Living with Amputation: Anxiety and Depression Correlates

Assessment of Disability and Depression Following Amputation Among Adults in Korea

This nationwide, population-based, retrospective cohort study assesses the risk of depression following amputation among adults in Korea.

Rehabilitation professionals' perspectives of factors influencing return to occupation for people with lower limb amputation in East, South, and Southeast Asian developing countries: A qualitative study

Objective

To identify barriers and enablers for return to occupation (RTO) for people with lower limb amputation (LLA) in East, South, and Southeast Asian developing countries from the perspective of rehabilitation professionals.

Methods

A convenience sample of rehabilitation professionals working in Asian developing countries participated in online in-depth interviews between September 2021 and February 2022. Interview transcripts were analyzed and thematically coded to the modified Health Care Delivery System Approach (HCDSA) framework. COREQ guidelines were followed.

Results

Twenty-eight interviewees from 13 countries shared their experiences of factors related to RTO for people with LLA. Identified factors described barriers and facilitators for RTO at all four HCDSA framework levels. The "environmental" level had the most identified factors (n = 56) and the "care team" level the least (n = 31). Common environmental RTO challenges included cultural attitudes to women; lack of rural/remote services; inadequate numbers and regulation of rehabilitation professionals; inappropriate prosthesis; limited government support for rehabilitation, and reliance on charitable models.

Conclusions

Despite varied cultural, religious, and geographical characteristics, consistent factors impacting RTO were identified within these thirteen countries. Identified barriers to RTO underline the need for improvements throughout service systems from the acute-care focus on saving life without consideration of RTO, the rehabilitation focused primarily on mobility, to the lack of occupational rehabilitation services and supporting policy in these countries. These interlinked factors at different levels of healthcare service systems reinforce the importance of systems approaches to best utilize limited resources toward improving RTO in this region.

Prosthetic vascular graft management in above-knee amputations

OBJECTIVE

Critical limb ischaemia (CLI) is the most severe state of peripheral arterial disease and is one of the major causes of lower-limb amputations. One of the treatment choices is prosthetic vascular grafts. Despite treatment, CLI may lead to amputation owing to infection or progressive ischaemia. The aim of this study was to show that multidisciplinary planning and surgery for CLI patients with prosthetic grafts decreased the duration of hospital stay, costs, risk of infection and ascending conversion of the amputation level.

METHODS

Forty-two above-knee amputation patients with grafts were retrospectively evaluated. Group A patients (n = 24) had partial excision and group B patients ( n = 18) total excision with or without saphenous patch-plasty, according to the patency of the deep femoral artery. Growth in wound culture, antibiotic therapy duration, conversion to hip disarticulation and hospitalisation periods were compared.

RESULTS

Differences in growth of wound culture (p = 0.007), antibiotic duration (p = 0.003), hip disarticulation (p = 0.029) and duration of hospital stay (p = 0.0001) between the two groups were found to be statistically significant (p < 0.05).

CONCLUSIONS

Management of CLI patients is a complex process, and a multidisciplinary approach is key to avoiding undesirable outcomes. Meticulous planning, including excision of the total graft, while ensuring the vascular supply, is essential.

Psychiatric morbidity in individuals with permanent orthopedic disability

BACKGROUND

Individuals with permanent orthopedic disability present with a number of physical and mental health issues. Psychiatric illnesses have been seen more frequently among people with disabilities as compared to normal population.

AIM

To study psychiatric morbidity among people with permanent orthopedic disability.

MATERIALS AND METHODS

This cross-sectional, observational, hospital-based study was conducted at the department of psychiatry of a tertiary care hospital attached to a medical college during January 01, 2018, to December 31, 2018. The study included subjects over the age of 18 years comprising two groups: Group A (n = 50) including consecutive subjects with orthopedic disability and Group B (n = 50) including normal age- and sex-matched controls. Permission was obtained from the institutional ethics committee before the start of the study. Prior informed consent was obtained from all subjects. Sociodemographic variables were recorded, and psychiatric morbidity was screened on Mini International Neuropsychiatric Interview.

