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VOLUME 3, ISSUE 1 

 2020 

 

 

LITERATURE  REVIEW 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-

tibial amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

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https://doi.org/10.33137/cpoj.v3i1.33640


 

1 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

 

 

 
LITERATURE  REVIEW 

 

A LITERATURE REVIEW OF THE QUALITY OF LIFE, HEALTH STATUS AND PROSTHESIS 
SATISFACTION IN OLDER PATIENTS WITH A TRANS-TIBIAL AMPUTATION 

 
Brunelli S1*, Bonanni C2, Foti C2, Traballesi M1     
 

1 Fondazione Santa Lucia, Scientific Institute for Research, Hospitalization and Health Care, Rome, Italy. 

2 Physical and Rehabilitation Medicine, Tor Vergata University of Rome, Rome, Italy. 
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

The lower limb amputation is a dramatic event that can 

negatively impact functional mobility, perceived health 

status (HS) and quality of life (QoL) of a person.1 In the past, 

QoL and HS outcome have not been considered as an 

important goal for a rehabilitation project. Moreover, QoL 

and HS assessments are rarely performed in routine clinical 

practice and in clinical trials, particularly in the field of 

prosthetics. The hypothesis that a better functional outcome 

(i.e. mobility and performance with the prosthesis), is 

associated with improved QoL is not always confirmed, as 

patients’ perception of overall well-being and satisfaction 

could be different from the predictions of physicians.2 For a 

complete and accurate assessment of multiple aspects of a 

person's status, it is important to differentiate between HS 

and QoL.3 Quality of life has been defined by the World 

Health Organization (WHO) as “individuals' perceptions of 

their position in life in the context of the culture and value 

systems in which they live and in relation to their goals, 

expectations, standards and concerns”.4,5 Health Status is 

often indistinct from QoL. The assessment of perceived 

 
OPEN  ACCESS Volume 3, Issue 1, Article No.3. 2020 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

BACKGROUND: Several reviews have been published regarding quality of life (QoL) and Health Status 

(HS) in persons with lower limb amputation (LLA). However, little has been discussed in the literature 

with respect to older populations (i.e. age>60 years) with trans-tibial amputation. Furthermore, the 

perceived satisfaction with prosthesis is another important aspect for consideration in the amputees’ life. 

OBJECTIVE: The purpose of this review was to evaluate the impact of trans-tibial amputation on the 

QoL, HS and prosthesis satisfaction, in order to determine the appropriate intervention to improve these 

aspects in older population of trans-tibial amputees (TTA). 

METHODS: Research articles, published between January 2000 to March 2019, were found using 

Scopus, PubMed and Google Scholar databases. The methodological quality of the selected articles was 

assessed using the Critical Review Form-Quantitative Studies checklist. 

RESULTS: Ten articles that met the inclusion criteria were selected. In these papers, we can summarize 

that people with trans-tibial amputation have a better QoL compared to those with above knee 

amputation. Moreover, physical functioning and mobility are the most influencing factors for QoL and HS 

in older people with lower limb amputation. Finally, the prosthesis weight reduction may improve 

satisfaction with the prosthetic limb. 

CONCLUSION: Efforts have to be made in order to improve mobility in older population with transtibial 

amputation for better QoL and HS. This can be accomplished by means of adequate rehabilitation, pain 

management and an accurate choice of appropriate prosthetic components. We observed that the quality 

of evidence in the literature available is inadequate and future research would benefit from more 

prospective observational cohort studies with appropriate inclusion criteria and larger sample sizes to 

better understand the QoL and HS in this population. 

ARTICLE INFO 

Received: February 3, 2020 

Accepted: May 16, 2020 

Published: May 21, 2020 

CITATION 

Brunelli S, Bonanni C, Foti 

C, Traballesi M. A literature 

review of the quality of life, 

health status and prosthesis 

satisfaction in older patients 

with a trans-tibial 

amputation. Canadian 

Prosthetics & Orthotics 

Journal. 2020;Volume3, 

Issue1, No.3. 

https://doi.org/10.33137/cpoj.

v3i1.33640 

KEYWORDS 

Quality of Life, Amputation, 

Satisfaction, Rehabilitation, 

Review, Prosthesis, 

Amputee, Lower Limb 

Amputation, Health Status. 

