Effect of Postacute Rehabilitation Setting on Mental and Emotional Health Among Persons With Dysvascular Amputations

An overview of the rehabilitation and psychiatric diagnoses of patients referred to a psychiatry consult liaison service at an inpatient rehabilitation hospital

BACKGROUND

Patients presenting for inpatient rehabilitation following injury or illness are commonly affected by comorbid psychiatric illness. Currently, little is known about the utilization of a psychiatry consult service in an inpatient rehabilitation hospital.

OBJECTIVE

To identify which rehabilitation patient populations most frequently received psychiatric consultation and recognize the most common psychiatric comorbidities after the implementation of a psychiatry consult liaison (PCL) service.

DESIGN

A retrospective observational study in the form of a chart review examining the utilization patterns of a psychiatric consultation liaison service in the inpatient rehabilitation setting. Chart review was performed to extract patient demographics (age and sex), rehabilitation diagnosis, cause of rehabilitation diagnosis (intentional, accident, self-inflicted, or disease), reason for referral to psychiatry, and psychiatric diagnosis on initial consultation. Statistical software was used for statistical analysis to answer the pre-specified research questions.

SETTING

A 178 bed, free-standing, academic rehabilitation hospital located in an urban Canadian center.

PATIENTS

Any patient admitted to the inpatient rehabilitation hospital who received a psychiatric consultation between September 2016 and December 2019 was eligible for inclusion.

RESULTS

A total of 1016 charts were reviewed in the initial chart review and  1008 were included. The most common rehabilitation diagnoses that were associated with a psychiatric consult were (% admissions receiving consultation): amputations (38%); burns (35%), neurologic disorder (28%), deconditioning (14%), and musculoskeletal injury (7%). Although 20% of patients did not meet criteria for a psychiatric diagnosis, most common psychiatric diagnoses included mood disorder, adjustment disorder, neurocognitive disorder, and delirium.

CONCLUSION

There are significant perceived needs for psychiatric services in the inpatient rehabilitation setting. Although some patient groups such as patients with amputations, burns, and trauma may exhibit the highest utilization, the service supports mental health needs from many patient groups.

An exploration of specialist clinicians' experiences and beliefs about inpatient amputee rehabilitation as a pathway option for adult primary amputees

PURPOSE

To explore specialist amputee physiotherapists' experiences and subsequent views about specialist inpatient rehabilitation (IPR) as a National Health Service (NHS) pathway option for adult primary amputees and their perceptions and beliefs about the effects of inpatient amputee rehabilitation.

MATERIALS AND METHODS

A qualitative study using a phenomenological approach. Semi-structured interviews were completed with seven physiotherapists experienced in working in both specialist amputee inpatient and outpatient rehabilitation settings. Interviews were audio-recorded and fully transcribed. Data were analysed using thematic analyses; inductive coding was completed; emerging themes are shown and a conceptual framework was developed. To promote rigour, this study was peer reviewed and coding was done by two people.

RESULTS

Clinicians believed inpatient amputee rehabilitation to be the preferred model of rehabilitation for the majority of adult primary amputees. A central theme of healthcare inequality within primary amputee rehabilitation provision emerged with four sub-themes: IPR, outpatient rehabilitation, barriers, the ideal world. Geographical variation was described in: type of rehabilitation provided, timescales of prosthetic rehabilitation provision, fitting a prosthesis with wounds, and the availability of community rehabilitation services.

CONCLUSIONS

Healthcare inequality is a central concern identified by clinicians who work within amputee rehabilitation in the UK. Clinicians interviewed believe NHS specialist amputee inpatient rehabilitation should be a more accessible pathway.Implications for rehabilitationClinicians believe healthcare inequality exists within primary amputee rehabilitation provision in the UK National Health Service (NHS).Geographical variation in type of care provision, fitting a prosthesis with wounds, timescales in prosthetic rehabilitation provision and community rehabilitation services were described.Clinicians believe inpatient amputee rehabilitation to be the preferred model of care for the majority of adult primary amputees and should be a more accessible pathway within the NHS.Inpatient rehabilitation facilities may be a way of compensating for amputee rehabilitation inequalities.

Patient Reported Outcome Measures for Major Lower Limb Amputation Caused by Peripheral Artery Disease or Diabetes: A Systematic Review

OBJECTIVE

Most major lower limb amputations are related to peripheral artery disease (PAD) or diabetes. Just 40% of patients who undergo major lower limb amputation will use a prosthesis yet measures of surgical success commonly focus on prosthesis use. Patient reported outcome measures (PROMs) are valuable to comprehensively evaluate health related quality of life (HRQL) after surgery. This systematic review aimed to identify and describe PROMs available to assess HRQL in patients after amputation for PAD or diabetes.

METHODS

A search was conducted based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) for systematic reviews of PROMs. Ovid MEDLINE, Ovid EMBASE, PsycINFO, CINAHL, and Cochrane CENTRAL were also searched from inception until August 2019. Included were articles describing the development, measurement properties, or evaluation of HRQL via a PROM in adult patients after amputation for PAD or diabetes. Studies of amputation exclusively for trauma or malignancy were excluded. Data were collected on study characteristics, PROM characteristics (generic/disease specific), and properties of amputation specific PROMs.

RESULTS

Of 3 317 abstracts screened, 111 full text articles were assessed for eligibility and 64 included. Fifty-six studies evaluated HRQL, with 23 (46%) of these using an amputation specific PROM to do so. Eleven different amputation specific PROMs were identified, 10 (91%) of which were developed only for prosthesis users. One measure was suitable for use in all patients after amputation. This "Amputee single item mobility measure" includes a single item evaluating mobility. Nine studies reported some psychometric testing of an amputation specific PROM.

