Quality of life among veterans with war-related unilateral lower extremity amputation: a long-term survey in a prosthesis center in Iran

Spinal Pathology and Muscle Morphologies with Chronic Low Back Pain and Lower Limb Amputation

INTRODUCTION

Low back pain (LBP) is highly prevalent after lower limb amputation (LLA) and contributes to substantial reductions in quality of life and function. Towards understanding pathophysiological mechanisms underlying LBP after LLA, this article compares lumbar spine pathologies and muscle morphologies between individuals with LBP, with and without LLA.

MATERIALS AND METHODS

We queried electronic medical records of Service members with and without LLA who sought care for LBP at military treatment facilities between January 2002 and May 2020. Two groups with cLBP, one with (n = 15) and one without unilateral transtibial LLA (n = 15), were identified and randomly chosen from a larger sample. Groups were matched by age, mass, and sex. Lumbar muscle morphology, Pfirrmann grades, Modic changes, facet arthrosis, Meyerding grades, and lordosis angle were determined from radiographs and magnetic resonance images available in the medical record. Independent t-tests compared variables between cohorts while multiple regression models determined if intramuscular fat influenced Pfirrmann grades. Chi-square determined differences in presence of spondylolysis and facet arthrosis.

RESULTS

Lordosis angle was larger with LLA (P = 0.01). Spondylolysis was more prevalent with LLA (P = 0.008; 40%) whereas facet arthrosis was similar between cohorts (P = 0.3). Muscle area was not different between cohorts, yet intramuscular fat was greater with LLA (P ≤ 0.05). Intramuscular fat did not influence Pfirrmann grades (P > 0.15).

CONCLUSIONS

Despite similar lumbar muscle size, those with unilateral LLA may be predisposed to progress to symptomatic spondylolisthesis and intramuscular fat. Surgical and/or rehabilitation interventions may mitigate long-term effects of diminished spinal health, decrease LBP-related disability, and improve function for individuals with LLA.

Quality of Life, Physical Activity Participation, and Perceptions of Physical Rehabilitation Among Community-Reintegrated Veterans With Lower Limb Amputation in Sri Lanka: Convergent Parallel Mixed Methods Study

BACKGROUND

Lower limb amputation (LLA) impacts physical activity (PA) participation and quality of life (QoL). To minimize the effects of these challenges, LLA survivors need to have opportunities to engage in appropriately tailored rehabilitation throughout their lives. However, in Sri Lanka, where a 3-decade civil war resulted in trauma-related LLA among young male soldiers, access to rehabilitation was limited to the immediate postinjury period. Developing rehabilitation interventions for these veterans requires an understanding of their current health status and rehabilitation perceptions.

OBJECTIVE

This study was conducted to evaluate the QoL and PA participation of veterans with LLA and explore perceptions of factors influencing their PA participation and expectations for a future community-based physical rehabilitation (CBPR) intervention.

METHODS

This mixed methods study combined a comparative cross-sectional quantitative survey with qualitative semistructured interviews in 5 districts of Sri Lanka. QoL and PA participation were assessed among community-reintegrated veterans with LLA (n=85) and compared with a matched able-bodied cohort (control; n=85) using Mann-Whitney U and Chi-square tests. PA was assessed in terms of metabolic equivalent of task (MET) minutes per week and was computed for walking, moderate-intensity, and vigorous-intensity activities. PA was classified as sufficiently active, low, or sedentary. The design of interview questions was guided by the Theoretical Domains Framework and followed a phenomenological approach. Interviews were conducted with 25 veterans and were analyzed thematically, and the perceptions regarding PA participation and CBPR were codified using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Based on the quantitative survey findings, scores for both physical (P<.001) and psychological (P<.001) well-being and participation in walking (P=.004) and vigorous-intensity activities (P<.001) were significantly lower among veterans than among controls. A "sedentary" classification was made for 43% (34/79) of veterans and 12% (10/82) of controls. Veterans mostly engaged in moderate-intensity PA inside the house (49/79, 62%) and in the yard (30/79, 38%). Qualitative interviews revealed that barriers to PA exist at individual (eg, comorbidity burden), primary care (eg, absence of community rehabilitation services), and policy levels (eg, limited resources) and facilitators exist primarily at societal (eg, inclusive community) and individual levels (eg, preinjury activity baseline and positive attitudes toward exercise). Expectations regarding CBPR included individualized rehabilitation parameters; functional exercises; and involvement of peers, amputee societies, and community health care providers. The nonresponse rate for interviews was 7% (2/27).

CONCLUSIONS

The findings of reduced PA participation, poor QoL, and physical and psychological impairments among relatively young veterans reveal the long-term impacts of living with LLA in the absence of long-term rehabilitation. Policy-level changes need to be implemented along with behavior-change strategies to promote PA participation and minimize physical inactivity-induced health issues. Veterans' perceptions regarding future CBPR programs were positive and centered on holistic, individualized, and peer-led activities.

Prevalence of chronic pain after severe lower limb injury (SLLI): A systematic review and meta-analysis

BACKGROUND

Globally, severe lower limb injuries (SLLIs) are the predominant cause of long-term injury related disability and poor functional outcomes. Chronic pain is a major source of this morbidity, but the magnitude of the contribution is not clearly understood. The aim of this systematic review and meta-analysis was to determine the prevalence of chronic pain following SLLIs in civilian and military patients.

METHOD

This systematic review was prospectively registered with The International Prospective Register of Systematic Reviews (PROSPERO) with study ID CRD42022313615. A systematic literature search (Medline, Embase, Ovid, and Web of Science) was performed to identify original studies that reported chronic pain outcomes for adults who underwent surgical treatment for SLLIs in a civilian or military setting. Risk of bias in included studies was assessed using the ROBINS-E tool, and quality assessment was reported at study level using the Newcastle-Ottawa Scale, and at outcome-level using the GRADE framework. Absolute (proportional) and relative (odds ratio) outcome measures were calculated and pooled using a random effects model.

RESULTS

Forty-three studies reporting the outcomes of 5601 patients were included. Estimated overall prevalence of pain was 63 % (CI 55-70 %). The prevalence of chronic pain in amputees (64 % (CI 55-73 %)) was similar to those who underwent limb salvage (56 % (CI 44-67 %)). The prevalence of chronic pain in civilian populations was 70 % (CI 63-77 %) compared to military populations (51 % (CI 35-66 %)). In amputees, the prevalence of residual limb pain was similar to phantom limb pain (OR 1.06 [0.64-1.78], p = 0.81, I2 = 92 %).

CONCLUSION

Most people who sustain a SLLI will suffer from chronic pain. Healthcare systems must continue to research interventions that can reduce the incidence and severity of long-term pain and ensure adequate resources are allocated for this common and debilitating complication.

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel

ABSTRACT

Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

The immediate effect of thoracolumbar fascia taping on biomechanical properties, low back pain and balance in individuals with transfemoral amputation

BACKGROUND

In individuals with transfemoral amputation (TFA), adaptations caused by prosthesis use may adversely affect contractile/noncontractile structures.

OBJECTIVE

To investigate the immediate effect of the thoracolumbar fascia (TLF) kinesiology taping (KT) on the tone and stiffness of the fascia, low back pain (LBP) and standing balance in individuals with TFA.

METHODS

Syrian male participants with TFA were enrolled in the prospective, single-blind, randomised controlled trial. Participants were divided into two groups: Experimental (EG with KT, n= 15) and Control (CG with sham KT, n= 14). A 6-minute walk test (6MWT) was performed, after which KT was applied. Measurements were taken at baseline, immediately after the 6MWT and 30 minutes after KT.