* CORRESPONDING AUTHOR: 
Stefano Brunelli, MD 
Santa Lucia Foundation, Scientific Institute for Research,                  
Hospitalization and Health Care, Rome, Italy. 
E-Mail: s.brunelli@hsantalucia.it 
ORCID: https://orcid.org/0000-0002-5986-1564 
 

INTRODUCTION   

 

https://doi.org/10.33137/cpoj.v3i1.33640
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v3i1.33640
https://doi.org/10.33137/cpoj.v3i1.33640
mailto:s.brunelli@hsantalucia.it
https://orcid.org/0000-0002-5986-1564


 

2 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 
Health Status has the goal of evaluating a persons’ 

perception of his or her disease influenced by the complex 

interactions of social, emotional and physical functioning.6 

The evaluation of QoL and HS, by means of reliable 

questionnaires, might determine which are the most 

influencing factors and thereby helping the rehabilitation 

team or the healthcare services to improve care of persons 

with limb amputation.7 A proper investigation of QoL in 

people with amputation could rely on the use of specific 

instruments developed for this purpose, such as: Trinity 

Amputation and Prosthesis Experience Scales (TAPES)8 

that investigate these domains: psychosocial adjustment; 

social, functional and athletic restriction; prosthesis 

satisfaction; pain and other medical problems, or the 

Prosthesis Evaluation Questionnaire (PEQ)9 which 

investigates ambulation, appearance, frustration, perceived 

response, residual limb health, social burden, sounds, utility 

and well-being. 

A comfortable prosthetic device allows amputees to walk 

and carry out daily activities without pain and could 

increases their satisfaction, independence and activity 

level.10 Even an aesthetically acceptable prosthetic device 

might favourably influence the social reintegration of the 

patient. A comprehensive life assessment of people with 

lower limb amputation must take into account their 

satisfaction with the prosthesis. Those satisfaction aspects 

are included in some items of TAPES and PEQ. 

Furthermore, the SAT-PRO (satisfaction with prosthesis) 

was developed specifically for this purpose.11 

Many studies have investigated functional outcome, 

functional status, mobility level and the predictor factors in 

LLA.12,13 However, rarely those data are associated with 

QoL, HS or satisfaction with the prosthesis. Moreover, 

studies rarely focus on different populations of LLA, in a way 

that the results can be differentiate between elderly or 

younger people with trans-tibial or trans-femoral 

amputation.14 

It should be noted that poor QoL in a person with lower limb 

amputation may depend not only on physical disability but 

also on pain, in particular low back pain or artrithis15,16 or 

phantom pain.17 In addition, traumatic amputation at young 

age is associated with better QoL.18 Some reviews about 

QoL and HS are available, however they are related 

exclusively to a general sample of LLA.14,19,20 

This literature review was undertaken with a purpose to 

support or refute any or all of the following assumptions: a) 

TTA have better mobility capacity than TFA21; b) people 

above 65 years old present lower physical performance 

than younger patients; and c) the performance status of 

older patients after amputation is generally poor.22 With 

these observations in mind, the aim of this review was to 

analyse the QoL, HS and satisfaction with the prosthesis in 

a specific group of trans-tibial amputees (i.e. age>60y). 

METHODOLOGY 

Search strategy 

Two authors, SB and CB, independently conducted a 

search in the spring 2019 to find related research articles 

using Scopus, PubMed and Google Scholar databases. The 

electronic literature search included articles published from 

January 2000 to March 2019, using the keywords 

“amputee”, “lower limb amputation”, “trans-tibial”, “below-

knee”, “health status,” “quality of life”, “outcome” and 

“satisfaction”. We have included the keyword “outcome” as 

sometimes the keyword of a study was the functional 

outcome and the QoL or HS described only as secondary 

aims. Moreover, “SF-36", "WHO QOL-BREF", "PEQ", "PPA 

(Prosthetic Profile for Amputee23)" and "TAPES-R", have 

also been searched as these are the most used tools for the 

measurements of QoL or HS in LLA. Combinations of 

keywords were made in order to refine the search results by 

using Boolean terms ‘AND’ and ‘OR’. 

Review process 

The reference lists of all screened articles were also 

examined for any potentially eligible studies. Reviews, case 

reports, congresses abstracts, comments, editorials, 

guidelines, letters and studies not in English were excluded. 

Articles that focused on individuals with upper limb 

amputation or solely on individuals with above knee 

amputation or on people with mean age<60 were excluded. 

The authors performed a second screening by reading the 

full-text of the selected articles, to understand if they could 

obtain data on QoL, HS or satisfaction with the prosthesis 

based on the following inclusion criteria: 1) persons 

diagnosed with TTA; 2) studies investigating QoL and/or HS 

and/or satisfaction with the prosthesis in persons aged >60 

years; 3) use of standardized evaluation measures. As all 

data was drawn from literature and as such no informed 

consent or ethical approval was needed for this study. 

Study quality 

The methodological quality of the selected articles was 

assessed using the Critical Review Form-Quantitative 

Studies checklist.24 The checklist consists of 15 questions 

pertaining to the quality of reporting, internal validity, 

external validity, and power of the studies. Higher scores 

representing better quality. Most questions were answered 

as “1” for a yes or “0” for a no. Some questions had the 

option “unable to determine”, these questions were 

excluded from the checklist.24  

RESULTS 

Article selection 

An initial electronic database search obtained 892 articles. 

An identification of duplicates excluded 616 articles. 

