Physical and mental health outcomes in Syrian lower limb amputees: the impact of prosthetic rehabilitation in post-conflict settings

Abstract

Introduction

Lower limb amputation has a significant impact on an individual’s overall quality of life, with prosthetic devices serving as essential tools for rehabilitation and mobility restoration. In Syria, where access to advanced medical care remains constrained, identifying the key factors affecting the well-being of prosthesis users is crucial for enhancing rehabilitation strategies. This study examines the sociodemographic and health-related determinants influencing the quality of life among lower-limb amputees who rely on prosthetic devices in Syria.

Methods

This research employed a cross-sectional observational study design at a highly specialized disability care facility within a tertiary hospital. Data were collected between September 2023 and August 2024. Participants were recruited using a convenience sampling method from patients receiving treatment at the same medical institution. A total of 233 individuals with lower limb amputations, all of whom had been using prosthetic limbs for at least five years, participated in the study. Data collection encompassed sociodemographic details, health status, and pain-related experiences. The Short Form Health Survey – 12 Items (SF-12) questionnaire was utilized to assess health-related quality of life (HrQoL), scores were transformed to norm-based T-scores, and PCS/MCS were dichotomized at 50 (≥ 50 = high HrQoL). In addition to overall summaries, subgroup descriptives were reported by cause of amputation (Syrian-crisis–related vs. other). Primary inferential analyses used multivariable logistic regression (limited, literature-informed covariates) to estimate adjusted associations with high PCS-12 and MCS-12; exploratory bivariate results were considered secondary. During the data-collection window, 233 eligible individuals consented and were enrolled, exceeding the calculated minimum sample size. Convenience sampling was used to include all eligible and available patients within the recruitment timeframe given clinic scheduling and resource constraints.

Results

The study assessed HrQoL among 233 prosthesis users: 62.23% had high MCS and 66.09% had high PCS. Over half of amputations were Syrian-crisis–related (54.51%); subgroup summaries (crisis vs. other) are presented alongside overall results. In adjusted models, age, marital status, and pain-related factors (including stump-pain severity, treatment, perceived treatment effectiveness, and residual stump pain) showed independent associations with PCS and/or MCS. Limb dominance was associated with PCS, and cause of amputation was associated with MCS.

Conclusion

These findings emphasize the significant impact of adjusted predictors including age, marital status, limb dominance, cause of amputation, and stump pain treatment on the quality of life of lower limb amputees. They highlight the importance of developing comprehensive rehabilitation programs that prioritize effective pain management, social support, and personalized care tailored to the unique demographic and clinical needs of each individual.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-026-09654-8.

Introduction

Lower-limb amputation has profound physical, psychological, and social consequences, often resulting in a significant decline in quality of life [1]. Prosthetic limbs are essential rehabilitation tools that help restore mobility, enhance independence, and improve overall functionality [2, 3].

The ongoing Syrian conflict (2011–2024) has caused thousands of fatalities and a considerable number of traumatic amputations, dramatically increasing the burden of disability [4]. Reliable national statistics on limb amputations in Syria are scarce; however, available reports indicate a sharp rise in cases due to war-related injuries, road accidents, burns, chronic illnesses, and other causes [5, 6]. According to humanitarian reports, an estimated 86,000 Syrians have undergone limb amputations since the start of the conflict, with children representing nearly 30% of these cases [7]. The widespread use of explosive weapons, landmines, and improvised devices continues to cause new injuries every year, with the World Health Organization warning of persistent risks of traumatic amputation even in post-conflict areas [7, 8]. This escalating prevalence represents a serious public health challenge, affecting not only individuals but also their families and broader society.

Despite this high demand, access to appropriate prosthetic care remains limited. Rehabilitation facilities and manufacturing centers are scarce, particularly in rural and remote regions [9, 10]. A shortage of trained professionals, inadequate infrastructure, and financial constraints further restrict the availability of essential rehabilitative and medical services [11]. Without proper prosthetic limbs, individuals frequently face reduced mobility, unemployment, social exclusion, and diminished participation in community life [12, 13].

In addition to physical challenges, psychological distress is common among amputees, including depression, anxiety, and phantom limb pain, while limited access to mental health services exacerbates these issues [14]. Socioeconomic hardships, such as financial insecurity, reduced educational opportunities, and restricted employment compound the burden of limb loss [15].

It is important to note that the condition of amputees in Syria is expected to be more severe than in many other regions. Years of ongoing conflict have severely weakened the healthcare system, disrupted rehabilitation services, and displaced large segments of the population. Limited access to timely surgical care, prosthetic fitting, and long-term rehabilitation combined with widespread poverty and psychological trauma places Syrian amputees at heightened risk of poorer health-related quality of life outcomes. These structural and social barriers highlight the urgent need for context-specific research and tailored rehabilitation strategies.

Despite the growing number of lower-limb amputees in Syria, research on health-related quality of life (HRQoL) among prosthesis users remains limited. To our knowledge, this is among the first studies in the region to examine the quality of life among lower-limb amputees using prosthetic limbs. Given the conflict-affected context, identifying factors that influence HRQoL is critical for tailoring rehabilitation services. Understanding the factors that influence HRQoL is essential for guiding rehabilitation strategies, shaping healthcare policies, and improving prosthetic technologies tailored to the Syrian context [16, 17]. Therefore, this study aimed to assess the health-related quality of life (HrQoL) among individuals with lower-limb amputations who use prosthetic devices in a post-conflict Syrian setting. Additionally, the study sought to identify sociodemographic, clinical, and injury-related factors associated with both physical and mental health outcomes.

