Factors influencing quality of life following lower limb amputation for peripheral arterial occlusive disease: A systematic review of the literature

Prosthetic fitting and mortality after major lower extremity amputation

BACKGROUND

Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit; however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality.

METHODS

We reviewed all patients who underwent LEA between 2015 and 2022 at two academic health care systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1 and 3 years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1 and 3 years of follow-up.

RESULTS

Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n = 488, 69.5%), predominantly non-Hispanic Black (n = 410, 58.4%), and nearly one-fifth were non-ambulatory before LEA (n = 139 [19.8%]). Of note, 14.3% of all subjects who were nonambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow-up; among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1 and 3 years of follow-up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post- coronavirus disease 2019 pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio, 0.24; 95% confidence interval, 0.14-0.40) as well as within 3 years (adjusted hazard ratio, 0.40; 95% confidence interval, 0.29-0.55).

CONCLUSIONS

Prosthetic fitting is associated with improved survival, and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the Department of Veterans Affairs, such as prosthetic department evaluation of all amputees, may represent a best practice.

Epidemiology and Burden of Peripheral Artery Disease in People With Type 2 Diabetes: A Systematic Literature Review

Type 2 diabetes (T2D) and lower-extremity peripheral artery disease (PAD) are growing global health problems associated with considerable cardiovascular (CV) and limb-related morbidity and mortality, poor quality of life and high healthcare resource use and costs. Diabetes is a well-known risk factor for PAD, and the occurrence of PAD in people with T2D further increases the risk of long-term complications. As the available evidence is primarily focused on the overall PAD population, we undertook a systematic review to describe the burden of comorbid PAD in people with T2D. The MEDLINE, Embase and Cochrane Library databases were searched for studies including people with T2D and comorbid PAD published from 2012 to November 2021, with no restriction on PAD definition, study design or country. Hand searching of conference proceedings, reference lists of included publications and relevant identified reviews and global burden of disease reports complemented the searches. We identified 86 eligible studies, mostly observational and conducted in Asia and Europe, presenting data on the epidemiology (n = 62) and on the clinical (n = 29), humanistic (n = 12) and economic burden (n = 12) of PAD in people with T2D. The most common definition of PAD relied on ankle-brachial index values ≤ 0.9 (alone or with other parameters). Incidence and prevalence varied substantially across studies; nonetheless, four large multinational randomised controlled trials found that 12.5%-22% of people with T2D had comorbid PAD. The presence of PAD in people with T2D was a major cause of lower-limb and CV complications and of all-cause and CV mortality. Overall, PAD was associated with poor quality of life, and with substantial healthcare resource use and costs. To our knowledge, this systematic review provides the most comprehensive overview of the evidence on the burden of PAD in people with T2D to date. In this population, there is an urgent unmet need for disease-modifying agents to improve outcomes.

Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-operative Phase

OBJECTIVE

To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation.

DESIGN

Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques.

SETTING

Regional hospital's ambulatory rehabilitation clinic.

PARTICIPANTS

Patients with major lower limb amputation (N=329).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP.

RESULTS

In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79.

CONCLUSION

The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Energy expenditure during typical household and community activities of daily living in persons with lower limb amputation: A pilot study

INTRODUCTION

Knowledge about the energy expenditure of typical activities of daily living (ADL) in persons with lower limb amputation (LLA) is lacking. This study investigated the following: (1) oxygen consumption per unit distance (V̇O 2 ; mL·kg -1 ·min -1 ), (2) proportion utilization of peak oxygen consumption (%V̇O 2 peak), (3) oxygen cost (energy cost; mL·kg -1 ·m -1 ), and (4) perceived exertion (rating of perceived exertion) of ADL in persons with LLA and able-bodied controls.

METHODS

Participants (21 with LLA/12 controls) performed 2 household ADL experiments: in-house walking and vacuuming and 3 community ADL experiments: marked shopping, fast walking, and stair negotiation. V̇O 2 peak was assessed with arm crank ergometry, and ambulatory activity was monitored for 7 days with a StepWatch.

RESULTS

Participants with LLA performed in-house walking, marked shopping, vacuuming, and stair negotiation at a similar V̇O 2 as controls, while their self-selected walking speed (WS) was significantly lower. Participants with LLA had significantly higher %V̇O 2 peak than controls during in-house walking and reported a significantly higher rating of perceived exertion for vacuuming and marked shopping. The highest possible WS of participants with LLA during fast walking was significantly lower than that of controls, but V̇O 2 was also significantly lower, indicating a limited capacity to walk at higher WS. Participants with LLA had a significantly lower daily step count, significantly lower-proportion high-intensity ambulation, but significantly higher-proportion low-intensity ambulation than controls, indicating that persons with LLA also walked at lower WS in daily life.

CONCLUSIONS

The results indicate that persons with LLA have increased physical and perceived effort during performance of ADL compared with persons without amputation, which has consequences for community participation, and hence independence and quality of life.

Risk Factors for Mortality and Promoting Factors for Ambulation After Major Lower Limb Amputation for End-Stage Arterial Disease: A Multicenter Study

BACKGROUND

Around 1%-2% of patients with peripheral arterial disease will require a lower limb amputation at some point. Despite advancements in prevention and treatment, mortality after major amputation remains high. The aim of this study was to investigate the risk factors related to mortality and promoting factors for ambulation postamputation.

METHODS

A multicenter retrospective study of consecutive major lower limb amputation patients performed at the department of thoracic and vascular surgery of the University Hospitals Ghent and Leuven between January 2008 and December 2017.

RESULTS

Three hundred and thirteen patients met the inclusion criteria. Overall, 1-year mortality rate was 29.7% with age being the most important risk factor. Above-knee amputations had significantly higher mortality (37%) than below-knee amputations (22%) at 1 year. Diabetes and number of vascular interventions were not linked to higher mortality. Age, amputation level, and presence of hypertension were the most important determining factors for successful ambulation.

CONCLUSIONS

Maintaining the independency of patients, whether this is obtained by maximizing limb salvage or primary amputation, is critical. Knowledge about the factors that play a role in the risk of death and the chance of regaining ambulation is important to include in the decision-making conversation with the patient.

Assessment of self-esteem and quality of life in patients with transtibial amputations using an exoskeletal prosthesis

BACKGROUND

Lower limb amputation can have profound physical, psychological, and social effects on individuals. Assistive aids like prosthetic lower limbs can help an individual regain mobility and thereby affect their self-esteem and quality of life.

OBJECTIVE

To assess self-esteem and quality of life in patients with transtibial amputations who are using a transtibial prosthesis and explore the association between sociodemographic and amputation-related factors with self-esteem and prosthesis-related quality of life measures.

DESIGN

A cross-sectional study.

SETTING

An orthotics and prosthetics center (Bhagwan Mahaveer Viklang Sahayata Samiti) in Jaipur, Rajasthan.

PARTICIPANTS

Patients with transtibial amputations using exoskeletal prostheses between July and September 2022, in Jaipur, Rajasthan.

MAIN OUTCOME MEASURES

The study used Rosenberg self-esteem questionnaire and Prosthesis Evaluation Questionnaire (PEQ) for self-esteem and quality of life assessment, respectively. Descriptive analysis was used to present the demographic details, and nonparametric tests examined the relationship between PEQ dimensions and sociodemographic variables.

