Lower limb amputation is a life-altering event with long-term physical, psychological, and social consequences. Globally, the leading causes of lower limb amputation include diabetes mellitus, peripheral vascular disease, trauma, malignancies, and infections (1). As diabetes and road traffic injuries increase in low- and middle-income countries, the burden of limb loss is expected to rise significantly in regions such as the Middle East and North Africa (MENA) (2). Jordan, like many countries in the region, faces an increasing prevalence of diabetes-related complications and traumatic injuries, yet comprehensive data on outcomes after amputation remain scarce (3).

Beyond the immediate surgical and physical recovery, amputation affects multiple domains of a person's life. These include mobility, independence, social integration, emotional well-being, body image, employment, and access to healthcare services (3, 4). To address the complex, multidimensional impact of limb loss, the measurement of health-related quality of life (HRQoL) has become central in evaluating rehabilitation outcomes. It is increasingly recognized that functional independence alone does not capture the lived experience of prosthetic users; emotional adaptation, social participation, and subjective well-being are equally important indicators of successful rehabilitation (5, 6).

One of the most widely used instruments to assess HRQoL is the Form-36 Health Survey (SF-36), a validated, multidimensional tool that evaluates eight key domains: physical functioning, role limitations due to physical or emotional problems, bodily pain, general health, vitality, social functioning and emotional well-being (7, 8). It provides a comprehensive profile of health status and has been adapted and validated in many languages, including Arabic (9, 10). The Arabic version of the SF-36 has demonstrated good reliability and internal consistency in several Arab-speaking populations and is suitable for use in both clinical and research settings (10–12).

Multiple studies have explored the factors associated with HRQoL in lower limb amputees (13). Physical function is often reported to be significantly reduced, especially among individuals with higher-level amputations (e.g., transfemoral) or limited access to rehabilitation services (9, 14). Emotional well-being and social functioning, however, may vary depending on cultural, familial, and psychosocial support structures (6, 15). Research suggests that men often report better physical and emotional outcomes than women, potentially due to differences in role expectations, physical strength, or access to prosthetic care (16, 17). Educational attainment, age, and prosthetic use are also variably associated with HRQoL outcomes, though the findings are not always consistent across countries and populations (15, 17).

In South Asia and Africa, studies have shown that poor pain management, phantom limb sensations, comorbidities, and unemployment negatively affect both physical and mental health among amputees (15, 18, 19). In contrast, studies in Western settings have found that emotional resilience, optimism, and adaptive goal setting can improve QoL despite high levels of physical impairment (20). However, such psychosocial constructs are rarely assessed in clinical practice, especially in resource-limited or culturally conservative settings.

In Jordan and other Arab countries, there is a lack of large-scale, systematic research on the quality of life of prosthetic users. Rehabilitation services vary widely between urban and rural areas, and users often face delays in prosthesis provision, limited follow-up, and inadequate psychological support (21, 22). Cultural norms and family expectations may further influence emotional adjustment and perceived well-being, but these factors remain under-explored.

Given this gap, the present study aimed to assess the quality of life among lower limb prosthetic users in Jordan using the Arabic version of the SF-36. The study also explored the relationship between demographic and clinical factors including age, gender, educational level, and amputation level and QoL outcomes. It was hypothesized that age, gender, and amputation level would significantly affect SF-36 scores. By identifying the domains most affected and evaluating potential predictors, this study provides new insights that can inform clinical practice, rehabilitation policies, and culturally sensitive interventions in Jordan and similar contexts.

A total of 293 participants were included in the study, with a mean age of 48.6 years (SD = 15.9). The majority were male (73.0%), and most had a transtibial amputation (72%). Educational backgrounds varied, with bachelor's and high school degrees being the most common. Table 1 presents the full socio-demographic breakdown.

The distribution of SF-36 domain scores was assessed using the Shapiro–Wilk test. All domains, including the Composite QoL score, showed significant deviation from normality (p < 0.001 for all), indicating non-normal distributions. Accordingly, non-parametric statistical tests were used in all group comparisons.

This study examined the quality of life (QoL) among lower limb prosthetic users in Jordan using the Arabic version of the SF-36 questionnaire. The results revealed a mixed pattern of outcomes. While participants reported relatively high scores in emotional and social domains, considerable impairments were observed in physical health–related domains, particularly physical functioning, general health, and role limitations due to physical health (Tables 2–4). These findings underscore the multifaceted nature of QoL among prosthetic users and align with the broader literature on amputation and rehabilitation outcomes (24–26).