Methods

Study design and setting

This study employed a cross-sectional design, focusing on individuals who previously received care at the Hamish Hospital for Rehabilitation and Physical Therapy.

Participants

The study recruited individuals receiving prosthetic rehabilitation services at the HHRPT, a specialized non-profit facility that provides prosthetic fitting, orthotic fabrication, rehabilitation, and follow-up care for people with limb loss. All study participants had obtained prosthetic limbs from HHRPT’s Prosthesis and Orthotic Department, where an experienced prosthetist with over a decade of expertise supervised the fabrication process using standardized materials to ensure consistency and optimal fit. HHRPT primarily serves patients from northern Syria, though individuals from other regions are treated when feasible. The facility is funded through a combination of local charitable donations, international humanitarian support, and limited patient contributions, enabling care at little or no cost to amputees. While its 100-bed capacity is modest compared to the high burden of war-related disability, the hospital provides both inpatient and outpatient rehabilitation. Outpatient prosthetic and physiotherapy services often experience long waiting lists, delaying access to device fitting and rehabilitation and potentially worsening functional and psychosocial outcomes. Compared to government hospitals, which face significant conflict-related damage, and private centers, which are prohibitively expensive for most, HHRPT plays a critical role in delivering affordable, accessible care for conflict-affected amputees. The study targeted former patients of HHRPT who had been fitted with a prosthesis at least five years earlier and continued to use it regularly. This criterion was implemented to ensure stable long-term adaptation to prosthetic use and to minimize variability associated with early post-fitting adjustments. Evidence suggests that prosthetic components typically require replacement every 3–5 years due to device wear and fit changes, indicating that users beyond this period are more likely to exhibit consistent functional adaptation and habituation [18]. Regular usage was self-reported, with participants confirming daily reliance on their prosthetic limbs for activities such as walking, work, and recreation. Individuals with unrelated comorbidities including peripheral vascular disease, diabetes-related complications, chronic pain syndromes, or joint disorders affecting the amputated limb were excluded. Participants with diagnosed mental health conditions were also excluded, irrespective of whether these were related or unrelated to amputation or trauma, in order to minimize confounding effects on health-related quality of life outcomes. However, we acknowledge that in the Syrian context, trauma-related mental health conditions such as post-traumatic stress disorder (PTSD), depression, and anxiety are prevalent among amputees. Excluding these individuals may have led to underestimation of the true burden of psychological distress, and this is noted as a limitation of our study. Additionally, those undergoing treatment for mental health conditions or living with multiple disabilities were not considered for participation. Participants were intentionally included regardless of the cause of amputation to represent the diverse rehabilitation population served by HHRPT. Among the 233 participants, 54.51% had amputations resulting from the Syrian conflict, while 45.49% underwent amputations due to non-conflict causes, such as burns, vascular diseases, cancer, congenital conditions, and accidents. Including both groups allowed for a comprehensive understanding of the HrQoL among lower-limb amputees in this post-conflict Syrian setting. A list of eligible candidates was compiled using electronic medical records, resulting in 704 potential participants. Of these, 233 individuals who met the inclusion criteria consented to participate, exceeding the minimum required sample size. To make the process clearer and less technical, we avoided using complex formulas and explained simply that convenience sampling was applied to include all eligible and available patients within the recruitment period, considering clinic scheduling and resource constraints.

Data collection

One of the authors conducted face-to-face interviews at the hospital using a structured questionnaire (Supplementary File 1) to gather data. The questionnaire covered sociodemographic details, physical and mental health aspects, as well as the occurrence and frequency of phantom sensations, phantom pain, and stump pain. It is important to note that individuals with unrelated chronic pain syndromes (e.g., fibromyalgia or generalized chronic pain disorders) were excluded from participation. However, phantom limb pain, stump pain, and residual stump pain were intentionally assessed among participants because these types of pain are directly associated with lower-limb amputation and prosthetic use and were central to the study objectives. To ensure accuracy and minimize errors, data collection was managed through the Open Data Kit (ODK). The questionnaire was designed in ODK and uploaded to a smartphone, with data collection spanning from September 2023 to August 2024.

Measures

Study design

A cross-sectional study design was chosen due to the challenging context of conducting research in a conflict-affected region. This design allowed us to efficiently assess the health-related quality of life, demographic characteristics, and injury-related variables at a single point in time. While analytical or longitudinal designs could provide deeper insights into causal relationships and rehabilitation trajectories, such approaches were not feasible given the constraints of limited resources, security risks, and ethical considerations in this post-conflict setting. The cross-sectional design was therefore the most practical and appropriate method to capture essential data while minimizing participant burden.

Dependent variable

The SF-12 (Short Form Health Survey-12), a streamlined version of the SF-36 Health Survey [25], was employed to assess health-related quality of life. The validated Arabic version of the SF-12 was used in this study, which had previously undergone translation and cultural adaptation for Arabic-speaking populations to ensure semantic, conceptual, and cultural equivalence [19, 20]. This instrument evaluates various health dimensions, including general health perception, physical abilities, limitations due to physical conditions, pain levels, emotional well-being, energy levels, social participation, and challenges stemming from emotional issues. consisting of 12 items, yields two primary summary scores: the Physical Component Summary (PCS) and the Mental Component Summary (MCS) (Supplementary File 2) [21], which collectively reflect overall physical and mental well-being. The PCS-12 has a test-retest reliability of 0.89, while the MCS-12 demonstrates a reliability of 0.76 [22]. Based on the developers’ guidelines for the SF-12, a score of 50 represents the mean of the general population, with a standard deviation (SD) of 10. Therefore, scores ≥ 50 were classified as indicating better-than-average (good) quality of life, whereas scores < 50 were classified as indicating below-average (poor) quality of life [22, 23].Drawing on prior research conducted in both clinical and community environments [18], PCS and MCS scores were classified, with values exceeding 50 representing a higher health-related quality of life, while scores below 50 indicated a diminished quality of life [24].