Screening of the title and abstract further excluded 184 

https://doi.org/10.33137/cpoj.v3i1.33640


 

3 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 
articles because they were not investigating the impact of a 

trans-tibial amputation on the QoL, HS or satisfaction with 

the prosthetic limb. Eighty-two articles were removed after 

reviewing the full texts. In total, 10 articles were selected for 

the purpose of this literature review (Figure 1). 

In our review of literature, no randomized controlled trial 

studies were found on the topic of interest. The majority 

were observational studies (n=5) and cross-sectional (n=3) 

studies while the others were cross-over (n=1) or 

retrospective studies (n=1). The results of the four studies,2, 

25-27 which evaluated QoL in older TTA are summarized in 

Table 1. Four studies17,28-30 evaluated HS in this population 

and their findings were summarized in Table 2 . Moreover, 

Table 3 shows two studies on patient level of satisfaction 

with the prosthesis.31-32 The only study that investigated 

both HS and QoL,27 is included in Table 1, as the main 

results were related to QoL. 

Table 1: Overview of studies reporting QoL data.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authors 
Evaluation 

tools 
Study 

protocol 
Characteristics of 

patients 
Aim of study Results 

Critical 
review 
form- 
total 
items 

Harness et 

al. (2001)2 
PEQ Follow up 

60 dysvascular TTA 
(mean age 65.9 ± 
1.4 years) with 
successful use of 
current prosthesis 
for a minimum of 6 
months  

Determining QoL of a 
population of TTA 
who were successful 

prosthetic users 

The response to the PEQ domains of perceived 
responses, frustration, social burden, overall well-being 
and overall satisfaction were above 65% of the midline of 
the PEQ scores. The domains “ambulation” and “transfer” 
showed less favorable responses. Statistical study of the 
relationships between domains showed these 
correlations: 
a. “residual limb health” and “prosthetic appearance” with 
“social burden” “satisfaction” 

b. less “pain” with “satisfaction”. 
c.  “ability to ambulate” with “satisfaction” 
d. “transfer ability” with “satisfaction” and with decreased 
“social burden” 
e. “pain” and “residual limb health” with “ability to 
ambulate” 
f. “social burden” with “ambulation” 

10/12* 

Norvell et 

al.(2011)25 
 SWLS 

Prospective 
cohort study 

87 LLA (8 TFA, 52 
TTA, and 27 Trans-
metatarsal 
amputees). TTA 
mean age was 
61.5±9.1 years. 
Only 43 individuals 
reached 12-month 
follow-up  

Examining the 
association of “mobility 
success” with satisfaction 
with mobility and 
satisfaction with life; 
comparing rates of 
mobility success between 
various amputation levels; 
evaluating factors 
associated with mobility 
success 

This study did not find a significant difference in mobility 
results between TFA and TTA. This could depend on the 
very small number of TFA. 50% of TTA were satisfied with 
their mobility. No differences were found between TTA and 
transmetatarsal amputees in terms of mobility satisfaction. 
The satisfaction with life was 28% higher in amputees with 
higher mobility score. There is also a correlation between 
higher mobility score and satisfaction with mobility 

14/15 

Cox et al. 

(2011)26 

WHO QOL-
BREF 

Observational 
study 

87 LLA (64 TTA, 23 
TFA ) Mean age: 
62±9.9 years. 35 
males and 52 
females. All TTA 
males were > 60 
years. 78% of TTA 
females were >60 
years 

Determining the QoL of 
diabetic LLA  and  the  
relationship with gender, 
age and amputation level 

TTA showed a better QoL. Females were found to have 
higher scores in the QoL domains (physical health, 
physiological, social relationship and environment) than 
males, even if 40% had a transfemoral amputation. This 
might depend on the younger age of the females.  Females 
across the age groups had a significantly higher QoL 
average scores than males 

14/15 

Quigley et 

al.(2016)27 

TAPES-R 
and 
modified 
version of 
SF-36 (v2) 

33 

Cross-
sectional 
study 

33 LLA (23 TTA 
(mean age 68±10 
years), 10 partial 
foot amputees (63 
± 10 years) 

Comparing QoL in people 
with partial foot 
amputation secondary to 
peripheral vascular 
disease and determining 
factors influencing QoL 

The statistic analysis showed no significant differences in 
the SF-36v2 between TTA and partial foot amputation. Age 
was the only variable, which concurred significantly with 
QoL, while level of amputation did not 

14/15 

 
Abbreviations: LLA, lower limb amputees; TTA, transtibial amputees; TFA, transfemoral amputees; WHO QOL-BREF, World Health Organization Quality of Life Scale; QoL, quality of life;; PEQ, 
Prosthesis Evaluation Questionnaire;  SF-36, Short-Form General Health Survey; SWLS, Satisfaction with Life Scale; TAPES-R, Trinity Amputation and Prosthesis Experience Scale-Revised. 
 