RESULTS

The study included 138 participants, primarily <40 years old (45.7%) and mostly engaged in high-activity occupations. Self-esteem mean score (SD) was 19.9 (3.9), with 89.1% exhibiting normal self-esteem. Prosthesis-related quality of life, showed high satisfaction across various domains, including ambulation, appearance, frustration, perceived response, residual limb health, social burden, sounds, utility, and well-being. No significant associations were found between sociodemographic factors, amputation-related variables, and self-esteem. However, PEQ scales showed associations with gender, age, occupation, type of amputation, and years of prosthesis use.

CONCLUSION

These results highlight the potential advantages of exoskeletal prostheses in improving the standard of living for people with transtibial amputations. Further research is essential to develop targeted interventions for improving their overall quality of life.

Appraising the Physical Activity Levels of Saudis with Physical Disabilities: Effects of Disability Type, Mobility Assistive Devices, and Demographic Factors

Physical activity (PA) has numerous health benefits for individuals with physical disabilities (IWPD). However, it is common for activity levels to fall below the suggested limits. This study aimed to evaluate the prevalence, pattern, and levels of PA among IWPD in Saudi Arabia. It also investigated the effects of individuals' type of disability, mobility assistive devices, and demographic features on PA levels. Data were collected from 238 participants, mostly male (62.2%), aged 39.76 ± 12.19 years. Among them, 19.3% had spinal conditions, 14.7% had progressive muscular dystrophy, 15.1% had multiple sclerosis, 17.6% had cerebral palsy, 16.4% had poliomyelitis, and 16.8% had limb or foot amputations. The participants were assessed using the Arabic version of the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD-AR). The results showed that 62.6% (64.9% of males and 58.9% of females) met the minimum PA guidelines specified by the WHO. The average PASIPD-AR score was 10.33 ± 10.67 MET-hours/day, indicating lower PA levels, and 8.4% of individuals did not participate in any form of PA. Significant discrepancies were detected in disability type and mobility assistive device use after age adjustment. Marital status, education, and occupation greatly affected PA components. Greater attention should be paid to promoting an active lifestyle among IWPD in Saudi Arabia.

Anxiety and Depressive Symptoms in Moroccan Patients Following Major Lower Limb Amputation: A Three-Month Follow-Up

OBJECTIVE

Major amputation of a lower limb is a traumatic experience that causes physical and psychosocial disabilities. This study set out to ascertain how anxiety and depression symptoms changed during the three months following the amputation.

MATERIALS AND METHODS

A prospective longitudinal observational study was conducted between October 1, 2019, and January 1, 2021, in the Department of Vascular Surgery and the Department of Orthopedic Traumatology of the Ibn Sina Hospital Center in Rabat, Morocco. The study assesses symptoms of anxiety and depression in patients who have undergone a major lower limb amputation over a three-month interval.

RESULTS

In patients who had undergone a major lower limb amputation, the prevalence of anxiety and depression symptoms was very high immediately postoperatively (47.4% and 79.2%, respectively), with a significant decrease in these symptoms. Three months later, anxiety was reported in 24.4% of cases, and depressive symptoms in 65.1% of cases. Age, amputation level, stump pain, phantom limb pain, re-amputation, and emergency amputation were all associated with an increased risk of anxiety and depression. The patient's psychological preparation prior to the amputation, the anesthetic technique used during the procedure, the patient's mobility, and the patient's post-amputation professional status were all protective factors.

CONCLUSION

Our research findings bolster the necessity of promptly evaluating and managing anxiety and depression in the initial three months following major lower limb amputation. Thus, we believe that amputee patients ought to receive a formal psychological evaluation, which could be helpful, particularly for those whose anxiety or depression symptoms did not improve after three months.

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

PURPOSE

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

The Effect of Distant Reiki Applied to Individuals with Extremity Amputation on Pain Level and Holistic Well-Being: A Quasi-experimental Study

BACKGROUND

Pain felt in an amputated limb is quite common. Phantom pain affects the lives of individuals in many ways and can negatively affect the holistic well-being of individuals. Distant Reiki can be used in the management of these problems.

AIM

This study was conducted to examine the effect of distant Reiki applied to individuals with extremity amputation on pain level and holistic well-being.

METHOD

This a quasi-experimental single group pre-test. Post-test design research was conducted between September 2022 and April 2023 and included 25 individuals with extremity amputation. Then, according to Classical Usui Reiki, distant Reiki application has been performed for 20 minutes every day for 10 days. Data were collected at the beginning of the study and at the end of the 10th day. The data were obtained using an Introductory Information Form, the Visual Analog Scale for Pain, and Holistic Well-Being Scale.

RESULTS

The mean age of the participants was 51.32 ± 16.65 years. There was a significant difference between pre-test and post-test pain levels of the participants (p < .05) and HWBS subscale scores (p < .05). Accordingly, it was determined that after 20-minute distant Reiki sessions for 10 consecutive days, the pain levels of the individuals were significantly reduced and their holistic well-being improved.

CONCLUSION

Distant Reiki has been found to be easy to administer, inexpensive, non-pharmacological, and appropriate for independent nursing practice to be effective in reducing phantom pain levels and increasing holistic well-being in people with limb amputation.

Making decisions about amputation for chronic limb threatening ischaemia

INTRODUCTION

Chronic limb threatening ischaemia causes pain, loss of function and complex wounds, necessitating urgent interventions. While growing options for minimally invasive revascularisation make operating on frail and older persons safer, the challenge is knowing when to stop this option and offer amputation. Decisions about amputation are difficult for the person, or for the family who act as substitute decision-makers. Timely treatment decisions are important to optimise clinical outcomes but do not always align with outcomes that are acceptable to patients.

AIM

To provide a philosophically-based understanding of patient/family experiences of making decisions for chronic limb threatening ischaemia.

METHODS

Longitudinal qualitative study using Heideggerian phenomenology. Patient and family participants were recruited from three sites. Semi-structured interviews occurred at two time points: soon after advice to consider major amputation, and for those who experienced amputation, six-months post-operatively. The COnsolidated criteria for REporting Qualitative studies (COREQ) checklist guided this report.

FINDINGS

Variable timelines, disease progression, and interventions were encountered prior to confronting the possibility of amputation. Decision-making was interpreted as an initial irresoluteness (neglecting or renouncing decisions). For most, this was eventually followed by a resoluteness where participants either turned away or towards amputation, according to one's preferred mode of suffering, and thus owning the decision to turn. Those who opted for amputation often experienced better-than-anticipated outcomes.

CONCLUSION

Patients and families had difficulty making decisions about amputation. Clinicians may have been complicit in the neglecting and renouncing of decisions and have an important role in sharing decision-making through their authentic discourse.

IMPLICATIONS

Chronic limb threatening ischaemia requires complex discussions to support decisions and shared decision-making requires clinician presence and engagement in discourse. Patients and family members benefit from more time to experience and process the phenomenon as they move towards owning their decision about amputation.

Understanding transitions in care for persons with limb loss: a qualitative study exploring health care providers' perspectives

PURPOSE

To explore health care providers' (HCP) experiences related to transitions in care from inpatient rehabilitation to the community for patients with limb loss.

MATERIALS AND METHODS

A qualitative study was conducted using semi-structured interviews. Participants were eligible if they were HCPs currently working in amputation rehabilitation at a rehabilitation hospital in Ontario, Canada, with at least 1-year experience in this setting, and could speak and understand English. Data were analyzed thematically using the six-step process of the DEPICT model dynamic reading, engaged codebook development, participatory coding, inclusive reviewing and summarizing of categories, collaborative analyzing and translating.