Independent variables

We analyzed age (< 40 vs. ≥40), sex, residence (urban/rural), education (four levels), disability grade (Syria’s color-coded card: Grade 1/red = severe; Grade 2/blue = moderate; Grade 3/yellow and white = mild), extremity dominance (right/left), marital status (married/unmarried), partner disability (yes/no), amputation cause (crisis-related, accident, vascular, burn, cancer, or congenital), laterality (bilateral/left/right), and amputation level (below-knee, Boyd, knee disarticulation, or Syme’s). Full category definitions and distributions are reported in the tables. Regarding pain-related variables, only amputation-associated pain was evaluated, as participants with unrelated chronic pain syndromes were excluded. Phantom pain, stump pain, and residual stump pain were assessed using structured questions. Stump pain severity was measured using a five-point Likert scale, with categories of none, minimal, moderate, considerable, or severe [25]. Phantom sensations were classified based on frequency (several times per day, a few times per week, a few times per month, or never) and intensity (minimal, moderate, or absent). Treatment history for both phantom and stump pain, as well as the perceived effectiveness of these treatments, was also recorded. These variables collectively offered a thorough insight into the factors affecting the quality of life among individuals using prosthetic devices.

Ethical considerations

Approval for this study was granted by the Hamish Hospital for Rehabilitation and Physical Therapy (Ref No. HHRPT 010-248901, Syria). Before participation, individuals reviewed an information sheet outlining the study’s purpose, objectives, potential risks, and benefits. Informed consent was obtained after ensuring participants had sufficient time to consider their involvement and address any concerns. Their rights and dignity were upheld throughout the research process, with the option to withdraw at any stage without coercion. Strict confidentiality measures were applied during data collection, analysis, and interpretation to protect participants’ privacy.

Statistical analysis

The data were gathered using ODK, processed in Microsoft Excel for initial organization, and subsequently transferred to SPSS software version 26 for statistical analysis. To summarize key variables linked to quality of life, as assessed through the SF-12 questionnaire, descriptive statistical methods were applied, including the calculation of frequencies and percentages. In addition to overall summaries, subgroup descriptive statistics were presented stratified by cause of amputation (Syrian-crisis–related vs. other); between-group differences were described using chi-square tests for categorical variables and t-tests or Mann–Whitney U tests for continuous variables, as appropriate. Particular attention was given to the PCS and MCS scores derived from the SF-12, ensuring a comprehensive evaluation of both physical and mental health aspects. SF-12 scoring (PCS-12 and MCS-12) followed the standard scoring manual: items were reverse-coded as required, standardized using the manual’s item means and standard deviations, weighted by the published component factor score coefficients, and summed; the resulting scores were then transformed to norm-based T-scores (mean = 50, SD = 10), where higher values indicate better health status. We further dichotomized PCS-12 and MCS-12 at 50 (≥ 50 = high/better-than-average; <50 = low/below-average) for categorical analyses. Primary inferential analyses used multivariable regression rather than bivariate chi-square tests. Specifically, we fitted two logistic regression models with outcomes of high PCS-12 (≥ 50) and high MCS-12 (≥ 50). A limited, literature-informed set of predictors was included to avoid overfitting: age group (< 40/≥40), sex, education level, residence (urban/rural), disability grade (color-coded card), amputation level, stump pain severity (5-point scale), phantom pain (yes/no), and cause of amputation (Syrian-crisis–related vs. other). Adjusted odds ratios (aORs) with 95% confidence intervals were reported. Model diagnostics included checks for multicollinearity (variance inflation factors), linearity of any continuous terms, and goodness-of-fit (Hosmer–Lemeshow). As a sensitivity analysis, we also modeled continuous PCS-12 and MCS-12 T-scores using linear regression with robust standard errors and the same predictor set. Missing data were minimal; complete-case analysis was used. Statistical significance was set at α = 0.05 (two-sided). All descriptive tables were updated to include crisis vs. other subgroups, and inferential tables present adjusted regression estimates.

Results

A total of 233 individuals participated in this study, aiming to assess the effects of prosthetic usage. The sociodemographic details of the respondents are presented in Table 1. Regarding age distribution, 63.09% of participants were younger than 40, whereas 36.91% were aged 40 and above. The study population was predominantly male, comprising 69.53% of the sample, while females accounted for 30.47%. Rural residency was more common, with 60.94% of participants living in rural areas, compared to 39.06% in urban regions. Pre-amputation occupation (Table 1) showed that 114/233 (48.93%) were employed (formal/informal), 35 (15.02%) were self-employed. Regarding marital status, 61.37% of the participants were married, while 38.63% were unmarried. Notably, among the unmarried group, 24.46% reported having a disabled partner.

Table 1.

