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VOLUME 4, ISSUE 1 

 2021 

 

REVIEW ARTICLE 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian 

Prosthetics & Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

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1 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

 

 

 
REVIEW ARTICLE 

 

SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS: A SYSTEMATIC REVIEW 

Lee DJ*, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A  
 

Touro College, Department of Physical Therapy, Bayshore, NY, USA. 
 
 
 

 

 

  

 

 

 

 

 

 

 

 
 

 

 

 

INTRODUCTION   

In the United States, approximately 2 million individuals are 

living with limb loss.1 Common etiologies that may lead to 

amputation include trauma, cancer, and vascular 

complications secondary to diabetes.2 Regardless of the  

 

 

 

 

 

etiology of amputation, living without a limb requires  

biopsychosocial and  behavioral adaptations to successfully 

reintegrate into society.3,4 While biopsychosocial 

adaptations may be learned through the experience of 

participating in a comprehensive rehabilitation program,5 

the behavioral aspects related to lifestyle changes and self-

care may go under-emphasized. These behavioral and 

lifestyle changes for a person with limb loss specifically 

involve caring for the residual limb and prosthesis, as well 

as the interface between the two. When considered as a 

whole, the behavior and lifestyle changes are known as self-

management, a term used to describe the daily adaptions 

one must make when faced with a chronic condition.6,7 

 
OPEN  ACCESS Volume 4, Issue 1, Article No.5. 2021 

 

 

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

 

ABSTRACT 

BACKGROUND: Self-management is an integral component of managing long-term conditions and 

diseases. For a person with limb loss, this self-management process involves caring for the residual limb, 

the prosthesis, and the prosthetic socket-residual limb interface. Failure to properly self-manage can 

result in unwanted secondary complications such as skin breakdown, falls, or non-use of the prosthesis. 

However, there is little evidence on what self-management interventions are effective at preventing 

secondary complications. To understand the impact of self-management after the loss of a limb, it is 

necessary to determine what the current evidence base supports. 

OBJECTIVE(S): The purpose of this study is to examine the available literature on self-management 

interventions and/or outcomes for persons with limb loss and describe how it may impact residual limb 

health or prosthesis use. 

METHODOLOGY: A systematic review of multiple databases was carried out using a variety of search 

terms associated with self-management. The results were reviewed and selected based on the inclusion 

criteria: self-management interventions or direct outcomes related to self-management, which includes 

the skin integrity of the residual limb, problem-solving the fit of the prosthesis, and education in the 

prevention of secondary complications associated with prosthesis use. The Cincinnati Childrens’ 

LEGEND (Let Evidence Guide Every New Decision) appraisal forms were used to analyze the articles 

and assign grades. 

FINDINGS: Out of the 40 articles identified for possible inclusion in this study, 33 were excluded resulting 

in seven articles being selected for this review. Three out of the seven articles focused on silicone liner 

management while the other four articles focused on skin issues. 

CONCLUSION: Self-management for a person with limb loss is a key component of preventing 

complications associated with loss of limb and prosthesis use. There is a lack of high-quality 

experimental studies exploring the most appropriate intervention for teaching self-management when 

compared to other conditions, specifically diabetes. Further research in the area of self-management is 

necessary to understand how to best prevent unwanted secondary complications. 

ARTICLE INFO 

Received: February 18, 2021 

Accepted: May 24, 2021 

Published: June 4, 2021 

CITATION 

Lee DJ, Repole T, Taussig E, 

Edwards S, Misegades J, 

Guerra J, Lisle A. Self-

management in persons with 

limb loss: A systematic review. 

Canadian Prosthetics & 

Orthotics Journal. 2021;Volume 

4, Issue 1, No.5. 

https://doi.org/10.33137/cpoj.v4i

1.35098 

KEYWORDS 

Self-management, Limb Loss, 

Prosthesis, Amputation, 

Systematic Review 

 

* CORRESPONDING AUTHOR  

Daniel J. Lee, PT, PhD, DPT, GCS, COMT 

Touro College, Department of Physical Therapy, Bayshore, 

NY USA. 