The present study is consistent with earlier research conducted in Saudi Arabia (9), where lower limb amputees reported relatively preserved scores in emotional well-being and social functioning, while physical functioning and mobility were significantly compromised (Table 2). Similarly, research from Nepal using the SF-12 identified higher mental health scores relative to physical domains among prosthesis users, reinforcing the notion that emotional resilience and social integration may be sustained despite ongoing physical limitations (15). These cross-regional similarities may reflect common cultural and familial coping mechanisms in Middle Eastern and South Asian settings, such as strong family support systems and spiritual adaptation.

Recent work on disability in Jordan has emphasized that access to rehabilitation services, affordability of prosthetic components, and continuity of follow-up care are inconsistent, especially in public-sector clinics (27, 28). This context may help explain the moderate composite QoL scores observed in the current study. The use of a culturally adapted Arabic SF-36 provides an important foundation for future national evaluations and standardized patient outcome monitoring.

In terms of gender-related differences, group comparisons (Table 3) revealed that female participants scored significantly higher than males in the Role Emotional and Vitality domains. This contrasts with prior findings from both Middle Eastern and global studies, where women generally report lower QoL due to caregiving responsibilities and more restricted access to mobility resources (4, 9, 15, 29, 30). However, the regression analysis (Table 4) in the present study indicated that males scored higher in Physical Functioning after controlling for covariates. This suggests that gender differences may be domain-specific and context-dependent. One explanation could be that Jordanian women receive greater familial support or experience lower post-amputation work demands. Alternatively, sociocultural norms may influence how men and women express and report emotional well-being in self-assessments. These patterns may reflect culturally specific gender roles in Jordan, where men may face greater pressure to maintain physical functioning and return to work, while women often receive stronger familial and community support for emotional adjustment, as reported in regional rehabilitation studies (31, 32). These contrasting trends highlight the need for future qualitative research to explore gendered rehabilitation experiences and reporting behavior more deeply.

The divergence between domain-specific findings (Table 3) and the regression results (Table 4) suggested potential interaction effects, such as gender combined with age or amputation level. For instance, females reported higher scores in vitality and role-emotional domains, while males recorded higher scores in physical functioning after adjustment. These patterns indicated that gender influences may be context-dependent and moderated by other demographic or clinical variables.

Several age- and gender-related differences reached statistical significance (Tables 3, 4); however, the associated effect sizes were generally small to moderate. This finding indicated that while these demographic factors influenced quality of life, the magnitude of their practical impact was modest. For example, the gender-related difference in vitality (r = 0.20) (Table 3) represented a small but meaningful variation in perceived energy levels.

Age was a consistent negative predictor of physical QoL outcomes (Table 4). Older participants reported significantly lower scores in Physical Functioning, Role Physical, Pain, and Composite QoL domains. These findings are supported by previous studies from India, Iran, and Nepal, where older prosthesis users reported greater difficulty in ambulation, more comorbidities, and slower functional adjustment (6, 15, 33). Age-related declines in muscle strength, energy levels, and balance likely contribute to reduced prosthetic use and social reintegration. This reinforces the importance of targeted interventions for older adults, including physiotherapy, assistive devices, and tailored follow-up schedules.

While amputation level was significantly associated with several QoL domains in group comparisons (particularly Role Emotional, Role Physical, and Composite QoL, Table 3), it was not significantly associated with QoL in the multivariable regression analysis (Table 4). This finding differs from previous studies that reported poorer outcomes among individuals with transfemoral or hip disarticulation due to the greater energy demands and gait limitations associated with more proximal amputations (6, 9, 34). One possible explanation is that users with higher-level amputations in this cohort may have received more comprehensive prosthetic rehabilitation or psychosocial support, partially mitigating the expected negative effects. Alternatively, the limited number of hip and knee disarticulations in the sample (n = 4) may have reduced statistical power.

Level of education was not a significant predictor of QoL in this cohort (Table 4), despite literature suggesting a positive correlation between educational attainment and health outcomes. In contrast, studies from Saudi Arabia (9) and Pakistan (35) have shown that individuals with higher education report better QoL, potentially due to increased health literacy, better communication with clinicians, and higher expectations for rehabilitation. The lack of a significant education effect in the current study may be due to a relatively homogenous sample in terms of socioeconomic access to services or a cultural emphasis on familial care that buffers educational disparities. Other unmeasured confounding factors such as household income, digital literacy, and access to health information may also have contributed to this null finding (36).