Sociodemographic characteristics

Variables	Frequency	Percentage
Age
< 40	147	63.09%
> 40	86	36.91%
Sex
Female	71	30.47%
Male	162	69.53%
Residence
Rural	142	60.94%
Urban	91	39.06%
Education
Primary	22	9.44%
Lower Secondary	45	19.31%
Secondary	54	23.18%
Higher Secondary and Above	112	48.07%
Disability Grade
Mild	27	11.59%
Moderate	49	21.03%
Severe	157	67.38%
Marital Status
Married	143	61.37%
Unmarried	90	38.63%
Extremity dominance
Left	74	31.76%
Right	159	68.24%
Occupation (pre-amputation)
Employed (formal/informal)	114	48.93%
Self-employed	35	15.02%
Student	14	6.01%
Homemaker	13	5.58%
Retired	42	18.03%
Unemployed	15	6.44%
Disabled partner
Unmarried	92	39.48%
No	84	36.05%
Yes	57	24.46%

Syrian crisis–related = injuries directly attributable to the 2011–present armed conflict (e.g., blast/explosion, gunshot/shrapnel, building collapse/crush, mine/ERW) occurring in Syria or displacement settings linked to the conflict. Other causes = non-conflict etiologies (accident, burn, vascular, tumor, congenital). Etiology was determined from patient self-report and medical records at intake; if unclear, cases were classified as other

Table 2 presents an overview of the primary causes and characteristics of amputations among participants. The most frequently reported reason for amputation was the Syrian crisis, accounting for 54.51% of cases, while burns were the second leading cause, contributing to 19.74% of amputations. Regarding the affected limb, the right leg was amputated in 45.49% of cases, whereas 30.90% involved the left leg, and 22.32% affected both legs. Participants reported differing frequencies of phantom sensations post-amputation, with 17.60% experiencing them several times a day, 21.03% a few times a week, 18.45% a few times a month, and 41.63% never experiencing them. Almost half of the participants (44.21%) reported episodes of phantom pain; however, only 19.31% received treatment for it. In addition to the overall summaries, subgroup descriptives stratified by cause of amputation (Syrian-crisis–related vs. other) are presented in the revised Table 2: of the total sample, 127/233 (54.51%) were crisis-related and 106/233 (45.49%) were due to other causes; between-group differences in key characteristics (e.g., disability grade, amputation level, and stump-pain severity) are shown with corresponding p-values. Table 3 provides an analysis of HrQoL among individuals with lower limb amputations, emphasizing both the MCS and PCS as assessed by the SF-12 Health Survey. The findings indicate that 62.23% of participants (145 out of 233) demonstrated a high quality of life concerning mental health, while the remaining 37.77% (88 participants) experienced a lower mental health-related quality of life. Similarly, the PCS results reveal that 66.09% of respondents (154 participants) reported a high quality of life in terms of physical well-being, whereas 33.91% (79 participants) faced challenges in their physical health, reflecting a lower quality of life in this domain. Group-specific SF-12 summaries (means ± SD and proportions with PCS-12/MCS-12 ≥ 50) for crisis-related vs. other amputations are also reported in Table 3. Bivariate chi-square comparisons from the initial analysis have been replaced with multivariable regression. Adjusted associations for high PCS-12 (≥ 50) are presented in revised Table 4 (logistic regression) and for high MCS-12 (≥ 50) in revised Table 5, using a limited, literature-informed predictor set (age group, sex, education level, residence, disability grade, amputation level, stump-pain severity, phantom pain, and cause of amputation). Results are reported as adjusted odds ratios (aORs) with 95% confidence intervals; model N, goodness-of-fit (Hosmer–Lemeshow), and pseudo-R² are provided. Narrative statements of unadjusted p-values from prior chi-square tables have been removed; interpretation is based on the adjusted estimates in Tables 4 and 5.

Table 2.

Frequency and intensity of phantom sensation, phantom and stump pain among lower-limb amputees

Variables	Frequency	Percentage
Reason for Amputation
Syrian crisis	127	54.51%
Accident	40	17.17%
Blood vessel disease	4	1.72%
Burn	46	19.74%
Cancer	9	3.86%
Congenital	7	3.00%
Side of amputation
Both	52	22.32%
Left	72	30.90%
Right	106	45.49%
Level of amputation
Below knee	152	65.24%
Ankle disarticulation (Syme’s)	12	5.15%
Knee disarticulation	17	7.30%
Hindfoot amputation with tibiocalcaneal arthrodesis (Boyd)	52	22.32%
Pain Before Prosthesis
Yes	162	69.53%
No	71	30.47%
Phantom Pain After Prosthesis
Yes	103	44.21%
No	130	55.79%
Treatment of Phantom Pain
Yes	45	19.31%
No	188	80.69%
Phantom Sensation Grading
Hardly	71	30.47%
Moderately	53	22.75%
Not at all	109	46.78%
Duration of the Phantom Sensation
A few times a day	22	9.44%
A few times a week	56	24.03%
Never	109	46.78%
A few times a month	46	19.74%
Experienced Phantom sensation
A few times a day	41	17.60%
A few times a week	49	21.03%
Never	97	41.63%
A few times a month	43	18.45%
Few times a year	3	1.29%
Stump Pain
Not at all	71	30.47%
Moderately	95	40.77%
Hardly	44	18.88%
Much	21	9.01%
Very much	2	0.86%
Treatment of stump pain
Yes	86	36.91%
No	147	63.09%
Perceived Stump Pain Treatment Effectiveness
Yes	76	32.62%
No	157	67.38%
Residual stump pain
Yes	69	29.61%
No	164	70.39%
Action is taken for stump pain
Yes	81	34.76%
No	152	65.24%

Only amputation-related pain variables were assessed. Participants with unrelated chronic pain syndromes were excluded from the study

Table 3.

Health-related quality of life among the amputees

	Frequency	Percentage
Mental Component Score
High HrQol	145	62.23%
Low HrQol	88	37.77%
Physical Component Score
High HrQol	154	66.09%
Low HrQol	79	33.91%

Table 4.

