Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO’s Package of Interventions for Rehabilitation

Published:January 04, 2021DOI:



      To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG).

      Data Sources

      Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018).

      Study Selection

      Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the “Appraisal of Guidelines for Research and Evaluation.”

      Data Extraction

      Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation.

      Data Synthesis

      We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses.


      The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.


      List of abbreviations:

      AGREE (Appraisal of Guidelines for Research and Evaluation), be4rehab (best evidence for rehabilitation), CPG (clinical practice guidelines), LLA (lower limb amputation), ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification), PIR (Package Interventions for Rehabilitation), RCT (randomized controlled trial), UHC (universal health coverage), ULA (upper limb amputation), VaDoD (Veterans Affairs, Department of Defense), WHO (World Health Organization)
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