Subgroup analysis comparing participants with low vs. high composite QoL scores confirmed a statistically significant difference only in gender, again favoring females. No significant differences were found for age group, education level, or amputation level. This suggests that traditional demographic and clinical characteristics may not fully account for differences in QoL among prosthesis users in Jordan, and that additional variables such as prosthetic comfort, community integration, peer support, and psychological adaptation are likely to play a role and should be explored in future mixed-methods or longitudinal studies.

This study has several strengths, including a large and demographically diverse sample, the use of a validated Arabic SF-36 instrument, and comprehensive statistical analysis incorporating descriptive, inferential, and multivariable approaches. However, some limitations should be noted. The cross-sectional design does not allow for causal inference, and the absence of variables related to prosthetic type (design), duration of use, cause of amputation, pain severity, mobility level, socioeconomic status, and rehabilitation intensity limits the ability to explore key clinical and contextual influences. Other important factors, such as prosthetic fit, long-term comfort, and device type, were also not captured, even though they are likely to influence physical quality-of-life domains. Similarly, strong family support systems and religious coping strategies common in Jordanian society may have contributed to the relatively high emotional well-being scores observed. Convenience sampling across 14 centers may have introduced selection bias, and those with limited access to rehabilitation services may be underrepresented. The very small size of certain subgroups (e.g., hip disarticulations, n = 3) reduces statistical power and these comparisons should be interpreted cautiously. The regression models explained only 3%–19% of the variance in QoL domains, suggesting that important unmeasured factors contribute to quality-of-life outcomes. Additionally, reliance on self-reported data introduces the possibility of recall bias and response bias, and cultural norms may have influenced how participants reported emotional well-being. Future research should incorporate longitudinal designs, probability sampling, and broader clinical variables to provide a more complete and causally interpretable understanding of quality of life among prosthetic users.

Finally, the regression models explained only a small proportion of variance in QoL domains (3%–19% adjusted R²), indicating limited explanatory power. This suggests that unmeasured clinical, psychosocial, and environmental factors likely contribute to quality-of-life outcomes.

This study represents one of the first comprehensive evaluations of QoL in lower limb prosthetic users in Jordan. While emotional and social health domains are relatively preserved, physical limitations remain prominent and are significantly associated with age and gender. These findings are consistent with regional research while highlighting contextual differences that may shape rehabilitation outcomes. They underscore the importance of holistic, culturally sensitive rehabilitation strategies that address both physical and psychosocial dimensions of post-amputation care.

Furthermore, by evaluating health-related quality of life in a vulnerable population within a low- to middle-income country, this study contributes to the global efforts aligned with Sustainable Development Goal 3: Good Health and Well-being. The findings support the need for inclusive, accessible rehabilitation services that promote equity and functional recovery for persons with disabilities in underserved settings.

This study provides important insights into the quality of life of lower limb prosthetic users in Jordan. While emotional and social well-being domains were relatively preserved, significant impairments were observed in physical functioning and general health. Age and gender emerged as key factors associated with QoL, with older participants and males reporting lower scores in multiple domains. Although amputation level was not statistically significantly associated with QoL in multivariable regression, group comparisons revealed lower scores in role functioning and overall QoL among individuals with more proximal amputations. Education level did not show a significant association with QoL outcomes in either analysis.

These findings emphasize the importance of personalized, age-sensitive rehabilitation approaches and the integration of psychosocial support in prosthetic care. The results also underscore the utility of using multidimensional tools such as the SF-36 to capture the full spectrum of prosthetic users' experiences beyond physical recovery. Future research should build on these findings by incorporating longitudinal and mixed-methods designs to explore how clinical, functional, and contextual factors shape long-term QoL among amputees in Jordan and similar settings. Policy makers should consider expanding equitable access to prosthetic rehabilitation services, particularly in underserved regions, and clinical programs should integrate structured psychosocial support and culturally sensitive counseling for patients and families. Future research should test and refine rehabilitation models that incorporate these elements to improve both physical and emotional outcomes for prosthetic users in Jordan.