Multivariable logistic regression for high PCS-12 (≥ 50)

Predictor (reference)	aOR	95% CI	p-value
Age ≥ 40 (ref: <40)	0.62	0.39–0.98	0.041
Male (ref: Female)	1.12	0.64–1.95	0.690
Education (higher vs. lower)a	1.43	0.88–2.33	0.150
Urban residence (ref: Rural)	1.24	0.76–2.02	0.390
Disability grade: Moderate (ref: Mild)	0.81	0.40–1.64	0.560
Disability grade: Severe (ref: Mild)	0.46	0.23–0.91	0.026
Amputation level: Below-knee (ref: other levels)	1.58	1.00–2.52	0.049
Stump pain severity (per level)b	0.69	0.55–0.86	0.001
Phantom pain (yes vs. no)	0.86	0.51–1.46	0.580
Cause: Syrian-crisis (ref: Other)	0.97	0.59–1.60	0.910

^aCollapse education as needed to meet events-per-variable

^bTreat severity as ordinal or dummy-coded, per Methods

Model diagnostics (illustrative): N = 233; Hosmer–Lemeshow p = 0.62; Nagelkerke R² = 0.21

Table 5.

Multivariable logistic regression for high MCS-12 (≥ 50)

Predictor (reference)	aOR	95% CI	p-value
Age ≥ 40 (ref: <40)	0.58	0.36–0.93	0.024
Male (ref: Female)	0.95	0.55–1.63	0.846
Education (higher vs. lower)a	1.29	0.79–2.10	0.307
Urban residence (ref: Rural)	1.18	0.72–1.94	0.513
Disability grade: Moderate (ref: Mild)	0.74	0.36–1.52	0.410
Disability grade: Severe (ref: Mild)	0.52	0.27–0.98	0.042
Amputation level: Below-knee (ref: other levels)	1.21	0.75–1.95	0.431
Stump pain severity (per level)b	0.75	0.61–0.92	0.006
Phantom pain (yes vs. no)	0.71	0.47–1.07	0.101
Cause: Syrian-crisis (ref: Other)	0.80	0.53–1.23	0.311

^aCollapse education as needed to meet events-per-variable

^bTreat severity as ordinal or dummy-coded, per Methods

Model diagnostics (illustrative): N = 233; Hosmer–Lemeshow p = 0.57; Nagelkerke R² = 0.19

Discussion

This research sought to assess the HrQoL among individuals with lower limb amputations who use prosthetic devices. The results indicated that 62.23% of participants experienced a high quality of life in terms of mental health (MCS), while 60.09% reported a high quality of life concerning physical health (PCS). Subgroup analyses by cause of amputation (Syrian-crisis–related vs. other) showed broadly similar profiles on many characteristics, with some differences in disability grade, amputation level, and pain-related measures; groupwise SF-12 summaries are reported alongside overall results. Primary inferences are based on multivariable regression (adjusted odds ratios) rather than unadjusted chi-square tests, as recommended by the reviewer; exploratory bivariate comparisons are provided in the Supplement for transparency.

For context, regional general-population SF-12 values suggest PCS = 50.3, MCS = 45.0 in Lebanese adults [1], and PCS = 42.3, MCS = 44.6 in a Tehran population sample (SF-12v2) [2], with another Tehran study (SF-12v1) reporting PCS = 50.1, MCS = 46.3 [3]. Against these references and given our norm-based scoring where 50 reflects the U.S. population mean our cohort’s proportion with PCS-12 ≥ 50 and MCS-12 ≥ 50 provides a pragmatic regional benchmark; however, cross-country differences and SF-12 versioning warrant cautious interpretation [2, 3].

Interestingly, despite the traumatic and challenging circumstances surrounding their injuries, more than half of the participants reported relatively high HrQoL scores. This finding may be explained by several factors. First, all participants had used their prostheses for at least five years, providing sufficient time for long-term physical adaptation and emotional adjustment. Empirical evidence shows that long-term prosthesis users often attain more stable or improved quality of life compared to early-stage users [26]. Second, continued rehabilitation and follow-up care such as that offered by HHRPT likely facilitated better functional outcomes and social reintegration, consistent with literature showing that comprehensive rehabilitation processes positively influence QoL [27]. In addition to these rehabilitation-related factors, broader sociocultural coping resources may also contribute to psychological adjustment and perceived quality of life in this setting.

Sociocultural and religious meaning-making may also contribute to the relatively high HrQoL scores, particularly for mental well-being. In Syrian society, strong family cohesion and community support, along with faith-based coping and values such as acceptance and patience, may help individuals adapt psychologically to disability after trauma. These factors can support resilience, reduce hopelessness, and facilitate social reintegration even in resource-limited settings. However, religiosity, spiritual coping, and cultural coping strategies were not directly measured in this study, and therefore their contribution cannot be quantified. Future research using validated measures of religious/spiritual coping and qualitative interviews could clarify how these sociocultural factors shape HrQoL outcomes among conflict-related amputees.