RESULTS

62% (n = 31) of subjects in Group A had psychiatric morbidity as compared to Group B (22%, n = 11). Maximum psychiatric morbidity noted among subjects with disability was generalized anxiety disorder (22%, n = 11), followed by major depressive disorder (20%, n = 10) and alcohol dependence (18%, n = 9). Substance dependence was more in Group A (34%, n = 17) as compared to Group B (18%, n = 9). The most common substance dependence was for alcohol (18%, n = 9), followed by opioids (8%, n = 4) and tobacco (6%, n = 3).

CONCLUSION

Psychiatric morbidity including substance dependence is more common among people with orthopedic disability as compared to normal control subjects.

Psychiatric Disease after Isolated Traumatic Upper Extremity Amputation

Introduction  Psychiatric disease after traumatic limb loss impacts rehabilitation, prosthesis use, and quality of life. The purpose of this study was to evaluate the prevalence of psychiatric disease in civilians after isolated, traumatic upper extremity amputation and determine if any risk factors are associated with developing psychiatric disease. Materials and Methods  Demographics, time since injury, mechanism of injury, amputation level, hand affected (dominant vs. nondominant), Bureau of Workers' Compensation (BWC) status, and prosthesis use were retrospectively reviewed for all patients treated from 2012 to 2017. For patients with an International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) diagnosed psychiatric disease, the diagnosis and length of treatment were recorded. Patients were grouped by presence or absence of psychiatric diagnosis and data analysis was performed using descriptive statistics, Fisher's exact test, and relative risk. Results  Forty-six patients met the inclusion criteria. Thirty-one patients (67.4%) had at least one diagnosed psychiatric condition. Major depressive disorder was the most common ( n = 14), followed by posttraumatic stress disorder ( n = 11), adjustment disorder ( n = 11), anxiety ( n = 6), and panic disorder ( n = 2). No statistically significant correlation was seen between psychiatric illness and gender, age at the time of injury, time since injury, current employment status, BWC status, hand injured (dominant vs. nondominant), prosthetic use, or level of amputation. Conclusion  The rates of depression and anxiety after traumatic upper limb loss in the civilian population are similar to reported rates after combat injury. While we were unable to identify a statistically significant association with any of the studied variables, upper extremity surgeons should be aware of the high prevalence of psychiatric disease after traumatic upper extremity amputation.

Influence of Pain on the Quality of Life and Disease Acceptance in Patients with Complicated Diabetic Foot Syndrome

OBJECTIVE

The aim of the study was to evaluate the relationship between pain and quality of life and illness acceptance, anxiety and depression in a group of patients with complicated diabetic foot syndrome, following lower limb amputation.

PATIENTS AND METHODS

The studies were carried out in three stages: 7 days, 6 months and 12 months after surgery in a group of 100 patients after amputation of the lower limb due to complications resulting from type 2 diabetes. The study was performed using standardised instruments: WHOQOL-BREF, the Acceptance of Illness Scale (AIS), the Hospital Anxiety and Depression Scale (HADS), and the Visual Analog Scale (VAS) for pain intensity assessment.

RESULTS

Pain occurred in the examined patients throughout the study. The greatest intensity of pain was observed in the postoperative period and significantly weakened over time. Pain intensity was significantly associated with worse overall QoL perceived (-0.255, p=0.011/-0.283, p=0.005) and QoL scores in the physical and psychological domains at the first and second stage of the study (physical domains -0.257, p=0.011/-0.219, p=0.03 and psychological -0.22, p=0.029/-0.24/0.018). The intensity of pain negatively correlates with the acceptance of the disease in all three stages of the study, the greater the severity of pain, the lower the acceptance of illness (-0.298, p=0.003/-0.326, p=0.001/-0.26, p=0.009). The occurrence of anxiety and depression is highly dependent on the severity of pain, especially at the first and second stage of the study (anxiety 0.203, p=0.045/0.257, p=0.01, depression 0.299, p=0.003/0.253, p=0.012). The stronger the pain, the greater the severity of mood disorders.

