Enhancing Performance and Quality of Life in Lower Limb Amputees: Physical Activity, a Valuable Tool—A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Title: Enhancing performance and quality of life in lower limb amputees: physical activity, a valuable tool.

General Assessment

The manuscript presents a scoping review examining the role of physical activity interventions in individuals with lower limb amputation (LLA). The topic is clinically relevant and aligns well with the scope of Healthcare. The manuscript is generally well structured and follows PRISMA‑ScR guidelines; however, several conceptual, methodological, and reporting issues should be addressed to improve clarity, rigor, and interpretability.

 

Line 15: The databases are listed, but the time frame of the search should be explicitly reported in the abstract for transparency.

Line 55: The shift from traumatic to vascular etiology is important; nevertheless, the clinical implications of this shift for physical activity prescription should be more explicitly discussed.

Line 130: In addition to reporting the eligibility criteria according to PRISMA-ScR, the authors may consider explicitly structuring this section using the PECOS framework (Population, Exposure, Comparison, Outcomes, and Study design). Clearly defining each PECOS component—particularly Population and Exposure—would enhance transparency and help readers better understand the scope and methodological rigor of the review. This would complement the PRISMA framework without redundancy.

Line 138: The inclusion of narrative reviews alongside primary studies should be justified, as this may contribute to conceptual redundancy.

Line 203: The categorization of interventions is logical; however, overlap between ‘combined’ and ‘personalized’ training should be acknowledged. Add more details on the topic.

Lines 231–234: Statements regarding the superiority of strength training should be interpreted cautiously, given the heterogeneity and limited number of RCTs.

Lines 258–270: Thermoregulatory findings are interesting; however, environmental conditions and hydration status should be more clearly emphasized as confounders.

Lines 304–326: This section is a strength of the manuscript; however, clearer differentiation between structured and semi‑structured personalization approaches is recommended.

Lines 426–434: The proposal of remote monitoring is relevant, but should be supported with references or clearly framed as a perspective.

Line 437: In addition to the stated limitations, the lack of quantitative synthesis and absence of effect size considerations should be acknowledged.

Abbreviations: Please ensure consistency and clarity in the use of abbreviations throughout the manuscript. For example, CT is used to denote both Controlled Trials (Line 139) and Combined Training (Line 23), which may cause confusion.)

Line 239: "Two CT, one RCT, and one SR are included in this category. The two CT consist respectively". Clarification is required to specify whether CT refers to Controlled Trials or Combined Training.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding corrections highlighted in the re-submitted files.

Comment 1. Line 15: The databases are listed, but the time frame of the search should be explicitly reported in the abstract for transparency.

Thank you for pointing this out. We agree with this comment and added the time frame in the Abstract. (page 1, line 17 of the revised manuscript)

Comment 2. Line 55: The shift from traumatic to vascular etiology is important; nevertheless, the clinical implications of this shift for physical activity prescription should be more explicitly discussed.

Thank you for pointing this out. We agree with this comment and specified the implications of this shift. (page 4, lines 100-103 of the revised manuscript)

Comment 3. Line 130: In addition to reporting the eligibility criteria according to PRISMA-ScR, the authors may consider explicitly structuring this section using the PECOS framework (Population, Exposure, Comparison, Outcomes, and Study design). Clearly defining each PECOS component—particularly Population and Exposure—would enhance transparency and help readers better understand the scope and methodological rigor of the review. This would complement the PRISMA framework without redundancy.

We agree with this comment and accordingly structured the section according to PECOS criteria. (page 4, lines 167-180 of the revised manuscript)

Comment 4. Line 138: The inclusion of narrative reviews alongside primary studies should be justified, as this may contribute to conceptual redundancy.

Thank you for pointing this out. Since the aim of the present review is to map the breadth of evidence regarding the field and the topic is characterized by a paucity of studies in Literature, we decided to include all clinical and secondary studies. We changed the sentence and specified this choice. (page 4, lines 173-175)

Comment 5. Line 203: The categorization of interventions is logical; however, overlap between ‘combined’ and ‘personalized’ training should be acknowledged. Add more details on the topic.