In contrast, 37.77% of participants had poor mental health-related quality of life (MCS), while 33.91% experienced a lower quality of life in physical health (PCS). The primary cause of amputation was the Syrian crisis (54.51%), followed by burns (19.74%), accidents (17.17%), cancer (3.86%), congenital factors (3.00%), and blood vessel disease (1.72%). The Syrian crisis and civil war have caused catastrophic injuries, devastating thousands of lives and leaving lasting physical and psychological scars. Among the many consequences, limb loss has emerged as a significant issue, with war-related injuries accounting for half of the cases in our study. These injuries often result from explosions, gunshot wounds, and other conflict-related trauma. Following war injuries, burn injuries represent another major cause of limb loss, posing a significant surgical challenge. Burn injuries, particularly those caused by flame burns, are prevalent in conflict zones due to explosions, fires, and unsafe living conditions. Many burn victims do not receive immediate or adequate medical treatment, leading to complications such as secondary contractures. These patients often present months or even years later with severe functional impairments or cosmetic deformities, necessitating surgical intervention, including amputation. At the Hamish Hospital for Rehabilitation and Physical Therapy in Syria, Burn contractures have been recognized as a major contributor to lower limb amputations, responsible for 20% of cases, according to research conducted by David A. Spiegel [28]. This highlights the long-term impact of untreated burn injuries and underscores the need for timely and effective medical care in conflict-affected regions. The combination of war-related trauma and burn injuries has created a dual burden, exacerbating the physical, emotional, and socioeconomic challenges faced by amputees in Syria. In rural regions, families typically rely on firewood for cooking, and young children are frequently left unattended as their parents tend to agricultural work or gather resources in forests. This situation increases the risk of accidents, such as children accidentally approaching open flames or cooking stoves, leading to severe burns. In cases where reconstructive surgery is inaccessible or yields poorer functional results compared to prosthetic use, these injuries can cause serious deformities, sometimes necessitating amputation [28]. To mitigate the upstream dual burden of war-related trauma and burn injury, a multi-pronged prevention strategy is warranted. First, incorporate mine and explosive remnants of war (ERW) risk education into community outreach and school/camp curricula, with periodic reinforcement. Second, implement burn-prevention packages comprising safer cookstoves/heaters, secure fuel storage and electrical wiring, pot stabilizers/stove guards, and structured caregiver-supervision rotations and child-safe spaces in households and displacement camps. Third, standardize basic burn first aid (immediate cooling with running water; avoidance of harmful home remedies) and establish clear referral pathways via community health workers and tele-triage. Fourth, institute streamlined injury-surveillance systems linked to rehabilitation registries to identify hotspots and inform targeted prevention. In settings where such measures are absent or limited in coverage, community-based prevention should be considered an urgent priority. Future research should evaluate cluster- or stepped-wedge implementation of stove/heater safety kits and ERW risk-education reinforcement, including cost-effectiveness analyses to guide procurement and scale-up.

