Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation

Development of an Education Material Targeting Patients Undergoing Lower Extremity Amputation due to Severe Limb Ischemia-A Qualitative Study

INTRODUCTION

Critical limb-threatening ischemia (CLTI) is associated with a high risk of amputation, yet patients undergoing amputation due to CLTI have little knowledge of the amputation process and the rehabilitation that awaits. The aim of the present study was to develop and validate information material for patients undergoing amputation.

METHODS

Nine participants were included in the study. Two focus group interviews were performed with seven patients who had undergone lower extremity amputation due to CLTI within the past 2 y. Additionally, two individual interviews were carried out. A semistructured interview guide was used, and the interviews were transcribed verbatim and analysed using qualitative content analysis with a deductive approach.

RESULTS

Three themes were identified as essential for the design of the written information: Perspectives on design and formatting, Providing information to enhance participation in care, and Accessibility to information and support. The prototyped information leaflet was perceived as acceptable, useable, relevant, and comprehensible by the participants.

CONCLUSIONS

For patients to actively engage in their care, it is vital that their information needs are met and that they are provided with psychosocial support when needed. Written and oral information should be provided by a trusted healthcare professional.

Family concerns and relationship problems in anxious pregnant women and their associations with postnatal functional disability in Pakistan

OBJECTIVE

Expanding on existing research suggesting that strategies to reduce prenatal anxiety can decrease functional disability (e.g., difficulties in performing everyday activities and social participation), we examined if this effect varied by type of anxiety-producing problem (i.e., having family concerns and relationship problems versus other problems) reported during pregnancy. Further, we explored if perceived social support mediated this relationship.

METHODS

We used longitudinal data on 310 anxious Pakistani women who received any psychosocial intervention sessions as part of a program that was based on Cognitive Behavioral Therapy. The Psychological Outcome Profiles (PSYCHLOPS) was used to assess whether women had 'family concerns and relationship problems' or 'other problems.' The WHO Disability Assessment Schedule 2.0 assessed functional disability at six-weeks after delivery. Lack of support was measured using a 12-item Multi-dimensional Scale of Perceived Social Support. We employed linear regression to examine associations between types of problems reported during pregnancy and postnatal functional disability. Causal mediation analysis was used to assess whether postnatal social support mediated this relationship.

RESULTS

Of anxious pregnant women, 34% reported family concerns or relationship problems as primary problems in pregnancy. They were more likely to report higher functional disability at six-weeks after delivery than women who reported other problems (adjusted B = 2.40, 95% CI: 0.83-3.97). Lack of overall social support (Estimateindirect = 0.69, 95% CI: 0.04-1.38) and lack of support from friends (Estimateindirect = 0.62, 95% CI: 0.01-1.29) significantly mediated the relationship.

CONCLUSIONS

Findings suggest that complementing pre- and post-natal care with support programs and services that address family concerns and relationship problems, as well as enhancing social support is important to functional disability.

Rehabilitation experiences following major lower limb amputation due to complications of vascular disease: a UK qualitative study

PURPOSE

Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease.

METHODS

Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data.

FINDINGS

Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants' imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations.

CONCLUSIONS

Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.

The lower limb-loss rehabilitation continuum (LLRC) - a framework for program design and implementation