RESULTS

Although pain decreased below baseline in both groups at 30 minutes post intervention (p< 0.001), the rate of pain reduction was significantly higher in the EG (p= 0.016). Anterior-posterior sway with eyes open improved significantly 30 minutes after KT application only in the EG (p= 0.010). In the eyes closed condition, anterior-posterior and medio-lateral sway decreased significantly compared to baseline 30 minutes after taping in the EG (p= 0.010-0.032).

CONCLUSION

KT can be used as an effective method to support standing balance and reduce LBP in individuals with TFA.

Lumbar Degenerative Disease and Muscle Morphology Before and After Lower Limb Loss in Four Military Patients

INTRODUCTION

Low back pain (LBP) is highly prevalent after lower limb amputation (LLA). Reports describing longitudinal changes in spine health before and after amputation are rare. This study describes lumbar spine pathology, muscle morphology, and the continuum of care for LBP before and after LLA.

MATERIALS AND METHODS

We queried electronic medical records of patients who sought care for LBP before and after unilateral LLA between January 2002 and April 2020 and who had documented lumbar imaging pre- and post-LLA. Patient demographics, muscle morphology, spinal pathology, premorbid and comorbid conditions, self-reported pain, and treatment interventions were assessed.

RESULTS

Four patients with LBP and imaging before and after LLA were identified. Intervertebral disc degeneration progressed after amputation in three patients, whereas facet arthrosis progressed in both female patients. The fat content of lumbar musculature generally increased after amputation. Conservative management of LBP before and after amputation was standard, with progression to steroidal injections.

CONCLUSIONS

Lumbar spine health may degrade after amputation. Here, lumbar muscle size did not change after LLA, yet the fat content increased in combination with increases in facet and intervertebral disc degeneration.

Prevalence and risk factors of lower extremity disease in high risk groups in Malawi: a stratified cross-sectional study

OBJECTIVE

Low/middle-income countries face a disproportionate burden of cardiovascular diseases. However, among cardiovascular diseases, burden of and associations with lower extremity disease (LED) (peripheral arterial disease and/or neuropathy) is neglected. We investigated the prevalence and factors associated with LED among individuals known to have cardiovascular disease risk factors (CVDRFs) in Malawi, a low-income country with a significant prevalence of CVDRFs.

DESIGN

This was a stratified cross-sectional study.

SETTING

This study was conducted in urban Lilongwe Area 25, and the rural Karonga Health and Demographic Surveillance Site.

PARTICIPANTS

Participants were at least 18 years old and had been identified to have two or more known CVDRFs.

MAIN OUTCOME MEASURES

LED-determined by the presence of one of the following: neuropathy (as assessed by a 10 g monofilament), arterial disease (absent peripheral pulses, claudication as assessed by the Edinburgh claudication questionnaire or Ankle Brachial Pulse Index (ABPI) <0.9), previous amputation or ulceration of the lower limbs.

RESULTS

There were 806 individuals enrolled into the study. Mean age was 52.5 years; 53.5% of participants were men (n=431) and 56.7% (n=457) were from the rural site. Nearly a quarter (24.1%; 95% CI: 21.2 to 27.2) of the participants had at least one symptom or sign of LED. 12.8% had neuropathy, 6.7% had absent pulses, 10.0% had claudication, 1.9% had ABPI <0.9, 0.9% had an amputation and 1.1% had lower limb ulcers. LED had statistically significant association with increasing age, urban residence and use of indoor fires.

CONCLUSIONS

This study demonstrated that a quarter of individuals with two or more CVDRFs have evidence of LED and 2.4% have an amputation or signs of limb threatening ulceration or amputation. Further epidemiological and health systems research is warranted to prevent LED and limb loss.

Internalized stigma in obsessive compulsive disorder: Correlates and associations with quality of life

In the present study we aimed to measure IS among outpatients with OCD, and to assess its relationship with clinical and sociodemographic variables, and quality of life. Out of 100 patients assessed, 79 patients with OCD were included in the study. Each patient was assessed using the SCID-5 CV, Y-BOCS, ISMI Scale, and WHOQOL-BREF. There was a strong correlation of IS with lower QoL and severity of OCD symptoms. Avoidance behavior, psychological health and social relationship domains emerged as independent factors related to IS in the regression analysis. There is a need for further studies on a larger samples to identify the specifics of the development and impact of IS in people with OCD.

Lumbopelvic coordination while walking in service members with unilateral lower limb loss: Comparing variabilities derived from vector coding and continuous relative phase

BACKGROUND

Continuous relative phase and vector coding are two common approaches for quantifying lumbopelvic coordination and variability. Evaluating the application of such methodologies to the lower limb loss population is important for better understanding reported asymmetrical movement dynamics of the lumbopelvic region.

RESEARCH QUESTION

How do coordination variabilities derived from trunk-pelvic coupling angles and continuous relative phases compare among individuals with and without unilateral lower limb loss walking at self-selected speeds?

METHODS

Full-body kinematics were obtained from thirty-eight males with unilateral lower limb loss (23 transtibial and 15 transfemoral) and fifteen males without limb loss while walking along a 15 m walkway. Coordination variabilities were derived from trunk-pelvic coupling angles and continuous relative phases and compared using a multivariate approach, as well as in unilateral outcome measures between control participants and participants with lower limb loss.

RESULTS

Overall, tri-planar measures of continuous relative phase variability were 19-43% larger compared to coupling angle variabilities for individuals without limb loss and individuals with transtibial limb loss. Individuals with transfemoral limb loss had 27% and 31% larger sagittal and transverse variabilities from continuous relative phases compared to coupling angles, respectively. During both prosthetic and intact limb stance, individuals with transtibial limb loss had 19-35% greater tri-planar measures of continuous relative phase variability compared to coupling angle variabilities. During intact stance phase, tri-planar measures of continuous relative phase variability were 27%- 42% larger compared to coupling angle variabilities for individuals without limb loss.

SIGNIFICANCE

While both methods provide valid estimates of lumbopelvic movement variability during gait, continuous relative phase variability may provide a more sensitive estimate in the lower limb loss population capturing velocity-specific motions of the trunk and pelvis.

Deleterious Musculoskeletal Conditions Secondary to Lower Limb Loss: Considerations for Prosthesis-Related Factors

Significance: The intent of this work was to summarize the existing evidence of, and highlight knowledge gaps specific to, prosthetic devices/componentry and training regimes, particularly in the context of the human-device interaction and deleterious musculoskeletal conditions secondary to lower limb loss. Recent Advances: With the recent and evolving technological advancements in prostheses, there are numerous devices available to individuals with lower limb loss. Current literature demonstrates the importance of expanding the knowledge of all prosthetic device-specific factors and the significance of proper prescription, fit, and alignment, along with adequate device-/activity-specific training, to enhance human-device interaction, reduce gait abnormalities and compensatory motions, and as a result, mitigate risk for secondary musculoskeletal conditions. Critical Issues: Inadequate device prescription, fit, alignment, and training are evident owing to the lack of knowledge or awareness of the many device-specific properties and factors, leading to suboptimal use, as well as, biomechanical compensations, which collectively and adversely affect the function, activity level, and overall health of the prosthesis user. Future Directions: To maximize optimal outcomes after lower limb loss, it is essential to better appreciate the factors that affect both prosthesis use and satisfaction, particularly any modifiable factors that might be targeted in rehabilitation interventions such as device prescription, fit/alignment, and training regimes. A better understanding of such device-specific factors will help enhance the human-device interaction and resulting functional performance, thereby reducing secondary musculoskeletal conditions, allowing for the readiness of the fighting force (return-to-duty/redeployment) and/or improved reintegration into civilian society/work, and overall enhancing quality of life after lower limb loss.