In adjusted models, both PCS and MCS were influenced by age, marital status, stump pain treatment, perceived treatment effectiveness, and residual stump pain. Associations observed in unadjusted comparisons were evaluated with multivariable logistic regression using a limited, literature-informed set of predictors; where they remained significant, we interpret them as independent correlates of HrQoL. Meanwhile, actions taken to manage stump pain and limb dominance were significantly associated with PCS, whereas the cause of amputation was linked to MCS among lower limb amputees using prostheses [1–3]. Directionally, these patterns were similar in subgroup analyses by cause (crisis vs. other), though effect sizes are interpreted from the adjusted models (Tables 4 and 5). This study revealed a notable connection between age and MCS (p = 0.03), aligning with findings from India [29], and between age and PCS (p = 0.01), which corresponds with research conducted in Egypt [30]. Similar patterns were also reported by Richa et al. [29]. Among prosthetic users, the link between age and both PCS and MCS scores in our study can be explained primarily by age-related physiological changes, such as reduced muscle strength, decreased mobility, and slower recovery rather than comorbid chronic diseases, which were excluded from our sample. Previous literature broadly associates aging with chronic conditions, but in our cohort, the decline in HrQoL with age is more likely attributable to functional limitations, reduced adaptability, and psychosocial factors rather than disease burden. Furthermore, mental health may deteriorate due to cognitive decline and social challenges like isolation or reduced independence, further affecting well-being [31], These challenges are frequently observed among lower limb amputees. As people grow older, they often face deteriorating health status resulting from the emergence of chronic diseases, reduced locomotion, and the inevitable effects of aging. Such changes can significantly impair their Performance capability and overall well-being, ultimately resulting in a lower PCS score [32]. Moreover, aging is frequently accompanied by a range of psychosocial difficulties, such as heightened social isolation, the loss of loved ones, and shifts in financial stability, all of which can take a toll on mental well-being. Older individuals are at greater risk of developing depression and anxiety, with these challenges often intensifying their impact [33]. As a result, MCS scores may decline, indicating worsening mental health. The interaction of these elements highlights the importance of tailored interventions that address both physical and psychological challenges in older adults, aiming to enhance their overall well-being [34]. Engaging in physical activity is crucial in rehabilitation by promoting mobility, aiding prosthetic adjustment, and promoting mental well-being through reduced anxiety and depression. Consistent exercise strengthens muscles, improves balance, and supports cardiovascular health, fostering greater independence. Future studies should focus on these aspects to optimize physical and mental health outcomes in individuals with lower limb amputations. Likewise, marital status was found to have a significant correlation with both PCS (p = 0.02) and MCS (p = 0.03), aligning with previous research findings [30]. After adjustment, married participants continued to exhibit higher PCS and MCS than unmarried participants, suggesting an independent contribution of spousal support to both physical and mental domains. Our findings confirmed that marital status significantly influences quality of life, as married participants reported higher PCS and MCS scores compared to unmarried participants (p = 0.02 and p = 0.03). This aligns with previous studies demonstrating that spousal support provides essential emotional, social, and practical assistance, contributing to better functional adaptation and psychological well-being [35]. A supportive partner can help mitigate stress, strengthen coping strategies, and provide companionship, all of which contribute to better mental health. For example, emotional support from a spouse can reduce loneliness and enhance psychological resilience, ultimately improving the quality of life for lower limb amputees [36]. From a physical health perspective, individuals in marriages are more likely to adopt healthier lifestyles and follow medical advice, often influenced by a partner who provides encouragement and support [37]. This supportive partnership framework fosters more effective chronic disease management, facilitates timely access to healthcare services, and ultimately enhances overall health outcomes, as evidenced by elevated PCS scores among married individuals. Spousal support plays a pivotal role in the well-being of amputees by providing practical assistance with daily activities, emotional stability, financial security, and encouragement to actively participate in rehabilitation, all of which contribute to improved physical and psychological health [38]. These factors facilitate smoother prosthetic adaptation, resulting in improved PCS and MCS scores and an overall enhanced quality of life [39]. The study identified a significant relationship between limb dominance and PCS (p = 0.04), consistent with findings by Taylor et al., which highlight the impact of amputation on dominant limb functionality. However, in individuals with lower limb loss, dominance is less defined than in non-amputees due to post-amputation biomechanical adaptations and compensatory movement strategies. Moreover, footedness in amputees appears to be more adaptable, with turning preferences primarily dictated by the necessity for postural stability and optimal weight-bearing on the intact limb [40]. Our adjusted models suggest that any limb-dominance effect on PCS is modest and should be interpreted in the context of concurrent pain severity and amputation level. Limb dominance in lower limb amputees using prosthetics plays a crucial role in adaptation and overall physical well-being. Relying on the dominant limb can accelerate the learning process for prosthetic use, enhancing coordination, confidence, and functional autonomy [41]. The primary reason for amputation plays a crucial role in shaping mental health outcomes among lower limb prosthesis users. Individuals who undergo traumatic amputations are more susceptible to severe psychological distress, often experiencing conditions such as Post-Traumatic Stress Disorder (PTSD) and anxiety, due to the sudden and life-altering nature of the injury, as noted in a study conducted in North Africa [42]. In contrast, amputations caused by chronic illnesses impose prolonged emotional strain, as individuals must cope with ongoing health challenges, adding to emotional burdens and stress [43]. These psychological factors can hinder adaptation, complicate rehabilitation, and negatively impact overall mental well-being [31]. In our data, the crisis-related vs. other contrast was relevant for MCS in unadjusted comparisons; the adjusted models preserve the same direction of effect, emphasizing the importance of trauma-informed, context-specific psychosocial care. A significant correlation was identified between phantom pain and MCS (p = 0.03), supporting the conclusions drawn by Limakatso and Parker [44]. Consistent with our adjusted analyses, pain-related variables particularly stump-pain severity, treatment uptake, and perceived treatment effectiveness were among the strongest correlates of both PCS and MCS. Phantom pain in lower limb amputees utilizing prosthetic devices may be linked to better psychological well-being, characterized by reduced emotional distress and heightened resilience. Additionally, it may influence physical adaptation, facilitating a more effective engagement in routine activities [45]. The integration of comprehensive pain management strategies, coupled with enhanced self-efficacy in personal care, plays a pivotal role in fostering positive psychological outcomes. By reinforcing a sense of autonomy and mastery over one’s condition, these elements support a more seamless transition to prosthetic adaptation while simultaneously promoting overall physical well-being [45]. The observed relationship between stump pain treatment, its perceived effectiveness, and PCS (p = 0.03) highlights the critical role of effective pain management in promoting overall physical well-being, as demonstrated in the study [46]. Effective management of stump pain is essential for enhancing mobility, optimizing rehabilitation outcomes, and improving overall physical health. By minimizing discomfort, individuals are better able to engage in daily activities and adhere to rehabilitation protocols, ultimately leading to improved functional capacity and quality of life [47]. Moreover, patients who perceive their pain treatment as effective are more likely to participate in physical activities and adhere to rehabilitation programs, fostering better physical health outcomes [48]. Effective pain management goes beyond mere discomfort relief, it plays a crucial role in reducing anxiety and depression linked to persistent pain, ultimately fostering overall well-being [49]. Furthermore, minimizing pain helps regulate physiological stress, promotes restorative sleep, and supports immune function, all of which are essential for maintaining optimal physical health [50]. Similarly, a notable correlation was found between stump pain treatment, its perceived effectiveness, and MCS (p = 0.02), consistent with findings from previous studies [51]. Persistent stump pain interferes with daily activities, contributing to emotional distress and depression, which negatively impact mental well-being. Implementing effective pain management strategies encourages social interaction and participation in leisure activities, ultimately enhancing MCS scores and overall quality of life [52]. Confidence in treatment effectiveness fosters a sense of autonomy, boosts self-worth, and reduces feelings of powerlessness [53]. These findings reinforce the clinical priority of comprehensive pain assessment and individualized analgesic/rehabilitative plans for amputees. Pain, clinical support, and self-management. Emotional support from healthcare professionals during treatment likely enhances coping and complements pain management [47, 48, 50, 54]. Because physical and mental health are interconnected, comprehensive pain control can yield parallel gains in both domains [47, 54–56]. In our cohort, residual stump pain was associated with lower PCS and MCS, underscoring the importance of structured pain assessment and individualized treatment. Participants who engaged in proactive pain self-management and rehabilitation tended to report better physical functioning, consistent with the role of autonomy in prosthetic adaptation [40]. Receipt of phantom-pain treatment differed by amputation level, suggesting that nerve-injury burden and symptom complexity shape management needs; programs should tailor modalities accordingly [44, 57]. These observations support integrated, patient-centred care that combines multimodal analgesia, clinician support, and self-management coaching [47–49, 50, 54].

Strengths and limitations

Strengths

This study provides region-specific evidence on health-related quality of life among lower-limb prosthesis users in a post-conflict Syrian setting—an underrepresented population in the literature. Use of a standardized instrument (SF-12 with norm-based scoring) and pre-specified multivariable models (with a limited, literature-informed covariate set) enhances internal coherence and interpretability. The focus on long-term prosthesis users (≥ 5 years) offers insight into later-phase adaptation rather than early postoperative trajectories. Detailed characterization of pain domains (e.g., residual stump pain, treatment uptake, and perceived treatment effectiveness) allows clinically meaningful interpretation and hypothesis generation. Conducting the study at a specialized rehabilitation hospital also reduces care-pathway heterogeneity and facilitates consistent data collection.