RESULTS

Fourteen HCPs from a variety of health care professions participated in this study. Five key themes describe participants' perspectives on the factors impacting patients' transition in care following limb loss. Specifically, participants emphasized patient preparedness, HCP follow-up, finances and funding, patient self-management skills, and psychosocial support as factors that could influence the transition in care.

CONCLUSION

This study identified challenges to transitions in care for people with limb loss. Future research is needed to evaluate solutions to address these challenges in transitions in care.

Efficacy of rehabilitation after provision of ICRC lower limb prostheses in low-income and middle-income countries: A quantitative assessment from Myanmar

BACKGROUND

Low-income and middle-income countries (LMICs) have poorly resourced health services. Lack of access to assistive devices, such as prosthetics, may limit the functional outcomes of persons with amputation and affect quality of life (QoL).

OBJECTIVE

The objective of this study was to assess the functional level and QoL of prosthetic users in LMICs when prescribed a prosthesis made from International Committee for Red Cross (ICRC) components.

STUDY DESIGN

The study design included a quantitative descriptive methodology assessing functional outcomes and QoL after prosthetic provision.

METHODS

Participants were identified from the prosthetic service in Mandalay, Myanmar. Included participants were those with unilateral, traumatic, lower limb amputations, with ICRC devices delivered at least 6 months earlier. Participants attended the prosthetic service and were assessed using the Amputee Mobility Predictor with Prosthesis tool and the World Health Organization Quality of Life Brief and Disability modules.

RESULTS

Thirty-five participants completed the study; of them, 63% were persons with transtibial level amputation and 37% were with transfemoral level amputation. Approximately 83% achieved a score of more than 37 using the Amputee Mobility Predictor with Prosthesis. There is a strong positive correlation between QoL and physical health (r = 0.55; p < 0.001), social relationships (r = 0.66; p < 0.001), and inclusion (r = 0.53; p < 0.001). Participants had a better QoL and overall health when they had better psychological health.

CONCLUSION

The patient-based results presented within this study could be considered as a contribution to the evidence base and importance of provision of prosthetic services in LMICs. It was observed that participants with an amputation were able to achieve a high level of physical function with the ICRC prostheses while also reporting a high QoL.

Predictors of Ambulatory Status at 1 Year Following Major Lower Extremity Amputation

Nearly 60,000 major lower extremity amputations (AKA/BKA) are performed annually in the United States. We created a simple risk score for predicting ambulation at 1 year following AKA/BKA. We queried the Vascular Quality Initiative amputation database for patients who underwent above-knee (AKA) or below-knee (BKA) amputation (2013-2018). The primary endpoint was ambulation at 1 year either independently or with assistance. The cohort was divided into 80% derivation and 20% validation. Using the derivation set, a multivariable model identified preoperatively available independent predictors of 1 year ambulation and an integer-based risk-score was created. Scores were calculated to assign patients to risk groups-low, medium, or high chance of being ambulatory at 1 year. Internal validation was performed by applying the risk score to the validation set. Of 8725 AKA/BKA, 2055 met inclusion criteria-excluded: 2644 nonambulatory prior to amputation, 3753 missing 1-year follow-up ambulatory status. The majority-n = 1366, 66% were BKAs. The indications were CLTI; 47%, ischemic tissue loss; 9%, ischemic rest pain; 35%, infection/neuropathic; 9%, acute limb ischemia. Ambulation at 1 year was higher for BKA than AKA: 67%, versus 50%, p < .0001. In the final prediction model, contralateral BKA/AKA was the strongest predictor of nonambulation. The score provided reasonable discrimination (C-statistic = 0.65) and was well calibrated (Hosmer-Lemeshow p = .24). Sixty-two percent of patients who were ambulatory preoperatively remained ambulatory at 1 year. An integer-based risk score can stratify patients according to chance of ambulation at 1 year after major amputation and may be useful for preoperative patient counseling and selection.

Functioning among persons with lower limb amputation with or without prostheses in Rwanda

Background

Limb loss limits functioning and restricts participation in various environments. Persons with lower limb amputations (PLLA) experience challenges ranging from self-care and independence to psychological disorders that negatively impact their functioning.

Objectives

To assess the functioning and the level of disability of PLLA with or without prostheses in Rwanda.

Method

A descriptive, cross-sectional study was conducted among PLLAs aged 18 years and above in 10 districts of Rwanda. A total of 247 participants were purposively selected to fill the questionnaires. Descriptive and inferential statistics using t-test and binary logistic regression were performed to analyse data using Statistical Package for Social Sciences (SPSS) (version 21.0).

Results

Out of 247 PLLA, 99 (40.1%) had prostheses and remaining 148 (59.9%) did not. Majority of PLLA without prostheses reported having more difficulties in mobility (s.d. 3.98), participation (s.d. 5.18) and life activities (s.d. 3.87). The majority of PLLA reported mild and moderate functioning in the domains of cognitive (odds ratio [OR] 8.842, 5.384 with 95% confidence interval [CI]) mobility (OR 16.154, 2.485 with 95% CI) and participation (OR 13.299, 15.282 with 95% CI).

Conclusion

Persons without prostheses demonstrated reduced level of functioning and high levels of disability compared to those with prostheses in all domains. However, the mobility, self-activities and the participation domains were the mainly affected.

Contribution

The study helps to understand the needs of the PLLA and emphasises that not only having prostheses can improve functioning but also emphasises the psychosocial aspects to reduce disability.

A qualitative study exploring healthcare professionals' perceptions of lower limb 3D printed sockets

PURPOSE

The purpose of this study was to explore healthcare professionals' (HCPs) perceptions and experiences related to 3D scanning and 3D printing for fabricating lower limb prosthetic sockets.

MATERIALS AND METHODS

This study used a qualitative descriptive approach. Participants were recruited through HCPs' professional associations, social media posts, and snowball sampling. Purposive sampling was used to attain variation in provider type. One-on-one telephone interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was performed to identify the main themes.

RESULTS

Three themes were identified: (1) 3D scanning of the residual limb for designing prosthetic sockets is perceived as clean, quick, and convenient; (2) concerns about the strength and safety of 3D printed sockets for long-term use; (3) Adoption of 3D scanning and 3D printing technology for fabricating prosthetic sockets.

CONCLUSION

We identified perceived benefits and challenges with digital technologies for fabricating prosthetic sockets. To increase adoption, more research demonstrating its efficacy compared to conventional methods, increasing 3D printing material quality, and improving software training programs are needed.Implications for Rehabilitation3D printing and 3D scanning are emerging digital technologies that can be used as alternative methods for prosthetic socket manufacturing in the field of rehabilitation.Our research identified perceived benefits of using digital technologies for fabricating prosthetics sockets (3D scanning is perceived as clean, quick, and convenient) and perceived challenges (concerns about the strength and safety of 3D printed sockets for long-term use and a prolonged learning curve).To increase adoption of these digital technologies, more training should be provided to prosthetists and support provided to integrate new processes into staff workloads.

Comparing Patient and Provider Priorities Around Amputation Level Outcomes Using Multiple Criteria Decision Analysis

BACKGROUND

Patients with chronic limb threatening ischemia may require a transmetatarsal amputation (TMA) or a transtibial amputation. When making an amputation-level decision, these patients face a tradeoff-a TMA preserves more limb and may provide better mobility but has a lower probability of primary wound healing and may therefore result in additional same or higher level amputation surgeries with an associated negative impact on function. Understanding differences in how patients and providers prioritize these tradeoffs and other outcomes may enhance shared decision-making.