Pain Among an Inpatient Complex Chronic Care Population of Residents with and without Missing Limbs

Purpose

Limb loss occurs for various reasons (trauma, infection, vascular diseases, tumors, congenital absence). Limb loss is known to result in several types of pain. Little is known about pain in residents with missing limbs admitted to complex chronic care (CCC) facilities. This study examined the presence of pain and its intensity in CCC residents with and without missing limbs.

Methods

The Continuing Care Reporting System was accessed for data from residents admitted to Ontario com\plex chronic care facilities assessed with the Resident Assessment Instrument Minimum Data Set, V2.0. Propensity score matching (1:1 ratio) was used to identify a control resident without missing limbs for each case. McNemar’s test was used for dichotomous pain (Y/N) and Wilcoxon Signed Ranks test for ordinal pain (4-level and 7-level pain variables). Binary and multinomial logistic regression were used to quantify the relationship between missing limbs and reports of pain.

Results

Missing limbs were reported by 2961 residents (2.1%, original n=139,920) resulting in 2212 propensity matched pairs. A significantly higher proportion of missing limb cases had pain (80%) versus controls (70%), χ²=64.43, p<0.001. Significantly higher pain levels were found in cases versus controls (z=8.47, p<0.001 for 4-level pain; z=8.57, p<0.001 for 7-level pain). Residents with missing limbs were 1.46 (95% CI: 1.26–1.70) times more likely to report pain than controls, p<0.001.

Conclusion

The results point to the need to better manage pain in CCC residents with missing limbs.

Incidence and demographic characteristics of Syrian Civil War-related amputations: A multi-center study

Objectives

The aim of this study was to identify the causes, levels, and rates of amputations performed in civilians during the Syrian Civil War and to present epidemiological data of the amputees.

Patients and methods

Between August 2017 and February 2019, a total of 363 amputations of 307 amputees (266 males, 41 females; mean age 29.9±13.3 years; range, 6 to 86 years) were retrospectively analyzed in four prosthesis and orthosis centers managed by an international non-governmental organization and serving to individuals who experienced amputation during Syrian Civil War. Level, etiology, number of amputations and distribution of the amputations by years were investigated.

Results

Of the patients, 25.4% were under the age of 18 years. A total of 74% of all amputations were of the lower extremities. Transtibial and transfemoral amputations were the most common amputation levels. Of the amputees, 89.3% reported the cause of amputation as bombing.

Conclusion

Civil amputations during the Syrian Civil War are different from those in other civil wars due to the high rate of bombing-induced amputations and also the high rate of victims under the age of 18 years. Our study results show a high ratio of both lower and upper extremity amputations in these civilians.

Predictors of Health-Related Quality-of-Life Status Among Elderly Patients With Cardiovascular Diseases

OBJECTIVES

Quality of life is an important patient-reported outcome in the care of older patients with chronic diseases owing to aging-associated limited physical activity and poor health status. The current study aimed to evaluate health-related quality of life and its predictors among elderly cardiac outpatients.

METHODS

A descriptive, nonexperimental, cross-sectional study was carried out from May 2018 to October 2018 in outpatient departments of a tertiary-care hospital. The population under study were patients aged ≥65 years with at least 1 cardiovascular condition. The EQ-5D-3L (Euro QOL) and Barthel index were used to measure the quality of life and performance of activities of daily living, respectively. Linear regression analysis was performed by using SPSS version 21.

RESULTS

Of a total of 386 patients, 198 patients (51.3%) reported impairment in the mobility domain, and 70.5% (n = 272) of patients indicated impairment in the depression domain. Mann-Whitney tests revealed EQ-5D scores, and visual analogue scale scores significantly differed by hospital admissions (P = .001), fall history (P < 0.001), and activities of daily living (P < .001). Kruskal-Wallis analysis revealed that EQ-5D index value and visual analogue scale score were significantly lower among patients who had comorbidities and who were exposed to polypharmacy (5-9 medications) (P < .001). In multivariate linear regression analysis, self-reported health (P = .006) and performance of activities of daily living (P < .001) were reported as influencing factors on health-related quality of life.

CONCLUSION

Findings indicated poor quality of life among older patients with cardiovascular diseaese or heart diseases in Pakistan. Measures should be taken to improve patients' perception and to enhance awareness regarding the importance of doing daily living activities as a predictor of good quality of life.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation

PURPOSE

Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes.

MATERIALS AND METHODS

Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status.

RESULTS

Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning.

CONCLUSIONS

Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

More than half of persons with lower limb amputation suffer from chronic back pain or residual limb pain: a systematic review with meta-analysis

Purpose: The aim of this study is to systematically review and critically assess the methodological quality of literature regarding prevalence, characteristics and factors influencing pain, other than phantom limb pain (PLP) in persons with lower limb amputation (LLA).Materials and methods: A systematic review was performed (PROSPERO CRD42019138018). Literature was searched using PubMed, EMBASE, PsycINFO, and PEDro. Studies were included if describing pain other than PLP at least three months after amputation. For residual limb pain (RLP) and back pain, a meta-regression was performed.Results: Fifty-one studies were included in which predominantly young males with a unilateral traumatic amputation using a prosthesis were investigated. Pooled prevalence of RLP was 0.51 (95% CI 0.40-0.62) with a positive association with presence of back pain (p = 0.044) in the univariate meta-regression. Pooled prevalence of back pain was 0.55 (95% CI 0.45-0.64), with a positive association of time since amputation (p < 0.001) and co-occurrence of RLP (p = 0.050).Conclusions: Back pain and RLP are common after LLA. The prevalence of back pain was positively associated with the presence of RLP, and vice versa. Future studies should give more attention to other chronic pain types, to persons with a diabetic or vascular cause of amputation, and to pain-related interference.Implications for RehabilitationBoth back pain and residual limb pain occur in more than 50% of persons with lower limb amputation (LLA), and both pain types are positively associated.Clinicians should be aware that chronic pain is common after LLA and can have a significant impact on the functioning of persons with LLA.Future research on this topic should give more attention to other chronic pain types, to persons with a diabetic or vascular cause of amputation, and to pain-related interference.

Quality of life and its determinants among community re-integrated soldiers with permanent disabilities following traumatic limb injuries

PURPOSE

To assess health-related-quality of life (HRQOL) after the end of war and its associated factors among soldiers with permanent limb disabilities in Sri Lanka METHODS: A cross-sectional study was conducted among 500 rehabilitated and socially re-integrated Army soldiers having permanent disability following traumatic limb injuries during the last year of ethnic conflict of Sri Lanka. Females, soldiers with no updated data, and soldiers having permanent deafness/total blindness/total brain or spinal cord injury were excluded. The sample was randomly selected from updated 'Disabled Category Registries'. Personal and injury data were collected through postal questionnaire. HRQOL was assessed using SF-36 tool validated for Sri Lankan soldiers.

RESULTS

SF-36 scores obtained on HRQOL related to overall physical health (mean = 57.1; SD = 19) and mental health (mean = 58.8; SD = 17.2) were comparable. HRQOL was best in social functioning (mean = 73.4; SD = 24) and worst in vitality (mean = 48.4; SD = 15.5). Factors significantly associated with better HRQOL related to the overall physical and mental health were aged over 35 years, being married, being assigned duties, having only upper/lower limbs affected and absence of co-disability. Having duties assigned demonstrated better QOL in almost all domains. None were associated with income or education.