Purpose: The multistep journey to prosthetic device-enabled functioning following amputation requires a structured approach for optimal care delivery, but such program structures and outcomes are inadequately characterized. The study is responsive by describing an implementation framework for lower limb loss rehabilitation and evaluating its utility.Materials and methods: The lower limb loss rehabilitation continuum framework (LLRC) was developed using literature-based continuum of care and amputation phase concepts as well as input from limb loss rehabilitation stakeholders. LLRC structure includes five sequential steps (Postsurgical Stabilization (PS), Preprosthetic Rehabilitation (PPR), Limb Healing and Maturation (LHM), Prosthetic Fitting (PF), Prosthetic Rehabilitation (PR)) between six touchpoints of patient-healthcare interaction (Surgery, Preprosthetic Rehabilitation Admission and Discharge, Functioning Evaluation and Prescription, Prosthetic Rehabilitation Admission and Discharge). The utility of this framework was evaluated through LLRC program implementation in a semiurban US setting and program functioning and process outcomes assessment from an IRB-approved, retrospective observational study about patients with unilateral lower-limb amputations completing this program.Results: Program functional (FIM gain; efficiency) scores were greater for PPR(32.6(8);3.1) compared with PR(24.3(8.5);3.8). Program completion duration was 149.7(63.4) days. LHM(75.8(58.5) days) and PF(51.4(24.3) days) were the longest steps. PR duration was significantly longer(p = 0.033) for the transfemoral level.Conclusion: The LLRC framework is useful for the design and implementation of structured limb loss rehabilitation programs.IMPLICATIONS FOR REHABILITATIONThe lower limb-loss rehabilitation continuum (LLRC) is a novel implementation framework with a five-step structure from limb loss to completion of prosthetic rehabilitation between six touchpoints of patient-healthcare interaction, with standardized terminology and baseline and outcome metrics. The utility of the program was demonstrated by successful program development in a suburban health setting and actionable process outcomes and superior functioning outcomes compared with literature.The LLRC can be adapted by health systems, institutions, and care providers for program development. Programs can expect high FIM gains and efficiency for Preprosthetic rehabilitation and Prosthetic rehabilitation steps. With an LLRC completion time of 5 months, long Limb healing and maturation and Prosthetic fitting steps present areas of opportunity for improvement.

Social and community participation following traumatic lower limb amputation: an exploratory qualitative study

PURPOSE

To explore barriers and facilitators to social and community participation experienced by people following traumatic lower limb amputation (LLA).

METHODS

An exploratory qualitative study was conducted with nine adults with traumatic LLA in Victoria, Australia. Participants were a minimum of 18 months post amputation. Interview data was analysed using thematic analysis.

RESULTS

Participants referenced the inaccessibility of the built environment and physical challenges associated with prosthetic mobility as barriers to participation. Chronic and complex health concerns due to their injuries resulted in physical and emotional distress for some, further limiting their social and community engagement. Participants highlighted the benefit of peer-support networks and the value of supportive community groups in assisting the transition to their pre-amputation family, work and social roles. Participants also felt that a strong, positive attitude and being self-motivated were important to aid in their return to social and community participation.

CONCLUSION

People following traumatic LLA experience a number of physical, psychological and environmental challenges to participation. The role of peer-support networks, community groups and personal attitudes are important facilitators to assist a return to family, work and life roles. The findings of this study have informed the development of recommendations to guide clinical practice.IMPLICATIONS FOR REHABILITATIONPeer-support groups for people following traumatic lower limb amputation (LLA) may assist to improve their long-term adjustment to disability and community participationRetraining skills in an individual's own community should be considered when planning community-based therapy services for people following traumatic LLA.Ongoing psychosocial support including strategies to develop self-efficacy and positive mindset may improve social and community participationRegular medical and allied health reviews can be beneficial to promote early intervention for any complications that arise to minimise time off prosthesis.

Comparison of Pre-existing Mood Disorders and Chronic Kidney Disease as Predictors of Ambulatory Status After Major Limb Amputation