OBJECTIVES

Compare patient priorities with provider perceptions of patient priorities using Multiple Criteria Decision Analysis (MCDA).

METHODS

The MCDA Analytic Hierarchy Process was chosen due to its low cognitive burden and ease of implementation. We included 5 criteria (outcomes): ability to walk, healing after amputation surgery, rehabilitation program intensity, limb length, and ease of use of prosthetic/orthotic device. A national sample of dysvascular lower-limb amputees and providers were recruited from the Veterans Health Administration with the MCDA administered online to providers and telephonically to patients.

RESULTS

Twenty-six dysvascular amputees and 38 providers participated. Fifty percent of patients had undergone a TMA; 50%, a transtibial amputation. When compared to providers, patients placed higher value on TMA (72% vs. 63%). Patient versus provider priorities were ability to walk (47% vs. 42%), healing (18% vs. 28%), ease of prosthesis use (17% vs. 13%), limb length (11% vs. 13%), and then rehabilitation intensity (7% vs. 6%).

LIMITATIONS

Our sample may not generalize to other populations.

CONCLUSIONS

Provider perceptions aligned with patient values on amputation level but varied around the importance of each outcome.

IMPLICATIONS

These findings illuminate some differences between patients' values and provider perceptions of patient values, suggesting a role for shared decision-making. Embedding this MCDA framework into a future decision aid may facilitate these discussions.

A Comparison of Objectively Measured Free-Living Physical Behaviour in Adults with and without Lower Limb Amputation

Objectively monitored free-living physical behaviours of adults with and without lower limb amputation (LLA) were compared.

METHODS

57 adults with LLA wore an activPAL3™ for 8 days. A comparison data set (n = 57) matched on gender, age and employment status was used. Variables included: time sitting; standing; stepping; sit-to-stand transitions; step count and cadence. Comparisons were made between adults with and without LLA and between gender, level and cause of amputation.

RESULTS

Participants with LLA due to trauma versus circulatory causes were less sedentary and more active; however, no difference in physical behaviour was recorded across gender or level of amputation. Participants with LLA spent more time sitting (p < 0.001), less time standing and stepping (p < 0.001) and had a lower step count (p < 0.001). Participants with LLA took more steps in cadence bands less than 100 steps·min-1 and fewer steps in cadence bands greater than 100 steps·min-1 compared to participants without LLA.

CONCLUSIONS

People with LLA were less active and more sedentary than people without LLA and participated in less activity at a moderate or higher intensity when matched on age, gender and employment. Interventions are needed to promote active lifestyles in this population.

What Is Hidden behind Amputation? Quanti-Qualitative Systematic Review on Psychological Adjustment and Quality of Life in Lower Limb Amputees for Non-Traumatic Reasons

OBJECTIVE

This systematic review aims to investigate Quality of Life (QoL)/Health Related Quality of Life (HRQoL) and psychological adjustment in non-traumatic lower limb amputees (LLA).

METHODS

PubMed, Scopus, and Web of Science databases were used for the literature search. Studies were read and analysed using the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA statement procedure.

RESULTS

The literature search retrieved 1268 studies, of which 52 were included in the systematic review. Overall, psychological adjustment, especially depression with or without anxiety symptoms, influences the QoL/HRQoL in this clinical population. Other factors influencing QoL/HRQoL include subjective characteristics, physical aspects, the cause and level of the amputation, relational aspects, social support, and the doctor-patient relationship. In addition, the patient's emotional-motivational status, depression and/or anxiety symptoms, and acceptance play a key role in the subsequent rehabilitation process.

CONCLUSIONS

In LLA patients, psychological adjustment is a complex and multifaceted process, and QoL/HRQoL may be influenced by various factors. Shedding light on these issues may provide useful suggestions for promoting clinical and rehabilitative interventions that may be tailored and effective in this clinical population.

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

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

Development of an item bank for measuring prosthetic mobility in people with lower limb amputation: The Prosthetic Limb Users Survey of Mobility (PLUS-M)

BACKGROUND

Achieving mobility with a prosthesis is a common post-amputation rehabilitation goal and primary outcome in prosthetic research studies. Patient-reported outcome measures (PROMs) available to measure prosthetic mobility have practical and psychometric limitations that inhibit their use in clinical care and research.

OBJECTIVE

To develop a brief, clinically meaningful, and psychometrically robust PROM to measure prosthetic mobility.

DESIGN

A cross-sectional study was conducted to administer previously developed candidate items to a national sample of lower limb prosthesis users. Items were calibrated to an item response theory model and two fixed-length short forms were created. Instruments were assessed for readability, effective range of measurement, agreement with the full item bank, ceiling and floor effects, convergent validity, and known groups validity.

SETTING

Participants were recruited using flyers posted in hospitals and prosthetics clinics across the United States, magazine advertisements, notices posted to consumer websites, and direct mailings.

PARTICIPANTS

Adult prosthesis users (N = 1091) with unilateral lower limb amputation due to traumatic or dysvascular causes.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Candidate items (N = 105) were administered along with the Patient Reported Outcome Measurement Information System Brief Profile, Prosthesis Evaluation Questionnaire - Mobility Subscale, and Activities-Specific Balance Confidence Scale, and questions created to characterize respondents.

RESULTS

A bank of 44 calibrated self-report items, termed the Prosthetic Limb Users Survey of Mobility (PLUS-M), was produced. Clinical and statistical criteria were used to select items for 7- and 12-item short forms. PLUS-M instruments had an 8th grade reading level, measured with precision across a wide range of respondents, exhibited little-to-no ceiling or floor effects, correlated expectedly with scores from existing PROMs, and differentiated between groups of respondents expected to have different levels of mobility.

CONCLUSION

The PLUS-M appears to be well suited to measuring prosthetic mobility in people with lower limb amputation. PLUS-M instruments are recommended for use in clinical and research settings.

Health utility in community-dwelling adults with dysvascular lower limb loss

PURPOSE

Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA.

METHODS

Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests.

RESULTS

A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain.

CONCLUSION

Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Therapeutic benefits of lower limb prostheses: a systematic review

BACKGROUND

Enhancing the quality of life of people with a lower limb amputation is critical in prosthetic development and rehabilitation. Yet, no overview is available concerning the impact of passive, quasi-passive and active ankle-foot prostheses on quality of life.

OBJECTIVE

To systematically review the therapeutic benefits of performing daily activities with passive, quasi-passive and active ankle-foot prostheses in people with a lower limb amputation.

METHODS

We searched the Pubmed, Web of Science, Scopus and Pedro databases, and backward citations until November 3, 2021. Only English-written randomised controlled trials, cross-sectional, cross-over and cohort studies were included when the population comprised individuals with a unilateral transfemoral or transtibial amputation, wearing passive, quasi-passive or active ankle-foot prostheses. The intervention and outcome measures had to include any aspect of quality of life assessed while performing daily activities. We synthesised the participants' characteristics, type of prosthesis, intervention, outcome and main results, and conducted risk of bias assessment using the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021290189.

RESULTS

We identified 4281 records and included 34 studies in total. Results indicate that quasi-passive and active prostheses are favoured over passive prostheses based on biomechanical, physiological, performance and subjective measures in the short-term. All studies had a moderate or high risk of bias.