* Some questions had the option “unable to determine”. These questions were excluded from the checklist and this was the reason why some of selected studies might have a maximum score 

 of less than 15. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Records identified 
through database 

searching (n = 892) 

S
c
re

e
n

in
g

 
In

c
lu

d
e
d

 
E

lig
ib

ili
ty

 
Id

e
n
ti
fi
c
a
ti
o
n

 

Duplicates records removed 
(n = 616) 

Records 
screened 
(n = 276) 

Records excluded by title and 
abstract (n = 184) 

Full-text articles 
assessed for 

eligibility (n = 92) 

Full-text articles excluded, 
with reasons: 1) not possible 
to differentiate TTA from TFA 
(n = 39); 2) not possible to 
differentiate TTA >60y from 
younger (n = 30); 3) irrelevant 
(n 13) 

Studies included in qualitative 
synthesis (n = 10) 

Figure1: Flowchart summarizing the study selection process. 

https://doi.org/10.33137/cpoj.v3i1.33640


 

4 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 

Patients Characteristics 

Only three studies focused on TTA with a mean age>60 

years, two of which primarily investigated the effects of a 

new prosthetic foot.31,32 Only one study exclusively 

assessed the QoL of a population of non-traumatic TTA who 

were successful prosthetic users.2 In most of the selected 

studies, the sample consisted in a mixed group of TTA and 

TFA. In two articles25,27 the sample also included partial foot  

 

amputees and in two other studies28,30 there was a control 

group consisting of people with intact lower extremities or 

foot ulcer. 

QoL and HS measurement 

The most used tools were the Research and Development 

Corporation measure of Quality of Life 36-Item Health 

Authors 
Evaluation 

tools 
Study 

protocol 
Characteristics of 

patients 
Aim of study Results 

Critical 
Review 
Form- 
TOTAL 
items 

Van der 
Schans et 

al.(2002)17 

RAND-36 
Cross-
sectional 
study 

437 LLA, 62% TTA. 
71% males. Mean 
age 65±15 years 
(8% of the sample 
was older than 75 
years) 

Describing health-related 
quality of life in LLA  and 
investigating potential 
determinants: including 
phantom pain age, sex, 
level of amputation, 
amputation reason, 
phantom or stump pain 
and walking distance 

Health-related quality of life was positively influenced by 
a) absence of phantom pain, b) walking distance c) 
absence of stump pain d) amputation through or above 
the knee 

12/13 

Boutoille et 

al.(2008)28 

 MOS SF-
36 

Retrospective 
case control 
study 

6 TTA (mean 
age 68 years) and 9 
with a current foot 
ulcer, (mean age 70 
years) 

Evaluating the influence 
of amputation or 
conservative treatment for 
a diabetic foot ulcer on 
physical and social 
aspects of patients' QoL 

TTA group reported less pain but similar QoL compared 
to foot ulcer patients 

14/15 

Fortington 
et al. 

(2013)29 

RAND-36   
Longitudinal 
study. 

82 LLA. Mean age 
67.8±13 years. 63% 
TTA and 37% TFA. 
A total of 35 
remained in the 
study at 18 months 
follow up.  

Evaluating how the age 
and walking distance 
could influence QoL 18 
months after the 
amputation. Comparing 
QoL of LLA with a control 
group 

Only the domain “social function” was influenced 
significantly by the ability to walk. Except for physical 
function, the other domains were similar to population 
norm values. The domain “physical function” was 
positively correlated to lower levels of amputation and 
to age categories of less than 65 years. QoL improved 
after amputation, in particular in the first 6 months 

14/15 

Knezevic 
et al. 

(2015)30 

RAND- 36 
Cross-
sectional 
study 

28 LLA. 61% TFA, 
39% TTA. Mean 
age: 65.4 ± 13.6 
years. 

Assessing the QoL of the 
patients with LLA 
compared to a control 
group, taking into account 
the influence of age and 
level of amputation 

TTA are more mobile than TFA. The most significant 
difference was in the domains "physical functioning" 
and "general health", with higher scores reported by 
TTA 

14/15 

Abbreviations: LLA, lower limb amputees; TTA, transtibial amputees; RAND-36, Research and Development Corporation measure of Quality of Life 36-Item Health Survey 1.0 ; SF-36, Short-Form 
General Health Survey; MOS SF-36, Medical Outcomes Study 36-item short-form 

 

Authors Evaluation tools Study protocol 
Characteristics of 

patients 
Aim of study Results 

Critical 
Review 
Form- 

TOTAL 
items 

Bonnet et 

al.(2015)31 

Quebec User 
Evaluation of 
Satisfaction with 
Assistive 
Technology 2.0 
questionnaire 

Crossover study 
12 dysvascular TTA, 
mean age 77 years 

Evaluating the benefit of 
a NGF versus SACH 
foot for low-activity TTA 

Higher satisfaction level using NGF compared 
to SACH. The increase is significant for the 
global score of the questionnaire.  

14/15 

Delussu et 
al. 