E-mail: Daniel.lee29@touro.edu 

ORCID number: 0000-0003-1805-2936 

 

https://doi.org/10.33137/cpoj.v4i1.35098
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i1.35098
https://doi.org/10.33137/cpoj.v4i1.35098
mailto:Daniel.lee29@touro.edu


 

2 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

ISSN: 2561-987X SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS 

Lee et al. 2021 CPOJ 

 
While a universal definition of self-management after 

amputation is deficient, it is agreed that optimal self-

management requires the patient to be an active participant 

in decisions regarding their health and own care.8 For 

persons with limb loss, this can be thought of in three 

distinctive categories: residual limb care and hygiene, 

problem-solving the fit of the prosthesis, and making 

decisions regarding self-care.9 These decisions 

surrounding the daily self-care and hygiene associated with 

residual limb includes washing regimens, liner cleaning and 

drying, skin inspection, and wound prevention.10 Self-

management also involves problem-solving the fit of the 

prosthesis, which may include modification of sock-ply, 

sequencing components for donning, and maintaining 

awareness of how the fit changes throughout the day.11 

Finally, decision-making is concerned with recognizing 

when an issue presents, such as skin breakdown, and 

properly contacting the correct medical professional for 

assistance.12 

If self-management is not embodied and embraced by 

persons with limb loss they may be at an increased risk of 

injury, including but not limited to skin breakdown, wound 

formation, musculoskeletal issues, or falls.13-15 Conversely, 

proper self-management may be related to better outcomes 

after loss of limb, including maintaining the integrity of the 

skin, preventing wound formation, and improving quality of 

life.10,16 Currently, the greatest resources of self-

management education are found in clinical textbooks, 

patient handouts, and through professional organizations. 

However, despite the importance of self-management, 

there is a relative paucity of peer-reviewed materials on the 

subject published in scientific journals specific to which 

intervention is the most efficacious. While other conditions 

like diabetes mellitus have well established pathways for 

assessing and imparting self-management knowledge and 

behaviors,17-23 self-management after limb loss has not 

received the same level of attention in the scientific 

literature. To fully comprehend the impact of self-

management after loss of limb, it is necessary to determine 

what the current evidence base supports. Therefore, the 

purpose of this study is to examine the available published 

literature on self-management interventions and/or 

outcomes for persons with limb loss and describe how it 

may impact residual limb health or prosthesis use. 

METHODOLOGY 

CRITERIA FOR STUDIES CONSIDERED 

Types of Studies 

The study types considered for review were mixed 

methodologies, retrospective studies, case reports, 

randomized control trials, and qualitative studies. 

Participants of any age, gender, background, and limb 

deficiency were included if self-management was 

emphasized. Inclusion criteria consisted of studies that 

assessed functional outcome measures related to self-

management, participants of any age or gender, and 

individuals with upper or lower limb amputation or limb 

deficiency. Articles published between January 1965 and 

September 2019 were considered eligible for review. 

Exclusion criteria were studies published in a language 

other than English and opinion-based papers. Non-peer 

reviewed publications (e.g. textbooks, patient education 

materials) were excluded. 

Search Strategy 

A computerized literature search was conducted from 

September 2019 to December 2019 by the research team. 

The search strategy of this review consisted of combining 

keywords related to the self-management of individuals with 

limb loss into search permutations. Each permutation was 

inputted into five databases: PubMed, Cochrane Library, 

PEDro, Google Scholar and PsycNET. This strategy was 

developed to locate published studies relevant to individuals 

with amputations or limb differences and the individual’s 

ability to self-manage their residual limb or the residual limb-

prosthesis interface. Because there are many terms 

synonymous with limb loss and self-management different 

combinations of keywords were used. Search keywords are 

presented in Table 1.  

Selection and Rating 

The study eligibility flowchart is presented in Figure 1. The 

initial search provided numerous results from the keywords 

used for the search. Many of the results from this initial 

search were not explicitly related to the topic of self-

management in persons with limb loss. Results excluded at 

this stage were studies that focused on prosthetics for other 

anatomical structures and health conditions. Article 

duplicates and non-English studies were then excluded. 

The remaining 40 articles had an initial face value of being 

eligible for this systematic review, however upon further 

examination many focused towards quality of life in those 

with limb loss rather than self-management of the limb-

socket interface. The final remaining 11 articles underwent 

full evaluation for inclusion.  

Given the diversity of study designs represented in the 

literature, the evaluative tool needed to be flexible enough 

to account for the variety of results. The Cincinnati 

Childrens’ LEGEND (Let Evidence Guide Every New 

Decision) appraisal forms was determined to be the best fit. 

The LEGEND tool is a series of appraisal forms designed to 

help clinicians synthesize evidence and determine the 

quality of published studies of different designs.24 The 

LEGEND scale uses an algorithm to derive a grade of either 

good or lesser quality, then based on the summative quality 

of each review an overall score is given base on the types 

of studies included. 

https://doi.org/10.33137/cpoj.v4i1.35098


 

3 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

ISSN: 2561-987X SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS 

Lee et al. 2021 CPOJ 

 
Six of the reviewers were put into pairs and each pair was 

assigned four studies to review. Each reviewer 

independently assessed the quality of their assigned 

studies according to a standardized form determined by the 

study design, and then scores were compared. If there was 

a disagreement, a third reviewer assessed the study. 