Thank you for pointing this out. Although personalized training could seem to overlap the “combined training” group, it is focused on the customization of the program and based on the characteristics of the patient. We added this explanation. (page 9, lines 351-353 of the revised manuscript)

Comment 6. Lines 231–234: Statements regarding the superiority of strength training should be interpreted cautiously, given the heterogeneity and limited number of RCTs.

We agree. We interpreted them more cautiously and changed the sentence. (page 8, lines 272-273; page 14, lines 518-519; 542-548 of the revised manuscript)

Comment 7. Lines 258–270: Thermoregulatory findings are interesting; however, environmental conditions and hydration status should be more clearly emphasized as confounders.

We agree with this comment and specified their possible role as confounders. (page 8, line 314-315 of the revised document)

Comment 8. Lines 304–326: This section is a strength of the manuscript; however, clearer differentiation between structured and semi‑structured personalization approaches is recommended.

Thank you for pointing this out. We agree with this comment and implemented the description. (page 9, lines 368-370)

Comment 9. Lines 426–434: The proposal of remote monitoring is relevant, but should be supported with references or clearly framed as a perspective.

Thank you for pointing this out. We agree with this comment and changed the sentence. (page 14, lines 542-545)

Comment 10. Line 437: In addition to the stated limitations, the lack of quantitative synthesis and absence of effect size considerations should be acknowledged.

Thank you for pointing this out. We agree with this comment and implemented the section. (page 15, lines 561-562 of the revised manuscript)

Comment 11. Abbreviations: Please ensure consistency and clarity in the use of abbreviations throughout the manuscript. For example, CT is used to denote both Controlled Trials (Line 139) and Combined Training (Line 23), which may cause confusion.)

Thank you for pointing this out. We agree and changed the abbreviation for Combined training in ”Ct”. (page 7, line 255; page 10, line 411 of the revised manuscript)

Comment 12. Line 239: "Two CT, one RCT, and one SR are included in this category. The two CT consist respectively". Clarification is required to specify whether CT refers to Controlled Trials or Combined Training.

Thank you for pointing this out. We changed the abbreviation for combined training in Ct. (page 7, line 250 of the revised manuscript)

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the paper " Enhancing performance and quality of life in lower limb amputees: physical activity, a valuable tool".

I congratulate the authors on the subject matter, on the relevance of the subject matter, which contributes greatly to increasing knowledge in this area of great importance in terms of quality of life and rehabilitation.

For a better understanding of the authors' review, I will choose to do the same section by section.

Title

From my point of view, I suggest that the title should include the type of study, scoping review.

Abstract

In the abstract, I do not see the need to include bibliographical references.

In summary, I think you should rewrite it so that the heterogeneity of the interventions and studies included is  made clearer.

The conclusion should be revised as it does not reflect the results of the included studies.

Keywords should not be repeated in the title of the paper; they should be reviewed and changed.

Introduction 

They should revise the introduction, as it does not clearly justify the gap in the literature that warrants the development of this study.

The relevance of physical activity should be better justified, not only with reference to the WHO, but also with current and relevant references in the field. This aspect should be improved.

The objectives do not consistently reflect quality of life, only physical activity. Could you rephrase them?

 Materials and Methods 

Why choose two parallel PICO questions? Can you explain this decision in more detail?

How do you justify this research strategy? Does it not place excessive emphasis on biomedical terms?

Could the exclusion of studies in other languages have introduced bias? What is the justification for this?

They should better justify why interventions associated with other therapies and
competitive sports are excluded.

Could you please clarify and better explain how quality assessment was used in interpreting the results?

 Results

Is the exclusion process sufficiently transparent? Can this part be improved?

Figure 1 of the PRISMA is incomplete. Can you complete it in its entirety?