CONCLUSIONS

Physical and mental health components contribute equally to the HRQOL of rehabilitated soldiers with permanent limb disabilty. Their poorer HRQOL was determined by certain person- and injury-related factors. These need to be addressed during re-integration and post-rehabilitation services.

Characterizing and Understanding the Low Back Pain Experience Among Persons with Lower Limb Loss

Objective

This study preliminarily characterizes and compares the impact of lower limb loss and development of chronic low back pain (cLBP) on psychosocial factors, as well as the relationship between these factors and low back pain–related functional disability.

Design

Cross-sectional study.

Methods

Participants were adults, active duty or retired military, with traumatic lower limb loss with and without chronic low back pain. Psychosocial factors and low back pain–related functional disability were measured using common clinical self-report questionnaires. The presence of psychosocial factors was compared between those with and without cLBP using multivariate analysis of covariance (P &lt; 0.05), and correlations determined relationships between psychosocial factors and cLBP-related functional disability.

Results

There were no statistically significant differences among psychosocial factors between those with vs without cLBP (F(4, 13) = 0.81, P = 0.54, η2= 0.19). Employment status (ρ = 0.43, P = 0.02), anxiety (ρ = 0.45, P = 0.04), and kinesiophobia (ρ = 0.47, P = 0.04) were moderately associated with low back pain–related disability.

Conclusions

Psychological (i.e., anxiety) and social (i.e., employment status) factors may influence how persons with traumatic lower limb loss respond to self-reported measures of low back pain–related disability. The findings suggest that the Modified Oswestry Disability Index identifies cLBP-related functional disability in the context of lower limb loss. These results support the interdependence among biological, psychological, and social factors, which should be collectively considered during the development of rehabilitative strategies to treat secondary musculoskeletal conditions within this population.

Trunk-Pelvis motions and spinal loads during upslope and downslope walking among persons with transfemoral amputation

Larger trunk and pelvic motions in persons with (vs. without) lower limb amputation during activities of daily living (ADLs) adversely affect the mechanical demands on the lower back. Building on evidence that such altered motions result in larger spinal loads during level-ground walking, here we characterize trunk-pelvic motions, trunk muscle forces, and resultant spinal loads among sixteen males with unilateral, transfemoral amputation (TFA) walking at a self-selected speed both up ("upslope"; 1.06 ± 0.14 m/s) and down ("downslope"; 0.98 ± 0.20 m/s) a 10-degree ramp. Tri-planar trunk and pelvic motions were obtained (and ranges-of-motion [ROM] computed) as inputs for a non-linear finite element model of the spine to estimate global and local muscle (i.e., trunk movers and stabilizers, respectively) forces, and resultant spinal loads. Sagittal- (p = 0.001), frontal- (p = 0.004), and transverse-plane (p < 0.001) trunk ROM, and peak mediolateral shear (p = 0.011) and local muscle forces (p = 0.010) were larger (respectively 45, 35, 98, 70, and 11%) in upslope vs. downslope walking. Peak anteroposterior shear (p = 0.33), compression (p = 0.28), and global muscle (p = 0.35) forces were similar between inclinations. Compared to previous reports of persons with TFA walking on level ground, 5-60% larger anteroposterior and mediolateral shear observed here (despite ∼0.25 m/s slower walking speeds) suggest greater mechanical demands on the low back in sloped walking, particularly upslope. Continued characterization of trunk motions and spinal loads during ADLs support the notion that repeated exposures to these larger-than-normal (i.e., vs. level-ground walking in TFA and uninjured cohorts) spinal loads contribute to an increased risk for low back injury following lower limb amputation.

Understanding Low Back Pain in Traumatic Lower Limb Amputees: A Systematic Review

Objective

This systematic review aims to evaluate current literature for the prevalence, causes, and effect of low back pain (LBP) in traumatic lower limb amputees, specifically its association with the kinematics and kinetics of the lumbar spine and lower extremities.

Data Sources

Databases (EMBASE, MEDLINE, Scopus, CINAHL, PsycINFO) were searched systematically for eligible studies from inception to January 2018.

Study Selection

The inclusion terms were synonyms of low back pain, lower limb amputation, and trauma, whereas studies involving nontraumatic amputee populations, single cases, or reviews were excluded. 1822 studies were initially identified, of which 44 progressed to full-text reading, and 11 studies were included in the review.

Data Extraction

Two independent reviewers reviewed the included studies, which were evaluated using a quality assessment tool and the Grades of Recommendation, Assessment, Development and Evaluation system for risk of bias, prior to analyzing results and conclusions.

Data Synthesis

There was an LBP prevalence of 52%-64% in traumatic amputees, compared to 48%-77% in the general amputee population (predominantly vascular, tumor, trauma), attributed to a mixture of biomechanical, psychosocial, and personal factors. These factors determined the presence, frequency, and severity of the pain in the amputees, significantly affecting their quality of life. However, little evidence was available on causality.

Conclusion

The high prevalence of LBP in traumatic amputees highlights the necessity to advance research into the underlying mechanics behind LBP, specifically the spinal kinematics and kinetics. This may facilitate improvements in rehabilitation, with the potential to improve quality of life in traumatic amputees.

Low back pain in persons with lower extremity amputation: a systematic review of the literature

BACKGROUND CONTEXT

Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life.

PURPOSE

The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs.

RESULTS

Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES.

CONCLUSIONS

Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

Quality of life, self-stigma, and coping strategies in patients with neurotic spectrum disorders: a cross-sectional study

Background

Modern psychiatry focuses on self-stigma, coping strategies, and quality of life (QoL). This study looked at relationships among severity of symptoms, self-stigma, demographics, coping strategies, and QoL in patients with neurotic spectrum disorders.

Methods

A total of 153 clinically stable participants who met criteria for generalized anxiety disorder, social phobia, panic disorder, agoraphobia, mixed anxiety-depressive disorder, adjustment disorders, somatoform disorders, or obsessive-compulsive disorder were included in a cross-sectional study. Psychiatrists examined patients during regular psychiatric checkups. Patients completed the Quality of Life Satisfaction and Enjoyment Questionnaire (Q-LES-Q), Internalized Stigma of Mental Illness Scale (ISMI), a sociodemographic questionnaire, the Stress Coping Style Questionnaire (Strategie Zvládání Stresu [SVF] 78), and the Clinical Global Impression (CGI) scale.

Results

The diagnostic subgroups differed significantly in age and use of negative coping strategies, but not in other measured clinical or psychological variables. The findings showed that neither sex nor partnership played a role in perceived QoL. All Q-LES-Q domains correlated negatively with all ISMI domains, except school/study. Unemployed and employed groups of patients differed in QoL. Each of the coping strategies, except the need for social support, was related to self-stigma. The findings showed that sex, partnership, education, and employment played no role in self-stigma. No differences between sexes in positive coping strategies, severity of disorder, self-stigma, or QoL were found. QoL correlated significantly with all coping strategies, except for guilt denial. Multiple regression showed the most important factors to be positive coping, employment, and overall self-stigma rating, explaining 32.9% of QoL. Mediation analysis showed self-stigma level and negative coping strategies to be the most influential. The most substantial factors associated with self-stigma, as indicated by regression analysis, were Q-LES-Q total, subjective CGI, and positive coping strategies, which clarified 44.5% of the ISMI.

Conclusion

The study confirmed associations among self-stigma, quality of life, disorder severity, and coping strategies of outpatients with neurotic spectrum disorders.