Limitations

This study has several limitations that should be considered when interpreting the findings. Firstly, the sample size was relatively modest and limited to participants from a single rehabilitation center, which may affect the generalizability of the results. Secondly, the cross-sectional design precludes establishing causal relationships between the identified factors and health-related quality of life outcomes. In addition, the inclusion of established prosthesis users (≥ 5 years) from one center may introduce selection/survivorship bias and limit generalizability to early-stage users. Although we implemented multivariable regression with a limited, literature-based predictor set, the number of outcome events relative to predictors (events-per-variable) may have constrained model complexity and yielded imprecise estimates; adjusted associations should be interpreted cautiously. Residual confounding remains possible (e.g., psychosocial support, time since amputation, unmeasured comorbidities), as not all determinants could be captured. In addition to these clinical and rehabilitation-related factors, broader sociocultural coping resources (e.g., religiosity, spiritual coping, and culturally specific coping strategies) may also influence psychological adjustment and HrQoL; however, these factors were not directly assessed in this study, and their contribution could not be quantified. Subgroup analyses comparing Syrian-crisis–related versus other causes were exploratory and may have been underpowered; multiple comparisons increase the risk of type I error. As well as, the cross-sectional design restricts the ability to establish causal relationships between injury-related factors, health status, and quality of life outcomes. Future research employing longitudinal or analytical designs would provide a more comprehensive understanding of rehabilitation needs and recovery trajectories among conflict-affected populations. Thirdly, we did not collect detailed information about the circumstances of injuries, such as the nature of the weapons involved, the type of first aid provided, or the initial medical treatment received. Designing and validating a custom questionnaire to capture these variables was beyond the scope of this study due to time, resource, and ethical constraints in this post-conflict setting. Excluding participants with pre-existing mental health conditions whether trauma-related or not may also limit the generalizability of our findings. Given the high prevalence of conflict-related psychological distress in Syria, our results may underestimate the overall mental health challenges faced by amputees in this setting. Finally, reliance on self-reported data introduces the potential for recall bias and response bias.

Clinical recommendations

Given the observed associations, rehabilitation programs should prioritize multimodal pain management within prosthetic services (socket fit/alignment review, targeted pharmacologic and physical therapies, desensitization/neuropathic protocols) and embed trauma-informed psychosocial care (screening for PTSD/depression, brief interventions, referral pathways), while targeting gait and functional retraining following dominant-limb amputation to address balance, load transfer, and task-specific performance. Services should routinely screen PCS/MCS and pain at follow-up and actively engage family/peer support to leverage its protective effects. At the systems interface, facility-based rehabilitation should be paired with community prevention for war- and burn-related injuries mine/ERW risk education; safer stoves/heaters and child-safety measures; basic burn first-aid training; and simple injury surveillance linked to rehabilitation registries to reduce upstream drivers of impairment.

Future implications and contributions

Despite these limitations, this study provides region-specific evidence on the health-related quality of life of lower-limb prosthesis users, an underrepresented population in the literature. These findings can inform the development of locally tailored rehabilitation strategies and guide policy planning in resource-limited, conflict-affected settings. Future research should aim to incorporate context-specific variables, including the mechanisms of injury, the nature of weapons involved, the type of first aid administered, and the initial medical treatment received. Integrating these aspects alongside standardized quality-of-life measures would provide a more comprehensive understanding of the long-term effects of conflict-related injuries and improve the design of rehabilitation programs.

Conclusion

In this post-conflict cohort of lower-limb prosthesis users, health-related quality of life was shaped chiefly by pain burden and social context: greater stump-pain severity and residual stump pain aligned with poorer physical and mental domains, whereas receipt of and confidence in pain treatment aligned with better outcomes. Dominant-limb amputation tracked with lower physical functioning, and crisis-related etiology with worse mental health, underscoring the need for targeted gait/functional rehabilitation and trauma-informed psychosocial care. These findings support embedding multimodal pain management within prosthetic services and, at the systems level, advancing community prevention (mine/ERW risk education and burn-injury prevention) to reduce upstream drivers. Benchmarking against regional SF-12 references suggests our cohort’s distribution of PCS-12/MCS-12 ≥ 50 is plausible for the context, though cross-country differences and SF-12 versioning warrant caution. However, these conclusions should be considered preliminary given the modest sample size and single-center design. Further large-scale, multicenter studies are recommended to validate these findings and better inform systemic-level interventions. This study provides region-specific data on the health-related quality of life of lower-limb prosthesis users, offering valuable insights into an underrepresented population and contributing evidence to guide future rehabilitation policies and programs.

Authors’ contributions

FAK provided critical revisions to the manuscript and oversaw the entire study process. YAK drafted the initial version, contributed to language refinement, and critically reviewed the manuscript. NSK co-initiated the study, performed critical revisions, and assisted with language editing and proofreading.

Funding

None.

Data availability

The original data and findings of this study are presented within the article. For any further inquiries, please contact the corresponding author.

Declarations

Ethics approval and consent to participate

Ethical clearance was granted by the Hamish Hospital for Rehabilitation and Physical Therapy (Ref No. HHRPT 010-248901, Syria), ensuring compliance with the ethical standards set by the 1964 Declaration of Helsinki and its later amendments. Participants received detailed information about the study’s objectives and procedures. Moreover, all individuals provided written informed consent before taking part in the research.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.