Can you justify why the categorisation of interventions is conceptually clear and clinically useful?

They should justify the use of multiple instruments for QoL and whether they may compromise comparability.

Are the results of the highest quality studies consistent? Can you perform this analysis?

Discussion

In the discussion, it deserves a good justification if strength training is proportional to the quality and quantity of available evidence.

Why remote monitoring proposals, please explain further.

The limitations require further clarification.

 Conclusions 

The conclusions should be more cautious, could you please review them?

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding corrections highlighted in the re-submitted files.

Comment 1: From my point of view, I suggest that the title should include the type of study, scoping review.

Thank you for pointing this out. We agree with this comment and implemented the Title (page 1, line 3 of the revised document)

Comment 2: In the abstract, I do not see the need to include bibliographical references.

Thank you for pointing this out. We agree with this comment and cancelled the references (page 1, line 15 of the revised document)

Comment 3: In summary, I think you should rewrite it so that the heterogeneity of the interventions and studies included is made clearer.

Thank you. We have accordingly changed this point. (page 1, lines 22-32 of the revised document)

Comment 4: The conclusion should be revised as it does not reflect the results of the included studies.

Thank you. We have accordingly revised this section. (page 1, lines 32-36 of the revised document)

Comment 5: Keywords should not be repeated in the title of the paper; they should be reviewed and changed.

Thank you for pointing this out. We have accordingly changed the Keywords. (page 1, line 42 of the revised document)

Comment 6: They should revise the introduction, as it does not clearly justify the gap in the literature that warrants the development of this study.

Thank you for pointing this out. We agree with this comment and revised the introduction (page 3, lines 104-107 of the revised document)

Comment 7: The relevance of physical activity should be better justified, not only with reference to the WHO, but also with current and relevant references in the field. This aspect should be improved.

Thank you. We have accordingly implemented this point. (page 2, lines 64-70 of the revised document)

Comment 8: The objectives do not consistently reflect quality of life, only physical activity. Could you rephrase them?

Thank you for pointing this out. We have accordingly implemented this aspect. (page 3, lines 111-114, 122-123 of the revised document)

Comment 9: Why choose two parallel PICO questions? Can you explain this decision in more detail?

Thank you for pointing this out. Since the aim of the study was to analyse the effect of PA on two different outcomes (Quality of Life and Gait Performance), we structured two PICOs and two distinct strings. We added the explanation. (page 4, lines 143-145 of the revised document)

Comment 10: How do you justify this research strategy? Does it not place excessive emphasis on biomedical terms?

Thank you for pointing this out. Standard of living in amputees depends on the ability to walk with a prosthesis, therefore it is important to find strategies for enhancing their ambulatory capacities. We added this explanation.(page 3, lines 111-114 of the revised document)

Comment 11: Could the exclusion of studies in other languages have introduced bias? What is the justification for this?

Thank you for pointing this out. In order to avoid bias due to incorrect translations, we chose to select only the studies written in English or Italian. We added this explanation. (Page 4, lines 176-178 of the revised document)

Comment 12: They should better justify why interventions associated with other therapies and
competitive sports are excluded.

Thank you for pointing this out. High level performances often require more technical prosthetic elements, which have a significant effect on physical performance but are not always accessible due to the expensive costs; for this reason, we decided to exclude them from the study; in order to avoid bias, programs that associated PA to specific physiotherapy treatments were excluded. We added this explanation (Page 4, lines 180-187 of the revised document)

Comment 13: Could you please clarify and better explain how quality assessment was used in interpreting the results?

Thank you for pointing this out .Assessment tools were used to grade the studies, and then a summary of the quality of the literature included was performed. We added this explanation. (page 5, lines 205-206 of the revised document)

Comment 14: Is the exclusion process sufficiently transparent? Can this part be improved?

Thank you for pointing this out. We implemented the description of exclusion process. (Page 5, lines 212-222 of the revised document)

Comment 15: Figure 1 of the PRISMA is incomplete. Can you complete it in its entirety?