Life after conflict-related amputation trauma: a clinical study from the Gaza Strip

Background

More than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip.

Methods

We included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history.

Results

The amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family’s sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt.

Conclusions

The most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.

Chronic traumatic ankle and foot osteomyelitis: a nationwide case-control study

BACKGROUND

Osteomyelitis (OM) is an atypical consequence of ankle-foot trauma which is associated with long-term mental and physical morbidity and persistent pain. This study aimed to assess the health status of OM patients with war-related ankle-foot injuries.

METHODS

A total of 1129 veterans with ankle-foot injuries participated in a case-control study (2014-2016). Thirty patients with chronic OM of the ankle-foot were compared with 90 non-OM participants as the control group. Quality of life (QOL), life satisfaction and the ability to perform basic and instrumental activities of daily living were measured using the following questionnaires: short-form health survey (SF-36), satisfaction with life scale (SWLS), activity of daily living (ADL) and instrumental activity of daily living (IADL), respectively. OM patients were categorized according to their risk factors as A, B and C hosts using a modified version of the Cierny and Mader classification system. The one sample t-test, 2-independent sample t-test, ANOVA, Pearson correlation coefficient and multiple linear regression analyses were applied to analyze the data.

RESULTS

Ankle-foot pain leading to surgery (P < 0.001) and orthosis usage (P = 0.039) were more common in OM patients. There was no significant difference between the two groups in the prevalence of pulmonary and cardiovascular diseases or kidney failure and other related diseases. OM patients showed a significantly lower level of mental health compared to non-OM respondents (P = 0.025). Approximately, 70.0% of ankle-foot injured veterans were dissatisfied with their life, and there was no difference between the two groups (P > 0.05). Mobility was significantly lower in the OM patients than in the control group (P = 0.023). Life satisfaction (P = 0.001) and the ability to perform daily activities were the determinants for poor physical (P = 0.018) and mental (P = 0.012) health-related quality of life. According to the Cierny and Mader classification system, they were all included in the type C host classification, with one major and/or three or more minor risk factors.

CONCLUSIONS

A low level of quality and satisfaction of life and ability to perform activities of daily living were observed in OM patients with war-related ankle-foot injuries. Surgeries of the ankle and foot due to pain were much more common in OM patients than in non-OM participants. Since all the participants were classified as the C-host, health policy planning seems to be necessary.

Ageing, limb-loss and military veterans: a systematic review of the literature

The impact of losing a limb in military service extends well beyond initial recovery and rehabilitation, with long-term consequences and challenges requiring health-care commitments across the lifecourse. This paper presents a systematic review of the current state of knowledge regarding the long-term impact of ageing and limb-loss in military veterans. Key databases were systematically searched including: ASSIA, CINAHL, Cochrane Library, Medline, Web of Science, PsycArticles/PsychInfo, ProQuest Psychology and ProQuest Sociology Journals, and SPORTSDiscus. Empirical studies which focused on the long-term impact of limb-loss and/or health-care requirements in veterans were included. The search process revealed 30 papers relevant for inclusion. These papers focused broadly on four themes: (a) long-term health outcomes, prosthetics use and quality of life; (b) long-term psycho-social adaptation and coping with limb-loss; (c) disability and identity; and (d) estimating the long-term costs of care and prosthetic provision. Findings present a compelling case for ensuring the long-term care needs and costs of rehabilitation for older limbless veterans are met. A dearth of information on the lived experience of limb-loss and the needs of veterans’ families calls for further research to address these important issues.

Exercise intervention for unilateral amputees with low back pain: study protocol for a randomised, controlled trial

Background

Atraumatic lower limb amputation is a life-changing event for approximately 185,000 persons in the United States each year. A unilateral amputation is associated with rapid changes to the musculoskeletal system including leg and back muscle atrophy, strength loss, gait asymmetries, differential mechanical joint loading and leg length discrepancies. Even with high-quality medical care and prostheses, amputees still develop secondary musculoskeletal conditions such as chronic low back pain (LBP). Resistance training interventions that focus on core stabilization, lumbar strength and dynamic stability during loading have strong potential to reduce LBP and address amputation-related changes to the musculoskeletal system. Home-based resistance exercise programs may be attractive to patients to minimize travel and financial burdens.

Methods/design

This study will be a single-assessor-blinded, pre-post-test randomised controlled trial involving 40 men and women aged 18–60 years with traumatic, unilateral transtibial amputation. Participants will be randomised to a home-based, resistance exercise group (HBRX) or a wait-list control group (CON). The HBRX will consist of 12 weeks of elastic resistance band and bodyweight training to improve core and lumbopelvic strength. Participants will be monitored via Skype or Facetime on a weekly basis. The primary outcome will be pain severity (11-point Numerical Pain Rating Scale; NRS_pain). Secondary outcomes will include pain impact on quality of life (Medical Outcomes Short Form 36, Oswestry Disability Index and Roland Morris Disability Questionnaire), kinematics and kinetics of walking gait on an instrumented treadmill, muscle morphology (muscle thickness of multifidus, transversus abdominis, internal oblique), maximal muscle strength of key lumbar and core muscles, and daily step count.

Discussion

The study findings will determine whether a HBRX program can decrease pain severity and positively impact several physiological and mechanical factors that contribute to back pain in unilateral transtibial amputees with chronic LBP. We will determine the relative contribution of the exercise-induced changes in these factors on pain responsiveness in this population.

Trial registration

ClinicalTrials.gov, ID: NCT03300375. Registered on 2 October 2017.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2362-0) contains supplementary material, which is available to authorized users.

Health-related quality of life and the ability to perform activities of daily living: a cross-sectional study on 1079 war veterans with ankle-foot disorders

BACKGROUND

The ankle-foot injuries are among the war-related injuries that cause many serious secondary problems for a lifetime. This nationwide study aimed to assess health-related quality of life and the ability to perform activities of daily living in veterans with ankle-foot injuries due to the Iran-Iraq war.

METHODS

A total of 1079 veterans with ankle-foot injuries were enrolled in a cross-sectional study from 2014 to 2016. Demographic characteristics, including age, gender, marital status, disability percent, educational level, employment and additional injuries, were collected. The ability to perform daily activities was assessed using the Barthel activities of daily living (ADL) and Lawton instrumental activities of daily living (IADL) Indexes. Physical and mental health-related quality of life (HRQOL) data were measured via the SF-36 subscales. The data were compared with those of bilateral lower limb amputees (BLLAs) and of the general Iranian population. Statistical analyses, including Pearson's correlation coefficient, one-sample t-test and analysis of variance (ANOVA), were performed using SPSS16.0. A multiple linear regression model was used to determine the contribution of independent variables to the Physical Component Summary (PCS) and Mental Component Summary (MCS).

RESULTS

The highest and lowest scores were observed for mental health (48.93 ± 20.69) and bodily pain (28.16 ± 21.74), respectively. The mean scores of veterans with ankle-foot injuries on the SF-36 were significantly lower on all eight measures than those of the general Iranian male population and of the bilateral lower limb amputees (P < 0.001). The mean scores of ADLs and IADLs were 83.9 ± 16.3 and 5.3 ± 2.0, respectively. The higher dependency in ADLs (P < 0.001) and IADLs (P < 0.001), the higher disability rate (P < 0.001) and additional injury (P < 0.001) were significant determinants of the PCS. ADL (P < 0.001) and IADL (P < 0.001) limitations, additional injury (P < 0.001), history of hospitalization in the year preceding the study (P = 0.007) and employment (P = 0.001) were reported as determinants of the MCS.