Table 1: Search keywords.  

Keywords related to 

“amputee” 

Keywords related to “self-

management” 

Amputee 

Amputation 

Prosthetic 

Prosthetic leg   

Prosthesis 

Residual limb 

Limb loss 

  

  

Care 

Caring 

Self-care 

Self-evaluation 

Self-managed 

Self-management 

Self-managing 

Self-manage 

Evaluation 

Management 

Problem solve 

Problem solving 

Education 

Fluid fluctuation 

Volume 

Fluid loss 

Donning 

Doffing 

Socket 

Socket fit 

Prosthetic fit 

 

 

 

Figure 1: Article eligibility flow chart. 

RESULTS 

The majority of participants were males (approximate mean 

age of 61 years) with acquired transtibial level amputations. 

No randomized control trials including self-management 

interventions were included. Of the seven included articles, 

most were of good quality and focused on education and 

training. Table 2 presents a summary of articles and 

demographic characteristics. The specific breakdown of 

each included article can be found in Table 3. 

Table 2: Summary of the seven included articles and demographic 

characteristics. 

ARTICLE CHARACTERISTICS  
Historical Cohort 
Qualitative 
Case Report 
Descriptive 
 

QUALITY OF STUDIES 
Good Quality 
Lesser Quality 
 

SELF-MANAGEMENT  
Impact of Hand Function 
Efficacy of Education and Training 
Self-Management Practices 
Prosthetic Prescriptions 

  
1 
2 
2 
2 
 
 
4 
3 
 
 
1 
3 
1 
2 

PARTICIPANTS (259 people)  
Males 
Females 
Not Disclosed 

 
AGE 

Range 
Approximate Mean Age 

 
LEVEL OF AMPUTATION 

Trans-femoral 
Knee Disarticulation 
Trans-tibial 
Symes 
Not Disclosed (Includes UE and LE) 

 
TYPE OF LIMB LOSS 

Acquired 
Congenital 
Not Disclosed 

  
185 
54 
20 
 
 

18-90 
61 
 
 

33 
13 
128 
8 

77 
 
 

250 
7 
2 

 

DISCUSSION 

The purpose of this study was to examine the available 

literature on self-management interventions and/or 

outcomes for persons with limb loss and describe how it 

may impact residual limb health and prosthesis use. Despite 

a systematic search in multiple databases, only seven 

articles were found to directly address the inclusion criteria 

of this study. 

 

 Full-text articles deemed eligible (n=7) 

 Full-text articles rated with quality assessment tool (n=11) 

 Full-text articles assessed for eligibility (n=40) 

 Articles excluded (not meeting inclusion criteria) (n=280) 

 Articles after duplicates removed (n=320) 

 Articles retained from initial search (n=413) 

 Articles identified from each keyword  (n=41,712) 

https://doi.org/10.33137/cpoj.v4i1.35098


 

4 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

ISSN: 2561-987X SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS 

Lee et al. 2021 CPOJ 

 
 

 

 

 

Article title 
(year) 

Number of 
participants 
and age (SD) 

Level of 
amputation 

LEGEND 
grade 

Article type 
Outcomes of 
interest/intervention 

Results 

Skin problems of 
the stump and 
hand function in 
lower limb 
amputations 

(2008)25 

n=60 
(43 M, 17 F) 
 
Age: 62.3 (15.4) 

TT (50) 
KD (10) 

Good Quality 
(4a) 

Historic 
Cohort 
Explorative 
study 

Relationship between 
impaired hand function 
and liner-related skin 
problems of the 
residual limb. 

Impaired hand function was significantly 
related to liner-related skin problems. 

The effect of 
prosthetic 
rehabilitation in 
lower limb 

amputees (1995)26 

n=29 
(22 M, 7 F) 
 
Age: 64 (n/a) 

TT (19) 
TF (10) 

Lesser Quality 
(4b) 

Qualitative 
(Questionna
ire) 

Efficacy of training 
following prosthesis 
prescription in 
promoting constant use 
of the prosthesis. 

More effective communication between 
the patient and healthcare team is 
needed. 

Improper use of a 
transtibial 
prosthesis silicone 
liner causing 
pressure ulceration 

(2009)27 

n=1 (M) 
 
Age: 80 

TT 
Good Quality 
(5a) 

Case 
Report 

Importance of 
appropriate candidate 
selection for roll-on 
liners, proper patient 
and professional 
training, and 
management of patient 
comorbidities. 

