. A systematic literature review of physiotherapy and rehabilitation approaches to lower-limb amputation. Physiother Theory Pract. 2018 Nov;34(11):821\u0026ndash;34. \u003c/li\u003e\n\u003cli\u003eHighsmith MJ, Andrews CR, Millman C, Fuller A, Kahle JT, Klenow TD, et al. Gait Training Interventions for Lower Extremity Amputees: A Systematic Literature Review . Technol Innov. 2016;18(2):99\u0026ndash;113. \u003c/li\u003e\n\u003cli\u003eBrunelli S, Morone G, Iosa M, Ciotti C, De Giorgi R, Foti C, et al. Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial. Arch Phys Med Rehabil. 2015 Feb;96(2):181\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003ePurushothaman S, Kundra P, Senthilnathan M, Sistla SC, Kumar S. Assessment of efficiency of mirror therapy in preventing phantom limb pain in patients undergoing below-knee amputation surgery-a randomized clinical trial. J Anesth. 2023 Jun;37(3):387\u0026ndash;93. \u003c/li\u003e\n\u003cli\u003eTrevelyan EG, Turner WA, Summerfield-Mann L, Robinson N. Acupuncture for the treatment of phantom limb syndrome in lower limb amputees: A randomised controlled feasibility study. Trials [Internet]. 2016;17(1):1\u0026ndash;11. Available from: http://dx.doi.org/10.1186/s13063-016-1639-z\u003c/li\u003e\n\u003cli\u003eAbbas RL, Cooreman D, Al Sultan H, El Nayal M, Saab IM, El Khatib A. The Effect of Adding Virtual Reality Training on Traditional Exercise Program on Balance and Gait in Unilateral, Traumatic Lower Limb Amputee. Games Health J. 2021 Feb;10(1):50\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eScholl L, Schmidt A, Alfuth M. Efficacy of Mirror Therapy in Patients with Phantom Pain after Amputation of a Lower Limb: A Systematic Literature Review. Z Orthop Unfall. 2024 Dec;162(6):566\u0026ndash;77. \u003c/li\u003e\n\u003cli\u003eB Aledi L, Flumignan CDQ, Trevisani VFM, Miranda F. Interventions for motor rehabilitation in people with transtibial amputation due to peripheral arterial disease or diabetes. Cochrane Database Syst Rev. 2023;2023(6). \u003c/li\u003e\n\u003cli\u003eBarr S, Howe TE. Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation. Cochrane Database Syst Rev. 2018;2018(10). \u003c/li\u003e\n\u003cli\u003eDe Siqueira J, Russell DA, Siddle HJ, Richards SH, McGinnis E. Non-surgical interventions for preventing contralateral tissue loss and amputation in dysvascular patients with a primary major lower limb amputation. Cochrane database Syst Rev. 2024 Aug;8(8):CD013857. \u003c/li\u003e\n\u003cli\u003eHafner BJ, Askew RL. Physical performance and self-report outcomes associated with use of passive, adaptive, and active prosthetic knees in persons with unilateral, transfemoral amputation: Randomized crossover trial. J Rehabil Res Dev. 2015;52(6):677\u0026ndash;700. \u003c/li\u003e\n\u003cli\u003eAlmeida LV, Fukuchi CA, Sakanaka TE, Cliquet A. A low-cost easily implementable physiotherapy intervention clinically improves gait implying better adaptation to lower limb prosthesis: a randomized clinical trial. Sci Rep [Internet]. 2021;11(1):1\u0026ndash;13. Available from: https://doi.org/10.1038/s41598-021-00686-9\u003c/li\u003e\n\u003cli\u003eWong CK, Ehrlich JE, Ersing JC, Maroldi NJ, Stevenson CE, Varca MJ. Exercise programs to improve gait performance in people with lower limb amputation: A systematic review. Prosthet Orthot Int. 2016 Feb;40(1):8\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eAbou L, Fliflet A, Zhao L, Du Y, Rice L. The Effectiveness of Exercise Interventions to Improve Gait and Balance in Individuals with Lower Limb Amputations: A Systematic Review and Meta-analysis. Clin Rehabil. 2022 Jul;36(7):857\u0026ndash;72. \u003c/li\u003e\n\u003cli\u003eAnaforoğlu B, Erbah\u0026ccedil;eci F, Aksekili MAE. The effectiveness of a back school program in lowerlimb amputees: a randomized controlled study. Turkish J Med Sci. 2016 Jun;46(4):1122\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eImam B, Miller WC, Finlayson H, Eng JJ, Jarus T. A randomized controlled trial to evaluate the feasibility of the Wii Fit for improving walking in older adults with lower limb amputation. Clin Rehabil. 2017 Jan;31(1):82\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eSchafer ZA, Perry JL, Vanicek N. A personalised exercise programme for individuals with lower limb amputation reduces falls and improves gait biomechanics: A block randomised controlled trial. Gait Posture. 2018 Jun;63:282\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eZaheer A, Malik AN, Masood T, Fatima S. Effects of phantom exercises on pain, mobility, and quality of life among lower limb amputees; a randomized controlled trial. BMC Neurol. 