(2016)32 

SATPRO 
Observational 
study 

20 TTA, mean age 
66.6±6.7 years. 19  
amputees had a K-
level of 2 and 1 had a 
K-level of 1 

Assessing amputees 
satisfaction with 
prosthesis using two 
different prosthetic feet: 
1M10 Adjust and SACH 
in low-mobility TTA 

Participants showed a significantly higher 
improvement in SAT-PRO with “1M10 Adjust” 
than with SACH.  

12/13 

Abbreviations: TTA: Trans-Tibial Amputee, SAT-PRO: Satisfaction with Prosthesis, SACH: Solid Ankle Cushion Heel, NGF: New Geriatric Foot. 

 

Table 2: Overview of studies reporting HS data.                                                . 

Table 3: Overview of studies reporting satisfaction with the prosthesis data. 

https://doi.org/10.33137/cpoj.v3i1.33640


 

5 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 
Survey 1.0 (RAND- 36) (3 times) and the SF-36 (2 

times).34,35 The RAND-36 is a self-reported questionnaire 

which includes the same items as those of SF-36, but 

scoring is slightly different in the domains "pain" and 

"general health". PEQ and TAPES-R questionnaire was 

used one time (Table 4). 

Table 4: Overview of the tools used for HS and QoL. 

Evaluation tools Authors 

PEQ Harness et al (2001)2 

SWLS Norvell et al (2011)25 

WHO QOL-BREF Cox et al (2011) 26 

TAPES-R Quigley et al (2016)27 

SF-36 
Quigley et al (2016)27;Boutoille et al (2008)28; 

Knezevic et al (2015)30 

RAND-36 
Van der Schans et al (2002)17;Knezevic et al 

(2015)30; Fortington et al (2013)29 

 

DISCUSSION  

The intention of this review was to evaluate the impact of 

trans-tibial amputation on the QoL, HS and prosthesis 

satisfaction, in order to determine the appropriate 

intervention to improve these aspects in older trans-tibial 

amputees. Many studies reported a better QoL and HS in 

TTA compared to TFA,26 particularly in the “physical 

functioning” domain.29,30 Moreover, TTA also had 

significantly higher scores for functional independence 

compared to the TFA.26 Considering that TTA have better 

QoL than TFA, we investigated whether these patients 

could maintain high QoL throughout the aging process. 

Indeed, young age at the time of amputation was associated 

with better QoL in the categories of physical disability, 

energy level, emotional reactions and social isolation while 

advanced age was associated with reduced mobility and 

lower energy level than younger population.6 However, 

whether ageing affected QoL is still debated. A recent study 

stated that quality of life in LLA is significantly influenced by 

age,36 while Adegoke and co-workers (2012) reported that 

the patient’ age at the time of amputation did not affect 

general quality of life.37 In our review, we found that there 

are no longitudinal studies that describe changes in the 

quality of life during ageing. The “physical functioning” 

appears to be the main factor affecting QoL and satisfaction 

in older TTA. Indeed, Fortington et al., (2013) found that 

subjects over 65 years of age had lower outcome than 

younger amputees only for physical function, while other 

domains were comparable to population norm values.29 

The walking distance aspect of mobility is one of the main 

factors to be considered when evaluating QoL after LLA.17 

Elderly TTA with higher mobility scores were more likely to 

be satisfied with life,25 and perception of their social burden 

correlated strongly with their ability to walk using their 

prosthesis. Fortington et al.,29 reported that walking 

distance is associated with improved scores in social 

function. One study identified also that mobility capability 

was significantly influenced by these risk factors: age>65y, 

alcohol disorder, hypertension, anxiety or depression.25 

Another aspect that was postulated to interfere with QoL 

was the level of pain. Rather controversially the results did 

not confirm this assumption. In fact, in the only study in 

which TTA alone were enrolled, Harness et al., (2001)2 

found that the ability to walk using the prosthesis was  

correlated with the presence of pain and residual limb 

health.2 Moreover, the same study reported a correlation 

between the patient’s satisfaction and lesser pain level.2 

Even Knežević and co-workers reported no differences 

between TTA and TFA on role limitations due to pain and 

physical health.30 On the contrary, another study described 

how the presence of phantom pain might imply a poorer 

health-related quality of life.17 

An important role of pain was described by Boutoille et 

al.,(2008).28 The authors compared HS and pain in patients 

having experienced an amputation due to diabetic foot ulcer 

and patients suffering for a current foot ulcer with no 

previous history of amputation. They reported that a trans-

tibial amputation allows similar HS with less pain with 

respect to a conservative, unsuccessful, treatment for 

diabetic ulcer. 

