Exploring meaningful outcome domains of recovery following lower limb amputation (LLA) and prosthetic rehabilitation in low- and middle-income (LMIC) settings: a qualitative systematic review

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OBJECTIVES: To identify outcome domains of importance to adults undergoing prosthetic rehabilitation following lower limb amputation in low- and middle-income countries (LMICs), based on their lived experiences described in qualitative literature. DESIGN: Systematic review and qualitative synthesis informed by a critical realist perspective and reported according to ENTREQ (Enhancing Transparency in Reporting the Synthesis of Qualitative Research) guidelines. DATA SOURCES: CINAHL, PsycInfo, Web of Science and Trip databases were searched from inception to April 2024. ELIGIBILITY CRITERIA: We included qualitative studies exploring the views and experiences of adults (≥18 years) using lower limb prosthesis in LMICs (World Bank definition). Studies including upper limb amputees, non-prosthetic users, mixed samples that could not be disaggregated or not reporting first-person accounts were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently screened studies using predefined criteria. Data were extracted from results sections, including participant quotations and author interpretations. Reflexive thematic analysis was conducted to identify outcome domains across studies. Study quality was appraised using the CASP (Critical Appraisal Skills Programme) qualitative checklist; no studies were excluded based on quality. RESULTS: Five studies involving 55 participants from Nepal, Kenya, Cambodia, Bangladesh and Kiribati met the inclusion criteria. Four outcome domains were identified: (1) The importance of a prosthesis: highlighting access, socket comfort, durability and functional suitability; (2) valued activities: particularly the importance of work and participation in daily living tasks; (3) acceptance following limb loss: encompassing community participation and self and social acceptance; and (4) independence: including reduced reliance on family and greater control over daily life. Across settings, participants emphasised prosthesis durability, work participation and culturally relevant function. CONCLUSION: Evidence on meaningful outcomes of prosthetic rehabilitation in LMICs is extremely limited. Findings indicate that access to a comfortable and durable prosthesis enabling work and daily living is central to recovery, alongside social acceptance and independence. These domains may provide initial insights into outcome measurement and development in low-resource settings. Further primary research across diverse LMIC contexts is urgently needed.

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