2021 Oct;21(1):416. \u003c/li\u003e\n\u003cli\u003eBrunelli S, D\u0026rsquo;Auria L, Stefani A, Giglioni F, Mariani G, Ciccarello M, et al. Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation? Int J Rehabil Res Int Zeitschrift fur Rehabil Rev Int Rech Readapt. 2023 Jun;46(2):193\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGane E, Petersen P, Killalea T, Glavinovic P, Nash I, Batten H. The effect of rehabilitation therapies on quality of life and function in individuals with phantom limb pain after lower-limb amputation: A systematic review. Prosthet Orthot Int. 2024 Aug;48(4):431\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eDupuis F, Ginis KAM, MacKay C, Best KL, Blanchette V, Cherif A, et al. Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed. Arch Phys Med Rehabil. 2024 Jun;105(6):1194\u0026ndash;211. \u003c/li\u003e\n\u003cli\u003eMadou E, Sureshkumar A, Payne MW, Viana R, Hunter SW. The effect of exercise interventions on gait outcomes in subacute and chronic rehabilitation from lower-limb amputation: A systematic review and meta-analysis. Prosthet Orthot Int. 2024 Apr;48(2):128\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003ePage MJ, Moher D, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. 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The effect of a home exercise intervention on persons with lower limb amputations: a randomized controlled trial. Clin Rehabil. 2020 Jan;34(1):99\u0026ndash;110. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Lower-limb amputation, Physiotherapy, Rehabilitation, Quality of life, Functional outcomes, Gait training, Balance training, Prosthetic adaptation","lastPublishedDoi":"10.21203/rs.3.rs-7434620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7434620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Lower-limb amputation substantially affects mobility, functional independence, and quality of life (QoL) due to altered gait mechanics, pain, and psychosocial challenges. Physiotherapy interventions aim to restore function, improve gait, reduce falls, and manage pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e To systematically review randomized controlled trials (RCTs) evaluating the effectiveness of physiotherapy interventions on QoL and secondary functional outcomes in adults with lower-limb amputation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A systematic search was conducted in PubMed, Embase, Cochrane, and PEDro from 2015 to 2025, following PRISMA 2020 guidelines, yielding 302 records. Eligible RCTs involving physiotherapy interventions for adults with lower-limb amputation were included. Risk of bias was assessed using the PEDro scale and Cochrane tools, and the certainty of evidence for QoL outcomes was evaluated using GRADE methodology. The review was prospectively registered in PROSPERO (ID: 1128315). Due to heterogeneity in interventions, outcomes, and study designs, a narrative synthesis was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Seven RCTs (n = 185) met inclusion criteria. Interventions included back school programs, Wii Fit exercises, personalized exercise programs, low-cost physiotherapy programs, Hull Early Walking Aid, phantom exercises, and prosthetic knee training. Evidence indicates that physiotherapy interventions improve QoL and secondary outcomes, including walking speed, balance, gait biomechanics, pain management, and prosthesis adaptation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Physiotherapy interventions are effective in enhancing QoL and functional outcomes in adults with lower-limb amputation. Implementation of individualized, multi-component rehabilitation programs is recommended. Further large-scale RCTs with standardized protocols and long-term follow-up are needed to strengthen the evidence base and guide clinical practice.\u003c/p\u003e","manuscriptTitle":"Physiotherapy Interventions for Adults with Lower-Limb Amputation: Systematic Review of Effects on Quality of Life and Functional Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 05:54:13","doi":"10.21203/rs.3.rs-7434620/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"71998d96-ed13-4115-b9b3-975b1edadf7b","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-22T16:53:23+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 05:54:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7434620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7434620","identity":"rs-7434620","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}