CONCLUSION

Compared to passive ankle-foot prostheses, quasi-passive and active prostheses significantly enhance the quality of life. Future research should investigate the long-term therapeutic benefits of prosthetics devices.

Association between the level of partial foot amputation and gait: a scoping review with implications for the minimum impairment criteria for wheelchair tennis

OBJECTIVE

This scoping review examines how different levels and types of partial foot amputation affect gait and explores how these findings may affect the minimal impairment criteria for wheelchair tennis.

METHODS

Four databases (PubMed, Embase, CINAHL and SPORTDiscus) were systematically searched in February 2021 for terms related to partial foot amputation and ambulation. The search was updated in February 2022. All study designs investigating gait-related outcomes in individuals with partial foot amputation were included and independently screened by two reviewers based on Arksey and O'Malley's methodological framework and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews.

RESULTS

Twenty-nine publications with data from 252 participants with partial foot amputation in 25 studies were analysed. Toe amputations were associated with minor gait abnormalities, and great toe amputations caused loss of push-off in a forward and lateral direction. Metatarsophalangeal amputations were associated with loss of stability and decreased gait speed. Ray amputations were associated with decreased gait speed and reduced lower extremity range of motion. Transmetatarsal amputations and more proximal amputations were associated with abnormal gait, substantial loss of power generation across the ankle and impaired mobility.

CONCLUSIONS

Partial foot amputation was associated with various gait changes, depending on the type of amputation. Different levels and types of foot amputation are likely to affect tennis performance. We recommend including first ray, transmetatarsal, Chopart and Lisfranc amputations in the minimum impairment criteria, excluding toe amputations (digits two to five), and we are unsure whether to include or exclude great toe, ray (two to five) and metatarsophalangeal amputations.

TRIAL REGISTRATION

The protocol of this scoping review was previously registered at the Open Science Framework Registry (https://osf.io/8gh9y) and published.

Health-related quality of life in patients with lower limb amputation - an assessment of the measurement properties of EQ-5D-3L and EQ-5D-5L using data from the Swedish Amputation and Prosthetics Registry

PURPOSE

To assess the measurement properties of EQ-5D-3L and EQ-5D-5L in patients with a major lower limb amputation (LLA).

METHODS

This was a retrospective register-based study using data from the Swedish Amputation and Prosthetics Registry (SwedeAmp). Patients with a six-months follow-up (including either EQ-5D-3L or EQ-5D-5L) after a major unilateral LLA were included. The measurement properties of EQ-5D-3L and EQ-5D-5L were compared in terms of feasibility, response patterns, informativity, and convergent and known-group validity.

RESULTS

The sample included 700 patients with below-knee amputation (76%), above-knee amputation (18%), or knee disarticulation (7%). Responses to EQ-5D-3L and -5L were similar regarding feasibility (98% completion rate) and the proportion reporting no problems (7% and 6%). Compared to EQ-5D-3L, EQ-5D-5L showed higher absolute and relative informativity in all dimensions, with the largest improvement in the mobility dimension. In the analyses of convergent validity, the EQ-5D-5L generally showed stronger correlations with disease-specific measures. Only EQ-5D-5L was able to discriminate between subgroups with different amputation levels.

CONCLUSION

The findings support the use of EQ-5D-5L over EQ-5D-3L in patients with an LLA, mainly due to improved informativity and improved convergent and known-group validity.Implications for rehabilitationThe measurement properties of two EQ-5D versions, EQ-5D-3L and EQ-5D-5L, has so far not been evaluated in patients with a lower limb amputation (LLA)The results support the use of EQ-5D-5L over the use of EQ-5D-3L, mainly due to improved informativity and stronger correlations with disease-specific patient-reported outcome measuresThe five-level version of EQ-5D is recommended for future applications of EQ-5D in clinical outcome studies, health economic evaluations, and in the routine follow-up of patients with a major LLAIn the early rehabilitation process six months after an LLA, the majority of patients reported problems with mobility, pain/discomfort, and usual activities.

Short-term risk prediction after major lower limb amputation: PERCEIVE study

BACKGROUND

The accuracy with which healthcare professionals (HCPs) and risk prediction tools predict outcomes after major lower limb amputation (MLLA) is uncertain. The aim of this study was to evaluate the accuracy of predicting short-term (30 days after MLLA) mortality, morbidity, and revisional surgery.

METHODS

The PERCEIVE (PrEdiction of Risk and Communication of outcomE following major lower limb amputation: a collaboratIVE) study was launched on 1 October 2020. It was an international multicentre study, including adults undergoing MLLA for complications of peripheral arterial disease and/or diabetes. Preoperative predictions of 30-day mortality, morbidity, and MLLA revision by surgeons and anaesthetists were recorded. Probabilities from relevant risk prediction tools were calculated. Evaluation of accuracy included measures of discrimination, calibration, and overall performance.

RESULTS

Some 537 patients were included. HCPs had acceptable discrimination in predicting mortality (931 predictions; C-statistic 0.758) and MLLA revision (565 predictions; C-statistic 0.756), but were poor at predicting morbidity (980 predictions; C-statistic 0.616). They overpredicted the risk of all outcomes. All except three risk prediction tools had worse discrimination than HCPs for predicting mortality (C-statistics 0.789, 0.774, and 0.773); two of these significantly overestimated the risk compared with HCPs. SORT version 2 (the only tool incorporating HCP predictions) demonstrated better calibration and overall performance (Brier score 0.082) than HCPs. Tools predicting morbidity and MLLA revision had poor discrimination (C-statistics 0.520 and 0.679).

CONCLUSION

Clinicians predicted mortality and MLLA revision well, but predicted morbidity poorly. They overestimated the risk of mortality, morbidity, and MLLA revision. Most short-term risk prediction tools had poorer discrimination or calibration than HCPs. The best method of predicting mortality was a statistical tool that incorporated HCP estimation.

Sex and gender differences in quality of life and related domains for individuals with adult acquired lower-limb amputation: a scoping review

PURPOSE

To understand what is known about sex and gender differences in quality of life (QoL) and related domains for individuals with an adult acquired lower limb amputation (LLA).

METHODS

A computer-assisted literature search of four online databases was completed. Articles were included if they incorporated sex or gender as part of their data analysis with a focus on QoL-related domains. Data were analyzed using descriptive numerical analysis and thematic analysis.

RESULTS

One hundred and eleven articles were included in this review. Women were under-represented across studies, with most of the participants being men. No articles described the inclusion of trans or non-binary persons. Differences by sex or gender were reported by 66 articles. Articles reporting on gender seldom provided descriptions of how gender was defined. Overall, women/females seemed to have worse outcomes in terms of prosthesis-related outcomes, mental health, and return to occupations.

CONCLUSION

Articles included in this review were not clear with how gender was defined. In order for more targeted interventions that account for sex and gender differences, studies need to be more forthcoming about how they use and define gender. Future research should seek to include gender non-conforming participants to identify additional needs.Implications for rehabilitationSex and gender are important constructs that influence outcomes following lower limb amputation.Rehabilitation professionals should consider sex and gender-specific outcomes when tailoring programs to ensure ethical clinical care.