Thank you for pointing this out. We implemented the description. (page 6, line 225 of the revised document)

Comment 16: Can you justify why the categorisation of interventions is conceptually clear and clinically useful?

Thank you for pointing this out. The PA interventions administered to individuals in the studies were heterogeneous; to make them more clear and clinically useful, they have been grouped into categories. Each category represent a different approach with different outcomes and clinical relevance. We added this explanation. (page 7, lines 248-249, 253-254)

Comment 17: They should justify the use of multiple instruments for QoL and whether they may compromise comparability.

We agree. Due its multifaceted nature, QoL is assessed with multiple instruments (mainly questionnaires); all the surveys used in the studies are validated, thus giving more evidence. We have accordingly implemented this point in the Discussion section. (page 14, lines 545-554)

Comment 18: Are the results of the highest quality studies consistent? Can you perform this analysis?

Thank you for pointing this out. Consistency of the results of the highest quality studies is hard to analyse due to the large variety of interventions ad outcomes registered; however, the use of macro-categories makes it possible to draw some conclusions: in general, the studies share the evidence that endurance activities have positive effects on cardiovascular fitness, especially when combined with strength training; personalized interventions focusing on balance and gait in addition to strength and endurance showed improvements in walking ability, functionality and QoL; lastly, PA seems to positively influence QoL, independently from the type of intervention. We accordingly added this explanation. (page 14, lines 506-518)

 

Comment 19: In the discussion, it deserves a good justification if strength training is proportional to the quality and quantity of available evidence.

We agree. We interpreted them more cautiously and changed the sentence. (page 14, lines 524-525; 542-548)

Comment 20: Why remote monitoring proposals, please explain further.

Thank you for pointing this out. Some studies have noted that the benefits of PA may be only short-term; hence, it is crucial to plan long-term training programs to maintain these improvements over time. It would be advisable, furthermore, for long-term training programs to be periodically monitored by a professional to detect performance increases, create proper exercise progressions, and keep motivation high in users. Remote monitoring proposals are cited in Literature; future research could involve applications that track workout progress for both the user and the professional, through online sharable tools or periodic phone calls. We accordingly added this explanation. (page 14, lines 542-545)

Comment 21: The limitations require further clarification.

Thank you for pointing this out. We agree with this comment and implemented the section (Page 15, lines 561-570)

Comment 22: The conclusions should be more cautious, could you please review them?

Thank you for pointing this out. We agree with this comment and changed the sentence with a more cautious conclusion. (Page 15, 584-596)

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have adequately addressed all the comments provided in the initial review. The revised manuscript shows a clear improvement in quality and meets the journal's standards. 

Author Response

Comment: The authors have adequately addressed all the comments provided in the initial review. The revised manuscript shows a clear improvement in quality and meets the journal's standards. 

Thank you very much for taking the time to reply. We are grateful for your valuable feedback on our manuscript and appreciated your insightful comments.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the paper again.
The changes made were consistent with what was requested, which greatly improved the entire paper.
I have only two comments that you should review.
One is about the keywords: scoping review is repeated in the title, so you should remove or modify it as a keyword.
The other point is the PRISMA flowchart, which is still incomplete, as it lacks information on ‘identification of new studies via databases and registers.’

Author Response

Thank you very much for taking the time to reply and giving us the opportunity to submit a revised draft of our manuscript. We are grateful for your valuable feedback. Please find the detailed responses below and the corresponding corrections highlighted in the re-submitted files.

Comment 1: scoping review is repeated in the title, so you should remove or modify it as a keyword.
Thank you for pointing this out. We agree with this comment and removed the term; we added a different keyword, too.

Comment 2: The other point is the PRISMA flowchart, which is still incomplete, as it lacks information on ‘identification of new studies via databases and registers.’

Thank you for pointing this out. We implemented the PRISMA flowchart adding the search terms and reporting the number of records sought for retrieval. Please let us know if any other adjustments are required.