Objective We aim to compare the effects of pre-existing mood disorders and chronic kidney disease (CKD) on ambulation outcomes for patients who have undergone major lower extremity amputation (MLEA) while also stratifying by the presence of social factors. Methods  We performed a retrospective chart review of 700 patients admitted from 2014 to 2022 who underwent MLEA. We performed Chi-square tests and binomial logistic regression with p < 0.05 as our significance level. Results Mood disorder patients have higher rates of independent ambulation if they have familial support (p = 0.022), a listed primary care provider (PCP; p = 0.013), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). Patients with a history of mood disorder have significantly decreased odds of prosthesis usage (OR: 0.58, 95% CI: 0.40-0.86) but have higher rates of prosthesis usage if they have familial support (p = 0.002), a PCP listed (p = 0.005), a six-month follow-up (p < 0.001), or a one-year follow-up (p < 0.001). CKD patients have significantly decreased odds of eventual independent ambulation (OR: 0.69, 95% CI: 0.49-0.97) but have significantly increased rates of independent ambulation if they have familial support (p =0.041) and six-month (p < 0.001) or one-year follow-up (p < 0.001). CKD patients only have significant changes in prosthesis usage with a six-month (p < 0.001) or one-year follow-up (p < 0.001). Conclusions Pre-existing CKD and mood disorders are associated with decreased odds of independent ambulation and prosthesis usage, respectively. Social factors such as family support, a listed PCP, and timely follow-up are associated with markedly improved ambulatory outcomes for MLEA patients with mood disorders and CKD, with significantly improved prosthesis usage outcomes in only the mood disorder population.

Exploring links between Chinese military recruits' psychological stress and coping style from the person-environment fit perspective: The chain mediating effect of self-efficacy and social support

The choice of coping style of recruits under psychological stress in the process of military task execution has been an important topic in the promotion of military operations and cohesion of military forces. Taking a positive coping style under psychological stress can help recruits overcome the negative effects of stress and improve military morale and group combat effectiveness. Although soldiers' psychological stress in the process of military mission execution having an impact on coping style has been studied by a large body of literature, very little literature has focused on the mechanism of self-efficacy and social support between recruits' psychological stress and coping style from the person-environment fit perspective. Therefore, this study was conducted to analyze the impact of recruits' psychological stress on coping style through a chain mediation model and to discuss the role of self-efficacy and social support in this relationship. Two waves of survey data were utilized to test the research hypotheses on a sample of 1028 Chinese recruits performing military tasks. The results indicated that recruits' psychological stress negatively impacted positive coping styles and positively correlated with negative ones. In addition, self-efficacy and social support mediated the relationship between psychological stress and positive coping style, and self-efficacy mediated the relationship between psychological stress and negative coping style. More importantly, self-efficacy and social support play the chain mediating effect between psychological stress and positive coping style.

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users

OBJECTIVE

To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function.

DESIGN

Cross-sectional, observational study SETTING: General community.

PARTICIPANTS

Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire.

RESULTS

Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [β]=-0.15, P=.02), even after adjusting for depressive symptoms (β=-0.31, P<.001), prosthesis satisfaction (β=0.34, P<.001), number of chronic conditions (β=-0.19, P=.006), and assistive device use (βcane=0.01, P=.93; βother=-0.20, P=.003). Together, these variables explained 59% of perceived physical function variability.

CONCLUSIONS

Cognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

Examination of social disconnectedness and perceived social isolation on health and life satisfaction in community-dwelling adults with dysvascular lower limb loss

BACKGROUND

People with physical disabilities are at risk for social isolation, which has been shown to negatively influence health and well-being.

OBJECTIVES

The purpose of this study was to examine the association of social disconnectedness and perceived social isolation (PSI) on health-related quality of life (HrQoL) and life satisfaction in adults with dysvascular lower extremity amputation (LEA).

STUDY DESIGN

Cross-sectional survey.

METHODS

Data were collected from community-dwelling adults with dysvascular major LEA (N = 231). The main outcome measures were the Short-Form 36 and the Life Satisfaction-11. Other measures were used to quantify comorbidities/secondary health conditions, PSI, social disconnectedness, self-efficacy, social support, and social engagement. Three hierarchical regression models were conducted to predict (1) physical HrQoL, (2) mental HrQoL, and (3) life satisfaction.

RESULTS

Approximately one-third of the sample had high levels of social disconnectedness and PSI. The regression model predicting physical HrQoL accounted for 47% of the variance and only found that higher levels of mobility, lower perceived impact of comorbidities/conditions, and higher levels of social engagement and self-efficacy were associated with better physical HrQoL. A model predicting mental HrQoL accounted for 36% of the variance, with older age, lower PSI, and higher levels of self-efficacy being significant predictors. Finally, the model predicting life satisfaction accounted for 56% of the variance, with older age, lower perceived impact of comorbidities/conditions, and higher self-efficacy remaining as significant predictors.