Volume Fluctuations in Active and Nonactive Transtibial Prosthetics Users

This study aims to evaluate the validity and reliability of the Biosculptor’s Bioscanner system in capturing transtibial residual limb volume fluctuations in active and nonactive amputees during walking activity. Residual limb volume was obtained by measuring the limb circumference after amputees walked for 5 to 25 minutes for five consecutive days. The comparison of mean circumference between Bioscanner and manual measurements (i.e., tape measure) showed that the Bioscanner gave a higher estimation of circumference for the different amputees. Short-term changes in girth and volume due to an activity such as walking do not fluctuate uniformly. The results reflected as such as nonconsistence circumference change identified at different locations of the circumference profiles. Both amputees experienced a significant increase in circumference at the distal end of the limbs after 5 minutes of walking (7.35% change in nonactive and 8.83% in active amputees), and the measurement decreased as amputees walked longer. At 4-8 cm below the mid-patella tendon (pressure tolerant areas), both amputees experienced minor changes in the size of their circumference. The residual limb volume calculation resulted in the percentage difference between the two methods ranging from 2.4% to 9.3%. Pearson coefficient correlation obtained showed a high correlation between the two techniques, ranging from 0.97 to 1. The analysis of the limit of agreements showed that the majority of measurements were closed to the mean, suggesting that Bioscanner and manual techniques may be interchangeable and agree with one another. This study has implied that Bioscanner is comparable to the standard measurement method and may serve as an alternative tool in managing daily residual limb volume change.

Impact of the COVID-19 restrictions on physical activity and quality of life in adults with lower limb amputation

BACKGROUND

This study investigated the impact of COVID-19 restrictions on ambulatory activity and health-related quality of life (HR-QoL) in people with a lower limb amputation (LLA) in Norway. We hypothesized that the restrictions would negatively affect HR-QoL and decrease prosthetic wear time and ambulatory activity in participants with already limited mobility.

METHODS

Twenty individuals with LLA (age and time since amputation 56.2 ± 11.9 and 22.3 ± 20.1 years, respectively) participated. Ambulatory activity (stepwatch: prosthetic wear time; steps per day; minutes of low-intensity (1-15 steps min-1), moderate-intensity (16-40 steps min-1), and high-intensity ambulation (>40 steps min-1)) and HR-QoL (EQ-5D-5L) data were collected prepandemic and 8-12 months later during pandemic restrictions. Semistructured interviews identified personal experiences of coping with restrictions.

RESULTS

Prosthetic wear time decreased significantly (-1.0 ± 1.5 hours day-1, p < 0.05). Steps per day (440 ± 1481), moderate-intensity and high-intensity ambulation (3.7 ± 23.4, and 4.8 ± 13.9 minutes day-1, respectively), and EQ-5D-5L index (.02 ± .10) increased, whereas low-intensity ambulation decreased (-1.5 ± 16.1 minutes day-1), all nonsignificant changes. Qualitative analysis identified three themes related to coping with restrictions: (1) personal situation, (2) a prosthetic user's perspective, and (3) mindset.

CONCLUSIONS

Increased time spent at home might explain the decreased prosthetic wear time. Contrary to the hypothesis, participants did not decrease their physical activity, and the declined low-intensity ambulation was offset by increased moderate-intensity and high-intensity ambulation. A positive mindset, intrinsic motivation, and health awareness may be important factors for maintaining ambulatory activity and HR-QoL in people with LLA.

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

BACKGROUND

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

OBJECTIVES

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

STUDY DESIGN

Cross-sectional survey.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding the experience of veterans who require lower limb amputation in the veterans health administration

Purpose

There is limited qualitative research on the experience of patients undergoing lower limb amputation due to chronic limb threatening ischemia (CLTI) and their participation in amputation-level decisions. This study was performed to understand patient lived experiences related to amputation and patient involvement in shared decision making.

Materials and methods

Phenomenological interviews were conducted with Veterans 6–12 months post transtibial or transmetatarsal amputation due to CLTI. Interviews were read and summarized by two analysts who discussed the contents of each interview and relationships between interviews to identify emergent, cross-cutting elements of patient experience.

Results

Twelve patients were interviewed between March and August 2019. Three cross cutting elements of patient lived experience and participation in shared decision making were identified: 1) Lacking a sense of decision making; 2) Actively working towards recovery as response to a perceived loss of independence; and 3) Experiencing amputation as a Veteran.

Conclusions

Patients did not report a high level of involvement in shared decision making about their amputation or amputation level. Understanding patient experiences and priorities is crucial to supporting shared decision making for Veterans with amputation due to CLTI.

Factors that Influence Time to Prosthesis Receipt after Lower Limb Amputation: A Cox Proportional Hazard Model Regression

INTRODUCTION

Early mobility, functional independence, and ambulation are associated benefits after LLA, while an increased risk of clinical complications is associated with no prosthesis.

OBJECTIVE

The aims of this study were to describe time to prosthesis receipt after amputation and to assess the impact of patient demographic and health factors on the rate of prosthesis receipt within 12 months post-LLA.

DESIGN

A retrospective cohort analysis using commercial administrative claims data. Kaplan-Meier and Cox proportional-hazards models were applied to assess time to prosthesis receipt.

SETTING

Watson/Truven administrative database 2014-2016.

PARTICIPANTS

Adults age 18-64 with LLA who maintained their current insurance enrollment for 12 months after amputation.

INTERVENTIONS

Independent variables included diabetes/vascular disease status, amputation level, age, sex, and region.

MAIN OUTCOME MEASURE

Prosthesis receipt was defined based on the presence of codes billed for prosthesis services. Time was measured in days from date of amputation surgery.

RESULTS

Among the sample, 510 individuals maintained enrollment for 12 months post-amputation, of which 443 individuals received a prosthesis within that period (79% BK and 21% AK). The adjusted average rate of time to prosthesis receipt was 138 (95% CI: 113-185) days. Individuals with diabetes/vascular disease were 22% (HR: 1.22 95% CI: 1.02-1.49) more likely to receive a prosthesis earlier than individuals without diabetes/vascular disease and females received a prosthesis later than males at 141 (95% CI: 126-162) days vs 106 (95% CI: 96-119) days, respectively.

CONCLUSION

This study expands the understanding of factors that influence the likelihood of receiving a prosthesis along with the timing of prosthesis receipt after LLA among commercially insured adults. At least half of this sample received a prosthesis within 5 months or less. Disparities in timing and access to a prosthesis based on amputation level and sex were noted, future efforts are needed to address these issues. This article is protected by copyright. All rights reserved.

Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations

BACKGROUND

Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation.

OBJECTIVES

To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach.

MAIN RESULTS

We did not identify RCTs that met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.

Geographical Variation in the Management of Peripheral Arterial Occlusive Disease: A Nationwide Danish Cohort Study

OBJECTIVE

Equal access for equal needs is a key goal for many healthcare systems but geographical variation research has shown that this is often not the case in areas other than vascular surgery. This study assessed the variation across specialised vascular centres of an entire healthcare system in the costs and outcomes for patients having first time revascularisation for peripheral arterial occlusive disease.

METHODS

This was a national study of all first time revascularisations performed in the Danish healthcare system between 2009 and 2014. Episodes were identified in the Danish Vascular Registry (n = 10 300) and data on one year follow up in terms of the costs of specialised healthcare (€) and amputation status were acquired from national registers. Generalised gamma and logit regressions were used to predict margins between centres while adjusting for population heterogeneity (age, sex, education, smoking, hypertension, diabetes, use of prophylactic pharmacological therapy, indication and type of revascularisation). Cost effectiveness frontiers were used to identify efficient providers and to illustrate the cost of reducing the system level risk of amputation.