Two studies focused on the effect of a prosthetic foot in 

hypomobile older TTA.31,32 Both studies investigated the 

performance and satisfaction utilizing different feet 

compared to the traditional SACH (solid ankle cushion heel) 

foot. The SACH is considered to be the most appropriate 

foot for hypomobile TTA and also the most prescribed foot 

as it is inexpensive, easy to use, and perceived as stable.39 

Delussu et al.,(2016) tested the “1M10 Adjust” foot that is a 

multi-axial lightweight foot that allows stiffness heel 

adjustments to adapt to individual needs.32 In another study 

a new geriatric foot was evaluated which shape and type of 

foam in this foot allows to be shorter and lighter compared 

to SACH.31 Both studies reported greater patient 

satisfaction with the tested prosthetic feet. Moreover, the 

new geriatric foot reduced the mean pressure in the socket 

and the “1M10 Adjust” showed a statistically significant 

reduction of the energy cost of walking.31,32 The common 

feature between these two tested prosthetic feet is the 

lighter weight compared to SACH. This may lead us to 

hypothesize that lighter prosthetic components for 

hypomobile mature TTA could positively affect their 

satisfaction with the prosthesis. 

In this review we selected only articles published from 

January 2000 to March 2019 which might be a limitation. 

https://doi.org/10.33137/cpoj.v3i1.33640


 

6 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 
We did not search studies prior to 2000 because of the 

important progress in technology of the socket and 

suspension system in the late 1990s (from Patellar Tendon 

Bearing to Total Surface Bearing). 

CONCLUSION 

Our review has pointed out that there are very few studies 

that have investigated this particular population of 

amputees (TTA aged >60 years). Only one study 

exclusively investigated QoL in older TTA.2 We have 

observed authors have rarely used specific tools for 

measurement of QoL and HS in LLA. In general, the QoL 

and HS of LLA is influenced mostly by daily activities.40 

Patients with amputation often encounter difficulties in 

everyday activities because they have lost their 

independence and must rely on others. This could influence 

negatively many aspects of their lives, such as social and 

financial. For this, it is very important, when studying QoL of 

amputees, to also analyse their social environment.41 On 

the basis of the main results of this review we can conclude 

that efforts have to be taken in order to improve mobility in 

TTA for a better QoL, by means of adequate rehabilitation, 

reduction of pain, and appropriate prosthetic components. 

The literature available on this specific population is 

insufficient and future research will benefit from more 

prospective observational cohort studies. Such studies will 

need to be conducted with  appropriate inclusion criteria and 

larger sample sizes to better understand the QoL and HS in 

this population. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors declared no potential conflicts of interest with respect 

to the research, authorship, and/or publication of this article.  

AUTHOR CONTRIBUTION 

Stefano Brunelli: designed the study, online databases search 

and led the writing of the manuscript. 
 

Cinzia Bonanni: online databases search, data extraction and 

supported the writing of the manuscript. 
 

Calogero Foti: revised the manuscript critically for important 

intellectual content. 
 

Marco Traballesi: revised the manuscript critically for important 

intellectual content. 

 

SOURCES OF SUPPORT 

The authors received no financial support for the research, 

authorship, and/or publication of this article. 

ABBREVIATIONS 

QoL: Quality of Life, HS: Health Status, LLA: Lower Limb Amputee, 

TTA: Trans-Tibial Amputee, TFA: Trans-Femoral Amputee, 

TAPES: Trinity Amputation and Prosthesis Experience Scales, 

PEQ: Prosthesis Evaluation Questionnaire, WHO QOLBREF: 

World Health Organization Quality of Life Questionnaire, SF-36: 

The 36-Item Short Form Health Survey, NHP: Nottingham Health 

Profile, RAND- 36: Research and Development Corporation 

measure of Quality of Life 36-Item Health Survey 1.0, SAT-PRO: 

Satisfaction with Prosthesis, NGF: New Geriatric Foot, SWLS: 

Satisfaction with Life Scale. 

REFERENCES 

1.Pernot HF, Winnubst GM, Cluitmans JJ, De Witte LP. Amputees 

in Limburg: incidence, morbidity and mortality, prosthetic supply, 

care utilisation and functional level after one year. Prosthet Orthot 

Int. 2000;24:90-6. DOI:10.1080/03093640008726531 

2.Harness N, Pinzur MS. Health related quality of life in patients 

with dysvascular transtibial amputation. Clin Orthop Relat Res. 

2001;383:204-7. DOI:10.1097/00003086-200102000-00023 

3.Bradley C. Importance of differentiating health status from quality 

of life. Lancet 2001;357:7-8. DOI:10.1016/S0140-6736(00)03562-5 

4.The World Health Organization quality of life assessment 

(WHOQOL): position paper from the World Health Organization. 

Soc Sci Med. 1995 Nov; 41(10):1403-9. DOI:10.1016/0277-

9536(95)00112-K 

5.World Health Organization. WHOQOL-BREF: Introduction, 

administration and generic version of the assessment. Geneva, 

Switzerland: WHO Programme on Mental Health; 1996 

6.Hunt SM, Mckenna SP, Mcewen J, Backett EM, Williams J, Papp 

E. A quantitative approach to perceived health-status – a validation-

study. J Epidemiol Community Health. 1980;34(4):281–6. 