CONCLUSION

A well tested, multidimensional PROM applicable to wheelchair and prosthetic users after amputation is lacking and urgently needed for studies in this field. Future work to develop an appropriate measure is required.

Financial difficulty in community-dwelling persons with lower limb loss is associated with reduced self-perceived health and wellbeing

BACKGROUND

Socioeconomic status has been shown to be an important factor in the disparate prevalence and selected treatment of limb loss, but how personal financial difficulty affects patients' health outcomes is currently unclear.

OBJECTIVE

Examining how presence and experience of personal financial difficulty affects perceived health and wellbeing in individuals with lower limb loss.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 90 participants (68 males, mean age 58.7 ± 16.7 years) were recruited from local physical therapy and prosthetic and orthotic clinics, rehabilitation hospitals, and a regional amputee patient support group. All participants were community-dwelling, non-military adults with amputation involving at least one major lower limb joint. Participants were interviewed, and each completed a survey that included basic demographic/medical information, self-reported health and wellbeing (Short-Form Health Survey, SF-36v2), and a question to determine their financial situation after limb loss. Multiple regression analyses were used to examine the effect of financial difficulty on the eight subscales of SF-36v2 while accounting for age, gender, and amputation level.

RESULTS

Experiencing financial difficulty significantly and negatively affected Role-Physical and Role-Emotional subscale scores (p < 0.01 and p = 0.02, respectively). Individuals with financial difficulty scored approximately 60% lower in these two specific subscales.

CONCLUSION

Experiencing financial difficulty is a significant predictor for diminished work or daily activity participation due to physical and emotional stresses. Clinicians and health policy makers need to understand how socioeconomic factors may prevent individuals with lower limb loss from achieving higher levels of functional recovery and community re-integration after amputation.

CLINICAL RELEVANCE

Our findings showed that presence or experience of financial difficulty was significantly associated with diminished community re-integration in community-dwelling, non-military adults with lower limb loss. It affects both physical and emotional aspects of wellbeing. Clinicians should be aware how socioeconomic factors may affect social re-integration after amputation.

Bent Knee Temporary Prosthesis to Support Early Ambulation after Transtibial Amputation: A Case Report

Postoperative immobility can exacerbate the physical and psychologic effects of limb loss. This case report presents a 37-year-old mother of two children who required a transtibial amputation. She received an early ambulation device called the bent knee temporary prosthesis (BKTP), which aids in early postoperative ambulation. Several early ambulation devices have been utilized in the past but have not found widespread favor. Although there is a paucity of research on this topic, available data suggest patient tolerance and benefit of early ambulation. A customizable, temporary below knee prosthesis such as the BKTP is valuable to study the safety and efficacy of early postoperative ambulation for improving outcomes for transtibial amputees.

A prospective study of short-term functional outcome after dysvascular major lower limb amputation

This study investigates functional status on Day 21 after dysvascular major lower limb amputation compared with one month pre-amputation and evaluates factors potentially influencing outcome.

METHODS

A prospective cohort study design was used. Data were collected via in-person interviews using structured instruments and covered functional level (Barthel index 100) one month pre-amputation and on Day 21. Out of a consecutive sample of patients having major lower limb amputation (tibia, knee or femoral) (n = 105), 51 participated on Day 21 follow-up. Clinical, demographic, body function and environmental data were analysed as factors potentially influencing outcome.

RESULTS

From pre-amputation to Day 21, participants' functional level decreased significantly in all ten activities of daily living activities as measured by the Barthel Index. Almost 60% of participants were independent in bed-chair transfer on Day 21. Being independent in transfer on Day 21 was positively associated with younger age and attending physiotherapy after discharge.

CONCLUSIONS

The findings indicate that short-term functional outcome is modifiable by quality of the postoperative care provided and thus highlights the need for increased focus on postoperative care to maintain basic function as well as establish and provide everyday rehabilitation in the general population of patients who have dysvascular lower limb amputations.

Activities of daily living in people with lower limb amputation: outcomes of an intervention to reduce dependence in pre-prosthetic phase

PURPOSE

The main objective was to assess the change in the functional independence in basic activities of daily living (ADL) following a pre-prosthetic intervention in people with lower-limb amputation (LLA). Secondary objectives were to identify the factors contributing to the success of this intervention, and to analyze the effects on the presence of unmet needs for home adaptation.

METHOD

The ADL intervention was early and pre-prosthetic; it was focused on six self-care activities. Fifty-two adults with LLA, who required assistance in self-care, were included. Functional independence (Barthel) was assessed at baseline and after intervention (T2). Successful intervention was defined as independent performance of all self-care activities.

RESULTS

There was a significant improvement in Barthel scores between baseline and T2 in toileting (p < 0.001), bed-chair transfers (p < 0.001), dressing (p < 0.001), bathing/showering (p < 0.001), and feeding (p = 0.025). The proportion of homes with an unmet need for adaptation decreased significantly in bathroom (p = 0.008) and other internal areas (p = 0.031). Intervention was successful for 61.5% of participants. In a multivariate model, age was significantly associated with successful intervention (OR 0.66, 95%CI 0.52-0.83).

CONCLUSIONS

A short and pre-prosthetic ADL intervention improves functional independence and reduces the need for home adaptation. ADL programs should be included in rehabilitation strategies. Implications for Rehabilitation Because basic activities of daily living (ADL) can be seriously compromised after a lower-limb amputation, it is important for this population to improve or maintain their level of independence. A short and pre-prosthetic ADL intervention is an effective method for an early recovery of functional independence in self-care activities and promotes home adaptation. Age is an important determinant of functional recovery, and most subjects can achieve independence in basic ADL regardless of the level of amputation. A pre-prosthetic ADL program should be included in rehabilitation strategies for adults with lower-limb amputation.