CONCLUSION

The results strongly suggest that veterans with ankle-foot injuries suffer from critically poor health-related quality of life. The main predicting factors of HRQOL were the disability to perform ADLs/IADLs, suffering two or more injuries, a history of hospitalization in the year preceding the study and unemployment.

Impact of Traumatic Lower Extremity Injuries Beyond Acute Care: Movement-Based Considerations for Resultant Longer Term Secondary Health Conditions

Significance: Advances in field-based trauma care, surgical techniques, and protective equipment have collectively facilitated the survival of a historically large number of service members (SMs) following combat trauma, although many sustained significant composite tissue injuries to the extremities, including limb loss (LL) and limb salvage (LS). Beyond the acute surgical and rehabilitative efforts that focus primarily on wound care and restoring mobility, traumatic LL and LS are associated with several debilitating longer term secondary health conditions (e.g., low back pain [LBP], osteoarthritis [OA], and cardiovascular disease [CVD]) that can adversely impact physical function and quality of life. Recent Advances: Despite recent advancements in prosthetic and orthotic devices, altered movement and mechanical loading patterns have been identified among persons with LL and salvage, which are purported risk factors for the development of longer term secondary musculoskeletal conditions and may limit functional outcomes and/or concomitantly impact cardiovascular health. Critical Issues: The increased prevalence of and risk for LBP, OA, and CVD among the relatively young cohort of SMs with LL and LS significantly impact physiological and psychological well-being, particularly over the next several decades of their lives. Future Directions: Longitudinal studies are needed to characterize the onset, progression, and recurrence of health conditions secondary to LL and salvage. While not a focus of the current review, detailed characterization of physiological biomarkers throughout the rehabilitation process may provide additional insight into the current understanding of disease processes of the musculoskeletal and cardiovascular systems.

Prevalence of metabolic syndrome and health-related quality of life in war-related bilateral lower limb amputees

BACKGROUND

Lower limb amputation is correlated with considerable impairments in health-related quality of life (HRQOL) in veterans. The aim of this study is to determine the prevalence of metabolic syndrome (MetS) in veterans with bilateral lower limb amputation and to identify its association with HRQOL.

METHODS

This cross-sectional study was conducted on 235 Iranian male veterans with bilateral lower limb amputation. Demographics, anthropometrics, and biochemical measurements were assessed and MetS was defined by National Cholesterol Education Program Adult Treatment Panel III definition. HRQOL was assessed using the 36-item Short Form Health Survey (SF-36) questionnaire which measures eight health-related domains. The scores were compared between two groups of bilateral lower limb Amputees who have diagnosed with and without MetS.

RESULTS

The response rate was 40.7% and the mean age of the amputees was 52.05 years. 62.1% of participants were suffering from MetS (95% CI: 55.9%-68.4%). Patients with MetS were observed to have higher weight, waist and hip circumferences, FBS, TG, LDL and liver enzymes concentrations (P < 0.05). Although scores on all 8 subscales of SF-36 were low, no significant difference was observed in HRQOL scores between amputees with and without MetS. Moreover, the risk of MetS was not significantly different across subjects in the highest compared to the lowest quartile category of HRQOL scores.

CONCLUSIONS

Prevalence of MetS in veterans with bilateral lower limb amputation was higher and their HRQOL was lower compared to general population. Some strategies are needed to reduce the risk of cardiovascular diseases among this susceptible population.

Health Related Quality of Life in a Dutch Rehabilitation Population: Reference Values and the Effect of Physical Activity

PURPOSE

To establish reference values for Health Related Quality of Life (HRQoL) in a Dutch rehabilitation population, and to study effects of patient characteristics, diagnosis and physical activity on HRQoL in this population.

METHOD

Former rehabilitation patients (3169) were asked to fill in a questionnaire including the Dutch version of the RAND-36. Differences between our rehabilitation patients and Dutch reference values were analyzed (t-tests). Effects of patient characteristics, diagnosis and movement intensity on scores on the subscales of the RAND-36 were analyzed using block wise multiple regression analyses.

RESULTS

In total 1223 patients (39%) returned the questionnaire. HRQoL was significantly poorer in the rehabilitation patients compared to Dutch reference values on all subscales (p<0.001) except for health change (p = 0.197). Longer time between questionnaire and last treatment was associated with a smaller health change (p = 0.035). Higher age negatively affected physical functioning (p<0.001), social functioning (p = 0.004) and health change (p = 0.001). Diagnosis affected outcomes on all subscales except role limitations physical, and mental health (p ranged <0.001 to 0.643). Higher movement intensity was associated with better outcomes on all subscales except for mental health (p ranged <0.001 to 0.190).

CONCLUSIONS

HRQoL is poorer in rehabilitation patients compared to Dutch reference values. Physical components of HRQoL are affected by diagnosis. In rehabilitation patients an association between movement intensity and HRQoL was found. For clinical purposes, results of this study can be used as reference values for HRQoL in a rehabilitation setting.

Physical and social factors determining quality of life for veterans with lower-limb amputation(s): a systematic review

PURPOSE

Most veterans live for many years after their war-related traumatic lower-limb amputation, which is why understanding which factors influence health-related quality of life (HRQoL) remains important to their long-term management. The objective of this study was to perform a review of the literature to summarize any evidence on the physical and social determinants for HRQoL in veterans with uni- or bilateral lower-limb amputation(s).

METHOD

MEDLINE, EMBASE, PEDro, CINAHL, Scopus and Cochrane databases were searched systematically for eligible studies. Inclusion criteria were: traumatic lower-limb amputation(s), HRQoL outcome and veterans. Physical and social factors that influence HRQoL were extracted.

RESULTS

The literature search identified 2073 citations, leading to the inclusion of 10 studies in the systematic review. Physical activity level, sport participation, level of amputation, back pain, years of education, as well as duration and severity of phantom pain were found to be determining factors for HRQoL among veterans with lower-limb amputation.

CONCLUSIONS

The identified physical and social determinants were similar to those found in civilian traumatic amputees. More high quality research designs, interventions and complex statistical analyses are warranted to identify the physical and social factors that influence the HRQoL of veteran amputees. Implications for Rehabilitation Rehabilitation staff should promote physical activity and participation in sport among veterans with lower-limb amputation(s). Level of amputation, back pain severity, years of education, duration of phantom pain and severity of phantom pain have been found to be determining factors for HRQoL and should be taken into consideration when planning rehabilitation programs for veterans with lower-limb amputations.

Persons with unilateral transfemoral amputation experience larger spinal loads during level-ground walking compared to able-bodied individuals

BACKGROUND

Persons with lower limb amputation walk with increased and asymmetric trunk motion; a characteristic that is likely to impose distinct demands on trunk muscles to maintain equilibrium and stability of the spine. However, trunk muscle responses to such changes in net mechanical demands, and the resultant effects on spinal loads, have yet to be determined in this population.

METHODS

Building on a prior study, trunk and pelvic kinematics collected during level-ground walking from 40 males (20 with unilateral transfemoral amputation and 20 matched controls) were used as inputs to a kinematics-driven, nonlinear finite element model of the lower back to estimate forces in 10 global (attached to thorax) and 46 local (attached to lumbar vertebrae) trunk muscles, as well as compression, lateral, and antero-posterior shear forces at all spinal levels.

FINDINGS

Trunk muscle force and spinal load maxima corresponded with heel strike and toe off events, and among persons with amputation, were respectively 10-40% and 17-95% larger during intact vs. prosthetic stance, as well as 6-80% and 26-60% larger during intact stance relative to controls.