RESULTS

For each of the indications of chronic limb threatening and acute limb ischaemia, the one year amputation risks varied from 11% to 16% across centres (p = .003, p = .006) whereas for intermittent claudication there was no significant difference across centres. The corresponding costs of care varied across centres for all indications (p = .027, p = .028, p = .030). Linking costs and outcomes, three of seven centres were observed to provide poorer quality at higher costs. Exponentially increasing costs to obtain the maximum reduction of the amputation risk were observed.

CONCLUSION

The results suggest that there is substantial variation in the clinical management of peripheral arterial occlusive disease across the Danish healthcare system and that this results in very different levels of efficiency - on top of potentially unequal treatment for equal needs. Further research is warranted.

Functional outcomes and user preferences of individuals with transfemoral amputations using two types of knee joints in under-resourced settings

BACKGROUND

Information relating to prosthetic performance can inform clinical practice and improve patient outcomes in under-resourced countries.

OBJECTIVES

The main goal of this study was to compare functional outcomes and user preferences of individuals with transfemoral amputations using common types of knee joints in an under-resourced country.

STUDY DESIGN

Prospective, longitudinal, before and after trial.

METHODS

Twenty individuals with unilateral transfemoral amputations from a center in Cambodia transitioned from a commonly used single-axis manually locking knee International Committee of the Red Cross (ICRC) to a more advanced multiaxis knee joint with stance control All-Terrain Knee (ATK). Data were collected for the ICRC knee joint and the ATK immediately after fitting, after acclimation, and as part of a long-term follow-up. A timed walk test assessed walking distance and efficiency. Mobility and user-preferences were evaluated through questionnaires.

RESULTS

Distance during the timed walk test was significantly higher for the ATK compared with ICRC (P < 0.001), with functional gains retained at follow-up. No differences were found for gait efficiency and the mobility questionnaires. All participants, except one, preferred the ATK prosthesis. Benefits included greater knee stability and fewer perceived knee collapses; however, some disliked the appearance of the ATK.

CONCLUSIONS

The findings suggest positive outcomes with prosthetic services in under-resourced regions and the ICRC system, as well as the potential for improved functional outcomes with more advanced multiaxis knee components.

Quality of Life Experienced by Major Lower Extremity Amputees

Lower extremity amputations and diabetic foot-related complications in the Caribbean population have been previously reported. However, there is a lack of evidence that assess the quality of life experienced in such amputees. This study aimed to determine the health-related quality of life (HRQoL) in patients after a major lower limb amputation.

Data collection was performed for all major lower limb amputations undertaken at a tertiary care institution in Trinidad and Tobago, between January 2012 to December 2016. The quality of life for patients who were accessible, alive, and willing to participate was assessed using the EuroQol 5D-5L tool. Statistical analysis was performed using the Mann-Whitney U and Kruskal-Wallis tests comparing medians across various subgroups.

A total of 134 individuals were still alive and willing to participate in the study. The average EQ-5D-5L index value for the cohort was (0.598), which was significantly lower compared to EQ-5D-5L population norms for Trinidad and Tobago p < 0.05. Statistically significant differences were also seen in median EQ-5D-5L index value for patients who ambulated with a prosthesis (0.787) compared to those who used another device for mobilization (0.656), p < 0.05, and to those patients who did not ambulate (0.195), p < 0.05. A comparable Quality of life was seen between the level of amputation (transtibial versus transfemoral) and gender (males versus females), p-values were 0.21 and 1.0, respectively.

Overall quality of life after major amputation, as well as independent mobilization with a prosthesis, continues to be problematic in the Caribbean population. Factors adversely related to the quality of life post major amputation include increasing age, problems related to mobility, and non-ambulatory patients.

Validity of measures for life space mobility and physical activity in older adults with lower-limb amputation

BACKGROUND

Older adults with lower-limb amputations (LLAs) often experience lack of confidence and poor balance, which limits their mobility. There are few validated measures for assessing these outcomes in the LLA population.

OBJECTIVES

To assess the validity of the Life Space Assessment (LSA) and the Physical Activity Scale for the Elderly (PASE) for older adults with LLA.

STUDY DESIGN

Secondary analyses of cross-sectional data.

METHODS

Sixty-eight older adults with LLA across Canada were recruited to complete the LSA and the PASE. Validity was assessed via correlations with the Activities-specific Balance Confidence (ABC), Four-Square Step Test (FSST), and Two-Minute Walk Test (2-MWT).

RESULTS

As hypothesized, the LSA was positively correlated with the ABC (ρ = 0.36, 95% confidence interval [CI] [0.17, 0.62]) and 2-MWT (r = 0.49, 95% CI [0.27, 0.70]) and negatively correlated with FSST (ρ = -0.39, 95% CI [-0.56, -0.10]). The PASE was positively correlated with the ABC (ρ = 0.34, 95% CI [0.10, 0.56]) and 2-MWT (ρ = 0.32, 95% CI [0.05, 0.52]), and negatively correlated with FSST (ρ = -0.36, 95% CI [-0.53, -0.07]).

CONCLUSIONS

The LSA has validity in measuring life space mobility. The PASE captures the physical activity with weaker support of validity in older adults with LLA.

CLINICAL RELEVANCE

The LSA and PASE are quick low-cost tools for clinicians to assess mobility-related functional health and physical activity, respectively, in older adults with LLA. However, the PASE may contain activities that are not common among older adults with LLA.

Disease acceptance and social support in patients with peripheral vascular diseases treated in the surgical ward

Aim

The purpose of this study is a comparative analysis of the degree of disease acceptance and social support in patients with peripheral vascular diseases and other medical conditions treated in surgery ward.

Design

A cross‐sectional study.

Methods

This cross‐sectional study compares disease acceptance and social support in a group of 212 patients with peripheral vascular diseases and other conditions treated in surgery ward. A standardized Acceptance of Illness Scale (AIS) and Social Support Scale were used to collect the research data.

Results

Overall, on the AIS, 14% of patients with surgical diseases and 34% of patients with vascular diseases had a low disease acceptance rate. A high level of support was demonstrated in 41% of study participants with surgically treated diseases and in 17% of participants with vascular diseases.

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

Fitting transtibial and transfemoral prostheses in persons with a severe flexion contracture: problems and solutions - a systematic review

PURPOSE

In persons with a hip or knee flexion contracture ≥25°, fitting a prosthesis is said to be difficult. This systematic review aims to assess the evidence for fitting of a prosthesis in persons with a severe contracture (≥25°) after a lower limb amputation.

METHOD

PubMed, Embase, Scopus, CINAHL, and Orthotics & Prosthetics Virtual Library databases were searched from inception to December 2019, using database specific search terms related to amputation, prosthesis, and contracture. Reference lists of included studies were checked for relevant studies. Quality of the included studies was assessed using the critical appraisal checklist for case reports (Joanna Briggs Institute).

RESULTS

In total, 13 case studies provided evidence for fitting of a prosthesis in more than 63 persons with a transtibial amputation and three with a transfemoral amputation, all of whom had a hip or knee flexion contracture ≥25°. Some studies found a reduction in contractures after prosthesis use.