Pressure ulcers may be prevented with 
proper education of caregivers and 
patients in correct use of all prosthetic 
components. 

Knowledge and 
skill of patients 
with regard to 
amputations stump 
bandaging, prior to 
a prosthesis 

(1998)28 

n=33 
(21 M, 12 F) 
 
Age: 23-78 
(average age and 
SD not specified) 

LLA 
Lesser Quality 
(4b) 

Descriptive 
Study 

Knowledge and skill of 
patients with regard to 
residual limb bandaging 
prior to fitting of a 
prosthesis. Success 
post-amputation is 
highly dependent on 
the quality of education 
on residual limb 
bandaging given. 

Success post-amputation is highly 
dependent on the quality of education 
on correct residual limb bandaging. 

Issues of 
importance 
reported by 
persons with lower 
limb amputations 
and prostheses 

(1999)29 

n=92 
(79 M, 13 F) 
 
Age: 55 (n/a) 
 
 

Through the 
knee, TT, 
Symes 

Good Quality 
(4a) 

Descriptive 
Study 

Improve decisions 
related to amputation 
levels and prosthetic 
prescription. 

Fit of the prosthesis socket with the 
residual limb, aspects of mechanical 
functioning of the prosthesis, other non-
mechanical qualities, and advice about 
adaptation to life with a prosthesis with 
support from others are the major 
themes deemed important to those 
living with LLA. 

Incorporating self-
management in 
prosthetic 
rehabilitation: case 
report of an 
integrated 
knowledge-to-
action process 

(2015)30 

n=20 (sex not 
specified) 
 
Age: adult 

LLA 
Good Quality 
(5a) 

Case 
Report 

Knowledge-to-action 
process for prosthesis 
self-management 
education. 

Group training adds value to the 
prosthesis management education 
process. 

Staying "just 
normal": 
preservation 
strategies in 
prosthesis use 

(2019)31 

n=24 
(19 M, 5 F) 
 
Age: 43.89 (12.66) 
 
 

Upper and 
Lower Limb 
Loss (7 
Congenital, 
17 acquired, 
2 not 
disclosed) 

Lesser Quality 
(4b) 

Qualitative 
Grounded 
Theory 

Practices used by 
persons with LLA to 
manage their prosthetic 
limbs. 

Individuals use a variety of preservation 
strategies to manage threats and 
limitations of prostheses in order to live 
“normally” with a prosthesis. 

Abbreviation: SD, Standard Deviation; n, number; M, Male; F, Female; TT, Trans-tibial; KD, Knee Disarticulation; TF, Trans-femoral; LLA, Lower Limb Amputation 
 

 

Table 3: Overview of studies included in the literature review. 

https://doi.org/10.33137/cpoj.v4i1.35098


 

5 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

ISSN: 2561-987X SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS 

Lee et al. 2021 CPOJ 

 
This is in contrast to diabetes, where a perfunctory search 

of PubMed using the terms “self-management” and 

“diabetes” results in thousands of results, including a meta-

analysis of systematic reviews.32 This brings attention to the 

lack of self-management-focused research in the limb loss 

literature as compared to other fields. Since the link 

between self-management and prevention of secondary 

complications is well established,13,33,34 the lack of strong 

evidence made apparent by this review limits the ability to 

provide significant clinical recommendations. 

Review of Studies  

When looking at the results of the review it is evident that 

certain aspects of self-management are promoted 

regardless of the study, namely the prevention of wound 

development, proper limb shaping, and contracture 

prevention. Considering that re-ulceration rates after certain 

amputations are as high as 70%35 it is conceivable that 

wound prevention is of the utmost importance. Additionally, 

contracture prevention through exercise and posturing,36 as 

well as limb shaping via bandaging remains a common 

practice37,38 and should be taught as a basic element of self-

management education. 

Three of the seven articles 25,27,29 directly addressed issues 

with silicone liners. Silicone liners are commonly used to 

suspend the prosthetic socket or decrease discomfort from 

weight-bearing. However, silicone liners have many issues, 

including creating an inhospitable environment for the 

residual limb that promotes excessive sweating.39 While 

silicone liners can be used after the initial amputation 

incision is closed to help shape the limb and decrease the 

time required for the rehabilitation stay,40 they can also 

result in skin breakdown if donned incorrectly, as 

exemplified in the case report by Bruno & Kirby.27 

Therefore, it is of critical importance that proper liner 

donning be taught as a foundational element of the self-

management education process after loss of limb.  