INTERPRETATION

During gait, larger spinal loads with transfemoral amputation appear to be the result of a complex pattern of trunk muscle recruitment, particularly involving co-activation of antagonistic muscles during intact limb stance; a period when these individuals are confident and likely to use the trunk to assist with forward progression. Given the repetitive nature of walking, repeated exposure to such elevated loading likely increases the risk for low back pain in this population.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees

BACKGROUND

Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation.

METHODS

The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered.

RESULTS

The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %).

CONCLUSION

The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Amputee mobility predictor-bilateral: a performance-based measure of mobility for people with bilateral lower-limb loss

The Amputee Mobility Predictor (AMP) is an outcome measure designed to assess mobility and functional capabilities for people with unilateral lower-limb amputation. No comparable measure exists for those with bilateral lower-limb amputation (BLLA). The purpose of this study was to examine the utility of the AMP-Bilateral (AMP-B) to measure the ability to perform functional tasks related to participation in advanced skill activities in those with BLLA and to determine whether AMP-B scores correlated with 6-minute walk test (6MWT) performance. Twenty-six male servicemembers (SMs) completed the study: 12 with bilateral transtibial amputation (BTTA), 7 with bilateral transfemoral amputation (BTFA), and 7 with combination transtibial and transfemoral amputation (TTA/TFA). Significant differences existed between the AMP-B scores (p < 0.001), AMP scores (p < 0.001), and 6MWT distance (p < 0.05) for SMs with BTTA and TTA/TFA and SMs with BTTA and BTFA but not between those with BTFA and TTA/TFA. Scoring of five AMP items was modified because they necessitate at least one intact knee joint to generate the necessary torque requirements to perform the activity without upper-limb assistance. Minor modifications in scoring of the AMP do not alter total score and allow clinicians to determine the mobility and functional capabilities of SMs with BTFA and TFA/TTA.

Reoperation after combat-related major lower extremity amputations

OBJECTIVE

Complication rates leading to reoperation after trauma-related amputations remain ill defined in the literature. We sought to identify and quantify the indications for reoperation in our combat-injured patients.

DESIGN

Retrospective review of a consecutive series of patients.

SETTING

Tertiary Military Medical Center.

PATIENTS/PARTICIPANTS

Combat-wounded personnel sustaining 300 major lower extremity amputations from Operations Iraqi and Enduring Freedom from 2005 to 2009.

INTERVENTION

We performed a retrospective analysis of injury and treatment-related data, complications, and revision of amputation data. Prerevision and postrevision outcome measures were identified for all patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome measure was the reoperation on an amputation after a previous definitive closure. Secondary outcome measures included ambulatory status, prosthesis use, medication use, and return to duty status.

RESULTS

At a mean follow-up of 23 months (interquartile range: 16-32), 156 limbs required reoperation leading to a 53% overall reoperation rate. Ninety-one limbs had 1 indication for reoperation, whereas 65 limbs had more than 1 indication for reoperation. There were a total of 261 distinct indications for reoperation leading to a total of 465 additional surgical procedures. Repeat surgery was performed semiurgently for postoperative wound infection (27%) and sterile wound dehiscence/wound breakdown (4%). Revision amputation surgery was also performed electively for persistently symptomatic residual limbs due to the following indications: symptomatic heterotopic ossification (24%), neuromas (11%), scar revision (8%), and myodesis failure (6%). Transtibial amputations were more likely than transfemoral amputations to be revised due to symptomatic neuromata (P = 0.004; odds ratio [OR] = 3.7; 95% confidence interval [95% CI] = 1.45-9.22). Knee disarticulations were less likely to require reoperation when compared with all other amputation levels (P = 0.0002; OR = 7.6; 95% CI = 2.2-21.4).

CONCLUSIONS

In our patient population, reoperation to address urgent surgical complications was consistent with previous reports on trauma-related amputations. Additionally, persistently symptomatic residual limbs were common and reoperation to address the pathology was associated with an improvement in ambulatory status and led to a decreased dependence on pain medications.

Three-dimensional joint reaction forces and moments at the low back during over-ground walking in persons with unilateral lower-extremity amputation

BACKGROUND

Abnormal mechanics of locomotion following lower-extremity amputation are associated with increases in trunk motion, which in turn may alter loads at the low back due to changes in inertial and gravitational demands on the spine and surrounding trunk musculature.

METHODS

Over-ground gait data were retrospectively compiled from two groups walking at similar self-selected speeds (~1.35m/s): 40 males with unilateral lower-extremity amputation (20 transtibial, 20 transfemoral) and 20 able-bodied male controls. Three-dimensional joint reaction forces and moments at the low back (L5/S1 spinal level) were calculated using top-down and bottom-up approaches. Peak values and the timings of these were determined and compared between and within (bilaterally) groups, and secondarily between approaches.

FINDINGS

Peak laterally-directed joint reaction forces and lateral bend moments increased with increasing level of amputation, and were respectively 83% and 41% larger in prosthetic vs. intact stance among persons with transfemoral amputation. Peak anteriorly-directed reaction forces and extension moments were 31% and 55% larger, respectively, among persons with transtibial amputation compared to controls. Peak vertical reaction forces and axial twist moments were similar between and within groups. Peak joint reaction forces and moments were larger (3-14%), and the respective timing of these sooner (11-62ms), from the bottom-up vs. top-down approach.

INTERPRETATION

Increased and asymmetric peak reaction forces and moments at the low back among persons with unilateral lower-extremity amputation, particularly in the frontal plane, suggest potential mechanistic pathways through which repeated exposure to altered trunk motion and spinal loading may contribute to low-back injury risk among persons with lower-extremity amputation.

Unilateral lower limb loss following combat injury

This is a case series of prospectively gathered data characterising the injuries, surgical treatment and outcomes of consecutive British service personnel who underwent a unilateral lower limb amputation following combat injury. Patients with primary, unilateral loss of the lower limb sustained between March 2004 and March 2010 were identified from the United Kingdom Military Trauma Registry. Patients were asked to complete a Short-Form (SF)-36 questionnaire. A total of 48 patients were identified: 21 had a trans-tibial amputation, nine had a knee disarticulation and 18 had an amputation at the trans-femoral level. The median New Injury Severity Score was 24 (mean 27.4 (9 to 75)) and the median number of procedures per residual limb was 4 (mean 5 (2 to 11)). Minimum two-year SF-36 scores were completed by 39 patients (81%) at a mean follow-up of 40 months (25 to 75). The physical component of the SF-36 varied significantly between different levels of amputation (p = 0.01). Mental component scores did not vary between amputation levels (p = 0.114). Pain (p = 0.332), use of prosthesis (p = 0.503), rate of re-admission (p = 0.228) and mobility (p = 0.087) did not vary between amputation levels.

These findings illustrate the significant impact of these injuries and the considerable surgical burden associated with their treatment. Quality of life is improved with a longer residual limb, and these results support surgical attempts to maximise residual limb length.

Cite this article: Bone Joint J 2013;95-B:224–9.

Pain and health-related quality of life in war veterans with bilateral lower limb amputations

Background

Amputation and pain may have considerable impact on health-related quality of life.

Objectives

The purpose of this study was to assess the impact of pain on health-related quality of life in a population of war related bilateral lower limb amputees.

Materials and Methods

The Veterans and Martyrs Affairs Foundation (VMAF) database documented 578 patients with bilateral lower limb amputation; 335 consented to the study (response rate = 58%). The majority of participants in the sample were males (96.7%). Types of pain were investigated using a questionnaire. Health-related quality of life (HRQOL) was investigated using the sf-36 questionnaire.