CONCLUSIONS

These findings highlight that one-third of our sample were at risk for being socially isolated and that PSI was influential on mental HrQoL and life satisfaction. There is a need for approaches to address social isolation for people with dysvascular LEA living in the community to optimize their long-term health and well-being.

Social Determinants of Health in Physiatry: Challenges and Opportunities for Clinical Decision Making and Improving Treatment Precision

Physiatry is a medical specialty focused on improving functional outcomes in patients with a variety of medical conditions that affect the brain, spinal cord, peripheral nerves, muscles, bones, joints, ligaments, and tendons. Social determinants of health (SDH) play a key role in determining therapeutic process and patient functional outcomes. Big data and precision medicine have been used in other fields and to some extent in physiatry to predict patient outcomes, however many challenges remain. The interplay between SDH and physiatry outcomes is highly variable depending on different phases of care, and more favorable patient profiles in acute care may be less favorable in the outpatient setting. Furthermore, SDH influence which treatments or interventional procedures are accessible to the patient and thus determine outcomes. This opinion paper describes utility of existing datasets in combination with novel data such as movement, gait patterning and patient perceived outcomes could be analyzed with artificial intelligence methods to determine the best treatment plan for individual patients in order to achieve maximal functional capacity.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation

OBJECTIVE

The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables.

METHODS

Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space.

RESULTS

Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space.

CONCLUSION

The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA.

IMPACT

The CD-RISC may be an appropriate tool to measure resilience following LLA.

Patterns of Sitting, Standing, and Stepping After Lower Limb Amputation

OBJECTIVE

The objectives of this study were to describe sitting, standing, and stepping patterns for people with lower limb amputation (LLA) and to compare sitting, standing, and stepping between people with dysvascular LLA and people with traumatic LLA.

METHODS

Participants with dysvascular or traumatic LLA were included if their most recent LLA was at least 1 year earlier, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Sitting, standing, and stepping were measured using accelerometry. Daily sitting, standing, and stepping times were expressed as percentages of waking time. Time spent in bouts of specified durations of sitting (<30, 30-60, 60-90, and >90 minutes), standing (0-1, 1-5, and >5 minutes), and stepping (0-1, 1-5, and >5 minutes) was also calculated.

RESULTS

Participants (N = 32; mean age = 62.6 [SD = 7.8] years; 84% men; 53% with dysvascular LLA) spent most of the day sitting (median = 77% [quartile 1 {Q1}-quartile 3 {Q3} = 67%-84%]), followed by standing (median = 16% [Q1-Q3 = 12%-27%]) and stepping (median = 6% [Q1-Q3 = 4%-9%]). One-quarter (median = 25% [Q1-Q3 = 16%-38%]) of sitting was accumulated in bouts of >90 minutes, and most standing and stepping was accrued in bouts of <1 minute (standing: median = 42% [Q1-Q3 = 34%-54%]; stepping: median = 98% [Q1-Q3 = 95%-99%]). Between-etiology differences included proportion of time sitting (traumatic: median = 70% [Q1-Q3 = 59%-78%]; dysvascular: median = 79% [Q1-Q3 = 73%-86%]) and standing (traumatic: median = 23% [Q1-Q3 = 16%-32%]; dysvascular: median = 15% [Q1-Q3 = 11%-20%]).

CONCLUSION

Participants had high daily volumes of long durations of sitting. Further, these individuals accumulated most physical activity in bouts of <1 minute.

IMPACT

High levels of sedentary behavior and physical inactivity patterns may place people with LLA at greater mortality risk relative to the general population. Interventions to minimize sedentary behaviors and increase physical activity are potential strategies for improving poor outcomes of physical therapy after LLA.