DOI:10.1136/jech.34.4.281 

7.Demet K, Martinet N, Guillemin F, Paysant J, André JM. Health 

related quality of life and related factors in 539 persons with 

amputation of upper and lower limb. Disabil Rehabil. 2003;25:480-

486. DOI:10.1080/0963828031000090434 

8.Gallagher P, MacLachlan M. Development and psychometric 

evaluation of the Trinity Amputation and Prosthesis Experience 

Scales (TAPES). Rehabil Psychol. 2000;45:130-154. 

DOI:10.1037/0090-5550.45.2.130 

9.Legro MW, Reiber GD, Smith DG, delAguila M, Larsen J, Boone 

D. Prosthesis evaluation questionnaire for persons with lower limb 

amputations: assessing prosthesis related quality of life. Arch Phys 

Med Rehabil. 1998;79:931-8. DOI:10.1016/s0003- 9993(98)90090-

9 

10.Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and 

satisfaction with prosthetic devices among persons with trauma 

related amputations: A long-term outcome study. Am J Phys Med 

Rehabil. 2001;80(8):563–71. DOI:10.1097/00002060-200108000-

00003 

11.Bilodeau S, Hébert R, Desrosiers J. Questionnaire sur la 

satisfaction des personnes amputées du membre inférieur face à 

leur prothèse: Développement et validation. Can J Occup Ther. 

Février. 1999;66(1):23-32. DOI:10.1177/000841749906600103 

12.Sansam K, Neumann V, O’Connor R, Bhakta B. Predicting 

walking ability following lower limb amputation: a systematic review 

of the literature. J Rehabil Med. 2009;41:593-603. 

DOI:10.2340/16501977-0393 

https://doi.org/10.33137/cpoj.v3i1.33640


 

7 

Brunelli S, Bonanni C, Foti C, Traballesi M. A literature review of the quality of life, health status and prosthesis satisfaction in older patients with a trans-tibial 
amputation. Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.3. https://doi.org/10.33137/cpoj.v3i1.33640 

ISSN: 2561-987X THE EVALUATION OF QUALITY OF LIFE, HEALTH STATUS AND SATISFACTION WITH THE PROSTHESIS 

Brunelli et al. 2020 

 
CPOJ 

 
13.Penn-Barwell JG . Outcomes in lower limb amputation following 

trauma: a systematic review and meta-analysis. Injury. 

2011;42:1474–1479. DOI:10.1016/j.injury.2011.07.005 

14.Sinha R, Van Den Heuvel WJA (2011) A systematic literature 

review of quality of life in lower limb amputees, Disabil Rehabil, 

33:11, 883-899.  DOI:10.3109/ 09638288.2010.514646 

15.Kulkarni J. Adams J, Thomas E, Silman A. Association between 

amputation, arthritis and osteopenia in British male war veterans 

with major lower limb amputations. Clin Rehabil, 1998;12(4):348-

353. DOI:10.1191/026921598672393611 

16.Kulkarni J, Gaine WJ, Buckley JG, Rankine JJ, Adams J. 

Chronic low back pain in traumatic lower limb amputees. Clin 

Rehabil. 2005;19(1):81. DOI:10.1191/0269215505cr819oa 

17.Van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. 

Phantom pain and health-related quality of life in lower limb 

amputees. J Pain Symptom Manage. 2002;24(4):429-36. 

DOI:10.1016/S0885-3924(02)00511-0 

18.Demet K, Martinet N, Guillemin F, Paysant J, Andre JM. Health 

related quality of life and related factors in 539 persons with 

amputation of upper and lower limb. Disabil Rehabil 2003;25:480-

6. DOI:10.1080/0963828031000090434 

19.Grzebień A, Chabowski M, Malinowski M, Uchmanowicz I, Milan 

M, Janczak D. Analysis of selected factors determining quality of 

life in patients after lower limb amputation-a review article. Polski 

przeglad chirurgiczny. 2017;89(2):57-61. DOI:10.5604/ 

01.3001.0009.8980 

20.Hawkins AT, Henry AJ, Cramdell DM, Nguyen LL. A systematic 

review of functional and quality of life assessment after major lower 

extremity amputations. Annals of vascular surgery. 2014;28(3):763-

780. DOI:10.1016/j.avsg.2013.07.011 

21.Seker A, Kara A, Camur S, Malkoc M, Sonmez MM, 

Mahirogullari M. Comparison of mortality rates and functional 

results after transtibial and transfemoral amputations due to 

diabetes in elderly patients-a retrospective study. Intern J Surg, 

2016;33:78-82. DOI:10.1016/j.ijsu.2016.07.063 

22.Schoppen T, Boonstra A, Groothoff JW, de VJ, Göeken LN, 

Eisma WH. Physical, mental, and social predictors of functional 

outcome in unilateral lower-limb amputees. Arch Phys Med Rehabil 

2003;84: 803-81. DOI:10.1016/S0003-9993(02)04952-3 

23.Gauthier-Gagnon C, Grise MC. Prosthetic profile of the amputee 

questionnaire: validity and reliability. Arch Phys Med Rehabil. 