Results

About two third of amputees reported phantom pain 66.7% (n = 223) and vertebral column pain 60.9% (n = 204). The most common type of pain was lumbosacral pain 52.8 % (n = 177) followed by neck 18.2 % (n = 61) and thoracic pain 9.6% (n = 32). Back pain affected on vitality, social function, mental health and mental component scale in our cases (P < 0.05). Neck pain affected all components of health-related quality of life (P < 0.05). Thoracic pain affected quality of life significantly (P < 0.05). The results obtained from logistic regression analysis indicated that none of the three spinal column pains including neck, thoracic and lumbosacral pain resulted in poor physical or mental component scales.

Conclusions

This study revealed that bilateral lower limb amputees suffer from different types of pain and poor health-related quality of life. Therefore, the assessment and management of all types of pain are necessary to improve quality of life in veterans.

Phantom Limb Pain After Lower Limb Trauma

Phantom sensations, that is, sensations perceived in a body part that has been lost, are a common consequence of accidental or clinical extremity amputations. Most amputation patients report a continuing presence of the limb, with some describing additional sensations such as numbness, tickling, or cramping of the phantom limb. The type, frequency, and stability of these phantom sensations can vary immensely. The phenomenon of painful phantom sensations, that is, phantom limb pain, presents a challenge for practitioners and researchers and is often detrimental to the patient’s quality of life. In addition to the use of conventional therapies for chronic pain disorders, recent years have seen the development of novel treatments for phantom limb pain, based on an increasing body of research on neurophysiological changes after amputation. This article describes the current state of research in regard to the demographics, causal factors, and treatments of phantom limb pain.

Outcomes in lower limb amputation following trauma: a systematic review and meta-analysis

INTRODUCTION

Lower limb amputation (LLA) is life-changing surgery. Shorter residual limbs are known to place greater physiological strain on patients than longer residual limbs; however, there is ongoing debate as to whether through-knee amputations are preferable to above-knee amputations. This analysis aims to resolve this question by systematically collecting and pooling published and unpublished data on this subject.

METHODS

An exhaustive search of Medline, Embase and Recal databases was made for outcome studies of patients with lower limb amputations following trauma. Studies concerned with amputations of the upper limb or foot and ankle were excluded as were papers reporting outcomes in a population of mixed trauma and non-trauma patients. Authors of studies published in the last 10 years were contacted for unpublished details. Patients were then divided, according to amputation height, into four groups: below-knee amputation (BKA), through-knee amputation (TKA), above-knee amputation (AKA) and bilateral amputation. The primary outcome measure was Physical Component Score (PCS) of the short-form-36 measure of quality of life and secondary outcomes were pain, employment, ability to walk 500m and proportion of time that prosthesis is worn.

RESULTS

As many as 27 studies were included, representing a total of 3105 patients, 1855 with a BKA, 104 with a TKA, 888 with an AKA and 258 bilateral amputees. There was progressive and significant lowering of PCS (worsening outcomes) as unilateral amputation height became more proximal from BKA to TKA and AKA. A significantly greater proportion of patients with a BKA or a TKA were able to walk 500m than those with an AKA or bilateral amputation (p=0.0035). However, patients with a TKA wore their prosthesis significantly less, and had significantly more pain than those with an AKA.

CONCLUSION

This study describes the impact of LLA of different levels on patients' lives. The results indicate that patients with a TKA have a better physical quality of life than those with an AKA and, therefore, support the surgical strategy of maintaining maximum length and performing TKA in preference to AKA, where possible.

Impact of pain in vertebral column on activities of daily living in the Iranian amputees with bilateral lower limb amputation

PURPOSE

To determine the impact of pain in the vertebral column on the activities of daily living (ADL) level of war victims with bilateral lower limb amputation.

METHOD

All the war-related bilateral lower limb amputees were invited. More than half of them (n = 335) participated and underwent a thorough assessment after giving informed consent.

RESULTS

The majority of the participants were male (97.6%). Their mean age was 42 years and 97.6% of them were married. The most common causes of injury leading to amputation were shells of artillery and mortar (56.7%). The most common level of amputation was bilateral transtibial (37.6%) and 64% were wearing the prosthesis of both sides. The most ADL dependency were transfer activities (27.8%) and bathing (23.3%) and the most independent functioning was eating (97.6%). Upper cervical vertebral pain was associated with dependency in the bowel and bladder management and dressing (p < 0.03 and p < 0.04, respectively). Pain in the lower cervical vertebrae was associated with dependency in toileting and dressing (p < 0.01 and p < 0.01, respectively). There were significant relationships between pain in the thoracic vertebrae and dependency in bathing, transfer activities and toileting (p < 0.02, p < 0.003 and p < 0.03, respectively). Pain in the lumbosacral region had a relationship with the level of amputation, transfer activities and toileting (p < 0.006, p < 0.03 and p < 0.05, respectively).

CONCLUSIONS

Vertebral pain in bilateral lower limb amputees, especially lumbosacral pain, was accompanied with higher dependency in ADL. Therefore, a multidisciplinary approach to the management of pain is required to minimize disability and maximize functioning.

The mind continues to matter: psychologic and physical recovery 5 years after musculoskeletal trauma

OBJECTIVES

Posttraumatic psychopathology may complicate recovery from musculoskeletal injury. This article details the 5-year follow-up of a cohort study examining the relationship between posttraumatic psychopathology and recovery after musculoskeletal trauma.

DESIGN

A prospective cohort study of patients with musculoskeletal injuries (Grampian Trauma Outcomes Study) assessed 5 years after their injury.

SETTING

Orthopaedic trauma unit, Level I equivalent.

PATIENTS

One hundred four of the initial group of 200 patients with musculoskeletal injuries.

INTERVENTION

Trauma care and prospective evaluation of physical and psychologic recovery.

MAIN OUTCOME MEASURES

Development of psychopathology (measured by the General Health Questionnaire [GHQ]) and functional outcome (measured by Short Form-36 [SF-36] and Musculoskeletal Function Assessment [MFA]).

RESULTS

Follow-up at 5 years was 104 patients (52%). GHQ caseness was predictive of physical dysfunction (SF-36, MFA), which had not returned to baseline levels by 5 years. Although injury severity was strongly predictive of psychological disturbance (GHQ caseness) at 5 years, linear regression analysis demonstrated that GHQ score was an important predictor of outcome, whereas Injury Severity Score contributed very little.

CONCLUSIONS

Psychologic disturbance after musculoskeletal trauma is related to adverse functional outcome. This is not influenced by preinjury state, but constitutes a sustained posttraumatic effect that is only weakly related to severity of injury.

Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations

Deliberate attention to the management of soft tissue is imperative when performing an amputation. Identification and proper management of the nerves accompanied by the performance of a stable myodesis and ensuring robust soft-tissue coverage are measures that will improve patient outcomes. Limb length should be preserved when practicable; however, length preservation at the expense of creating a nonhealing or painful residual limb with poor soft-tissue coverage is contraindicated. While a large proportion of individuals with a trauma-related amputation remain severely disabled, a chronically painful residual limb is not inevitable and late revision amputations to improve soft-tissue coverage, stabilize the soft tissues (revision myodesis), or remove symptomatic neuromas can dramatically improve patient outcomes. Psychosocial issues may dramatically affect the outcomes after trauma-related amputations. A multidisciplinary team should be consulted or created to address the multiple complex physical, mental, and psychosocial issues facing patients with a recent amputation.