CONCLUSIONS

Several techniques for fitting a prosthesis in case of a flexion contracture ≥25° were found. Contracture reduction occurred in some cases and was possibly related to prosthesis use. Fitting a transtibial or transfemoral prosthesis in persons with a lower limb amputation with a severe flexion contracture is possible.IMPLICATIONS FOR REHABILITATIONThis study provides information on prosthesis prescriptions and adaptations for persons with a transfemoral and transtibial amputation with a flexion contracture ≥25°.The fitting of bent prostheses is not limited by prosthetic components and techniques.Parallel to the use of bent prostheses, it is also important to treat the contracture.

Community ambulation in people with lower limb amputation: An observational cohort study

Lower limb amputation (LLA) is still a health issue requiring rehabilitation and long-term care even in industrial societies. Several studies on subjects with LLA have been focused on the efficacy of rehabilitation and factors influencing the use of prosthesis. However, literature data on the recovery of ability to walk outdoors, and thus to participate in social life in this population is limited.To investigate potential correlations between socio-demographic and clinical factors, and the use of the prosthesis for indoor and/or outdoor walking referred to as community ambulation (CA) in subjects with LLA.An observational cohort study on 687 LLA subjects was conducted. Socio-demographic and clinical characteristics of 302 subjects who received similar rehabilitative treatment with respect to the standard protocol were collected by a telephone survey with a structured questionnaire. The CA recovery, in terms of patient's autonomy and participation, assessed by Walking Handicap Scale, was considered as the main outcome.The univariate analysis demonstrated statistical significant positive correlation between CA and gender (χ2 = 3.901, P = .048); amputation level (χ2 = 24.657, P < .001); pre-LLA (χ2 = 6.338, P = .012) and current work activity (χ2 = 25.192, P < .001); prosthesis use (χ2 = 187.037, P < .01); and time from LLA (r = 0.183, P < .001); increasing age was negatively correlated with the outcome (r = -0.329, P < .001), while pain intensity was not significant. Being male (75.4%); trans-tibial (TT) amputation level (9.79%); working before (3.81%) and after LLA (7.68%); and the prosthesis use (24.63%) increased the probability of CA recovery. Multivariate binary logistic regression analysis confirmed that the prosthesis use (P < .001) and TT amputation level (P = .042) are predictors of a positive outcome (Walking Handicap Scale 4-6).These findings highlight the importance of the use of prosthesis in people with LLA for the restoration of a good capacity of participation (CA), especially in subjects with TT amputation level. The identification of predictive factors may help tailor-made rehabilitation approaches addressing an earlier reintegration to social life.

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.

Utilization Rates of Diagnostic and Therapeutic Vascular Procedures Among Patients Undergoing Lower Extremity Amputations in a Rural Community Hospital: A Clinicopathological Correlation

Background:

Significant geographical variations exist in amputation rates and utilization of diagnostic and therapeutic vascular procedures before lower extremity amputations in the United States. The purpose of this study was to evaluate the rates of diagnostic and therapeutic vascular procedures in the year prior to amputation in a contemporary population and correlate with pathological findings of the amputation specimens.

Methods:

A retrospective analysis was conducted of non-traumatic amputations from 2011 to 2017 at a rural community hospital. We reviewed the proportion of patients undergoing diagnostic (ankle brachial index with duplex ultrasound, computerized tomography angiogram and invasive angiogram) and therapeutic (endovascular and surgical revascularization) vascular procedures in the year prior to amputation. Prevalence of tissue viability and osteomyelitis were evaluated in all amputated specimens and atherosclerotic vascular disease (ASVD) was evaluated in major amputations. We also analyzed primary amputation rates among different subgroups.

Results:

698 patients were included with 248 (36%) major amputations and 450 (64%) minor amputations. Any diagnostic procedure was performed in 59% of the major amputations and 49% of the minor amputations (P = 0.01). Any therapeutic revascularization procedure was performed in 34% of the major amputations and 28% of the minor amputations (P = 0.08). The pathology of major amputation specimens revealed severe ASVD in 57% and mild-moderate ASVD in 27% of specimens. Tissue viability was significantly higher in major amputations (90% vs 30%, P = 0.04) and osteomyelitis was significantly higher in minor amputations (50% vs 14%, P = 0.03). Primary amputations were performed in 66% of major amputations, 72% of minor amputations, 81% with mild to moderate ASVD and 54% with severe ASVD.

Conclusion:

Diagnostic and therapeutic vascular procedures appear under-utilized for patients undergoing lower extremity amputations at a rural community hospital. ASVD rates and tissue viability imply that revascularization could be of significant benefit to avoid major amputation.

Impact of Time to Receipt of Prosthesis on Total Healthcare Costs 12 Months Postamputation

OBJECTIVE

The objective was to assess the impact of a prosthesis and the timing of prosthesis receipt on total direct healthcare costs in the 12-mo postamputation period.

DESIGN

Data on patients with lower limb amputation (n = 510) were obtained from a commercial claims database for retrospective cohort analysis. Generalized linear multivariate modeling was used to determine differences in cost between groups according to timing of prosthesis receipt compared with a control group with no prosthesis.

RESULTS

Receipt of a prosthesis between 0 and 3 mos post lower limb amputation yielded a reduced total cost by approximately 0.23 in log scale within 12 mos after amputation when compared with the no-prosthesis group. Despite the included costs of a prosthesis, individuals who received a prosthesis either at 4-6 mos postamputation or 7-9 mos postamputation incurred costs similar to the no-prosthesis group.

CONCLUSION

Earlier receipt of a prosthesis is associated with reduced spending in the 12 mos postamputation of approximately $25,000 compared with not receiving a prosthesis. The results of this study suggest that not providing or delaying the provision of a prosthesis increases costs by about 25%.

Prevalence of Low Back Pain and Relationship to Mental Health Symptoms and Quality of Life After a Deployment-related Lower Limb Amputation

STUDY DESIGN

Retrospective, cross-sectional study.

OBJECTIVE

To assess the prevalence and association of low back pain (LBP) with psychosocial factors in Service members with amputations.

SUMMARY OF BACKGROUND DATA

LBP is a common secondary health condition after amputation with important implications related to function and quality of life. A growing body of evidence suggests that psychosocial factors influence LBP in patients without amputation. However, there is a dearth of information regarding the association of psychosocial factors and LBP after amputation.

METHODS

Seventy-nine individuals with lower limb amputations who were a part of the Wounded Warrior Recovery Project were included in the analysis. Data on posttraumatic stress disorder (PTSD), depression, and quality of life (QOL) were collected from the Wounded Warrior Recovery Project, while data on LBP and LBP chronicity were extracted from the Military Health System Data Repository. General linear models were utilized to analyze associations between LBP and psychosocial factors, while controlling for injury severity and time since amputation.

RESULTS

In individuals with amputations, 19.0% had acute LBP and 49.4% had recurrent LBP. Individuals with amputations and recurrent LBP reported higher PTSD symptom severity compared with those without LBP (B = 9.213, P < 0.05). More severe depression symptoms were observed in those with amputations and recurrent LBP compared with those without LBP (B = 5.626, P < 0.05). Among individuals with amputations, those with recurrent LBP reported lower QOL compared with those without LBP (B = -0.058, P < 0.05). There were no differences in PTSD, depression or QOL in those with amputations with and without acute LBP.

CONCLUSIONS

Presence of recurrent LBP after amputation appears to be associated with more severe PTSD and depression symptoms as well as lower QOL. Further research is needed to assess the efficacy of addressing psychosocial factors for improving pain and function in service members with amputations and LBP.

LEVEL OF EVIDENCE

3.