1994;75:1309-14. DOI:10.1016/0003-9993(94)90278-X 

24.Law M, Stewart D, Pollock N, Letts L, Bosch J, Westmorland M. 

Guidelines for Critical Review Form—Quantitative Studies. 

McMaster University. 1998. Available at: https://srs-mcmaster. 

ca/wp-content/uploads/2015/05/Guidelines-for-Critical-Review-

Form-Quantitative-Studies. pdf. Accessed May 19, 2020 

25.Norvell DC, Turner AP, Williams RM, Hakimi KN, Czerniecki JM. 

Defining successful mobility after lower extremity amputation for 

complications of peripheral vascular disease and diabetes. J Vasc 

Surg. 2011;54:412-9. DOI:10.1016/j.jvs.2011.01.046 

26.Cox PS, Williams SK, Weaver SR. Life after lower extremity 

amputation in diabetics. West Indian Med J. 2011;60(5):536-40 

27.Quigley M, Dillon MP, Duke EJ. Comparison of quality of  

life in people with partial foot and transtibial amputation: a  

pilot study. Prosthet Orthot Int. 2016;40:467-74. DOI: 10.1177/ 

0309364614568414 

28.Boutoille D, Féraille A, Maulaz D, Krempf M. Quality of life with 

diabetes-associated foot complications: comparison between 

lower-limb amputation and chronic foot ulceration. Foot Ankle Int. 

2008;29:1074-8. DOI:10.3113/FAI.2008.1074 

29.Fortington LV, Dijkstra PU, Bosmans JC, Post WJ, Geertzen JH. 

Change in health-related quality of life in the first 18 months after 

lower limb amputation: a prospective, longitudinal study. J Rehabil 

Med. 2013;45(6):587-94. DOI:10.2340/16501977-1146 

30.Knezevic A, Salamon T, Milankov M, Ninkovic S, Jeremic-

Knezevic M, Tomasevic-Todorovic S. Assessment of quality of life 

in patients after lower limb amputation. Med Pregl. 2015;68(3-

4):103-8. DOI:10.2298/MPNS1504103K 

31.Bonnet X, Adde JN, Blanchard F, Gedouin-Toquet A, Eveno D. 

Evaluation of a new geriatric foot versus the solid ankle cushion 

heel foot for low-activity amputees. Prosthet Orthot Int. 

2015;39(2):112-8. DOI:10.1177/0309364613515492 

32.Delussu, A. S., Paradisi, F., Brunelli, S., Pellegrini, R., Zenardi, 

D., Traballesi, M. Comparison between SACH foot and a new 

multiaxial prosthetic foot during walking in hypomobile transtibial 

amputees: Physiological responses and functional assessment. 

Eur J Phys Rehabil Med. 2016;52(3),304-309 

33.Maruish MEE. User’s manual for the SF-36 v2 health survey. 

3rd ed. Lincoln, RI: QualityMetric Incorporated, 2011 

34.Ware LE & Sherbourne CD (1992). The MOS 36-item shortform 

health survey (SF-36): I. Conceptual framework and item selection. 

Medical care. 1992;30(6):473-83 

35.Hays RD, Sherbourne CD, Mazel RM. The RAND 36-Item 

Health Survey 1.0. Health Econ. 1993;2(3):217-27 

36.Mohammed SA, Shebl AM. Quality of Life among Egyptian 

Patients with Upper and Lower Limb Amputation. Sex Differences. 

Adv. Med. 2014;2014:674323. DOI:10.1155/2014/674323 

37.Adegoke BOA, Kehinde AO, Akosile CO, Oyeyemi AL. Quality 

of Life of Nigerians with Unilateral Lower Limb Amputation. 

Disability, CBR and Inclusive Development. 2012;23(4):76–89. 

DOI: 10.5463/dcid.v23i4.192 

38.Hays RD, Morales LS. The RAND-36 measure of health- 

related quality of life. Ann Med. 2001;33:350-357. DOI: 

10.3109/07853890109002089 

39.Andrews KL. Rehabilitation in limb deficiency, 3: the geriatric 

amputee. Arch Phys Med Rehabil. 1996;77:S14-7. DOI: 

10.1016/S0003-9993(96)90238-5 

40.Weiss, GN, Gorton, A, Read, RC, Neal, LA. Outcomes of lower 

extremity amputations. J Am Ger Soc. 1990;38:877-883. DOI: 

10.1111/j.1532-5415.1990.tb05703.x 

41.Gitter A, Bosker G. Upper and Lower Extremity Prosthetics. In: 

DeLisa J, editor. Physical medicine & rehabilitation: principles and 

practice. Philadelphia: Lippincott Williams & Wilkins; 2005;1326-55 

https://doi.org/10.33137/cpoj.v3i1.33640