Beyond just educating on proper self-management, it may 

also be necessary to examine the hand strength of the 

patient as it was shown that those hand impairments are 

more likely to have skin issues related to liner use.25 

Considering that older adults have both lower hand 

strength, more cognitive impairments, and are more likely to 

experience a lower limb amputation due to a dysvascular 

condition, the consideration of hand strength in the 

prescription of a silicone liner should be prioritized.41,42 

Bandaging remains common practice, however evidence 

may suggest that the use of rigid removal dressings may 

have greater benefit.37,43 Given the relative ease of donning 

and doffing, a rigid removable dressing benefits the patient 

by helping shape the limb, prevent contractures, and protect 

the limb from environmental impacts.44 Despite the benefits 

of a rigid removable dressing, elastic bandages are still 

frequently used, likely due to their ubiquitous and affordable 

nature. Since elastic bandaging comes with inherent risk of 

injury due to improper donning, education on how to 

properly apply, remove, and check the fit is necessary.45 

Therefore, proper self-management education on elastic 

bandage should be performed for any patient using this 

intervention. 

One of the included studies looked at the benefits of group 

training when learning to self-manage and use a 

prosthesis.30 This practice demonstrated both benefits and 

drawbacks. The benefits include the ability to socialize, 

learn from each other, and share in the experience. The 

drawbacks were that an individual participant in the group 

setting may offset the benefits based on their actions and 

beliefs. While self-management can effectively be taught 

through support groups,46 one-on-one educational sessions 

may still be necessary given the variability in learning styles 

inherent to learners. 

The final study included in this review examined the 

behaviors and adaptations that need to be made after loss 

of limb to maintain a state of normalcy.31 The behaviors 

identified in the study (vigilant self-awareness, threat 

identification, and risk avoidance) are key components of 

self-managing after loss of a limb. This study identifies that 

a person with limb loss must be proficient in self-

management to maintain a degree of stability and normalcy 

in their lives. Otherwise, a failure to self-manage can result 

in a disruption to their established routine, fracturing the 

state of normalcy that they have re-established since 

amputation. 

Quality Issues 

While the intent of this review was help guide clinical 

practice in terms of how to best educate the patient on self-

management, the paucity of evidence makes this difficult.  

This is due to the lack of high-quality evidence in the form 

of randomized control trials and interventional studies. As a 

result of the lack of primary sources of evidence, lower tier 

levels of evidence were the only included studies in this 

review. While descriptive, cohort, qualitative, and case 

studies are all beneficial in understanding the scope of the 

current self-management educational interventions, none of 

the included studies had a comparison group to determine 

if a specific intervention type was more effective.  

Future Focus 

 While systematic reviews such as this one brings attention 

to the need for more research in this area, it makes 

comparing intervention effectiveness difficult at this 

junction. As such, there are no explicit interventions for self-

management that can be recommended above others. To 

rectify this situation, future studies are needed to determine 

if a specific self-management intervention may benefit 

persons with limb loss more than the current model which 

depends on clinical expertise, textbooks, and extant patient 

https://doi.org/10.33137/cpoj.v4i1.35098


 

6 

Lee DJ, Repole T, Taussig E, Edwards S, Misegades J, Guerra J, Lisle A. Self-management in persons with limb loss: A systematic review. Canadian Prosthetics 
& Orthotics Journal. 2021;Volume 4, Issue 1, No.5. https://doi.org/10.33137/cpoj.v4i1.35098 

ISSN: 2561-987X SELF-MANAGEMENT IN PERSONS WITH LIMB LOSS 

Lee et al. 2021 CPOJ 

 
education material. The field of limb loss rehabilitation could 

benefit from the model used in study of diabetes which has 

explored numerous modes of delivering self-management 

education and their comparative effectiveness. Therefore, 

funding opportunities should recognize this gap in the 

literature and support high-quality interventional research 

studies in order to bolster the body evidence supporting self-

management for persons of limb loss. 

CONCLUSION 

Self-management is key in the prevention of secondary 

complications associated with the residual limb, the 

prosthesis, and the interface between the residual limb and 

socket. Research needs to be done on appropriate self-

management techniques, education, and implementation. 

Both the patient and their healthcare providers need to be 

active and engaged throughout the self-management 

process. 

ACKNOWLEDGEMENTS 

The authors would like to acknowledge Touro College's 

School of Health Sciences for their support in conducting 

and publishing this study. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors have no conflicting interests to disclose. 

AUTHOR CONTRIBUTION 

All authors contributed equally in the preparation of this 

manuscript. 

SOURCES OF SUPPORT 

There were no external sources of support to facilitate the 

completion of this work. 

ETHICAL APPROVAL 

Ethical approval was not needed for this study. 

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