CONCLUSION

Pain and its severity are associated with QoL in the patients with complicated diabetic foot syndrome following lower limb amputation. Disease acceptance was lower in patients experiencing more severe pain at all stages of the study. There is an association of pain with the occurrence of anxiety and depression in amputees, especially 6 months after surgery.

Human Gait Analysis and Prediction Using the Levenberg-Marquardt Method

A high-accuracy gait data prediction model can be used to design prosthesis and orthosis for people having amputations or ailments of the lower limb. The objective of this study is to observe the gait data of different subjects and design a neural network to predict future gait angles for fixed speeds. The data were recorded via a Biometrics goniometer, while the subjects were walking on a treadmill for 20 seconds each at 2.4 kmph, 3.6 kmph, and 5.4 kmph. The data were then imported into Matlab, filtered to remove movement artifacts, and then used to design a neural network with 60% data for training, 20% for validation, and remaining 20% for testing using the LevenbergMarquardt method. The mean-squared error for all the cases was in the order of 10-3 or lower confirming that our method is correct. For further comparison, we randomly tested the neural network function with untrained data and compared the expected output with actual output of the neural network function using Pearson's correlation coefficient and correlation plots. We conclude that our framework can be successfully used to design prosthesis and orthosis for lower limb. It can also be used to validate gait data and compare it to expected data in rehabilitation engineering.

Ex vivo limb perfusion for traumatic amputation in military medicine

BACKGROUND

Limb loss has a drastic impact on a patient's life. Severe trauma to the extremities is common in current military conflicts. Among other aspects, "life before limb" damage control surgery hinders immediate replantation within the short post-traumatic timeframe, which is limited in part by the ischemic time for successful replantation. Ex vivo limb perfusion is currently being researched in animal models and shows promising results for its application in human limb replantation and allotransplantation.

PRESENTATION OF THE HYPOTHESIS

The current lack of replantation possibilities in military operations with high rates of amputation can be addressed with the development of a portable ex vivo limb perfusion device, as there are several opportunities present with the introduction of this technique on the horizon. We hypothesize that ex vivo limb perfusion will enable overcoming the critical ischemic time, provide surgical opportunities such as preparation of the stump and limb, allow for spare-part surgery, enable rigorous antibiotic treatment of the limb, reduce ischemia-reperfusion injuries, enable a tissue function assessment before replantation, and enable the development of large limb transplant programs.

TESTING THE HYPOTHESIS

Data from in vivo studies in porcine models are limited by the relatively short perfusion time of 24 h. In the military setting, notably longer perfusion times need to be realized. Therefore, future animal studies must focus especially on long-term perfusion, since this represents the military setting, considering the time for stabilization of the patient until evacuation to a tertiary treatment center.

IMPLICATIONS OF THE HYPOTHESIS

The development and clinical introduction of ex vivo limb perfusion in the military setting could lead to a drastic reduction in the number of limb amputations among service members. Ex vivo limb perfusion enables replantation surgery in Role 4 facilities and changes the clinical setting from a highly urgent, life-threatening situation to a highly methodical, well-prepared starting point for optimal treatment of the wounded service member. With its introduction, the principle of "life before limb" will change to "life before limb before elective replantation/allotransplantation after ex vivo limb perfusion".

Anxiety and depression in patients with peripheral arterial disease admitted to a tertiary hospital

Background

Anxiety and depression are highly prevalent neuropsychiatric conditions and are associated with chronic diseases, pain, loss of autonomy, dependence on others to perform routine activities, and loneliness. Depression often has a cause-and-effect relationship with other diseases, such as: acute myocardial infarction (AMI), systemic arterial hypertension (SAH), diabetes mellitus (DM) and peripheral arterial disease (PAD).

Objectives

To estimate the frequency of anxiety and depression in patients of both sexes with PAD admitted to a tertiary hospital.

Methods

This is a descriptive, cross-sectional study, with a non-random sample selected consecutively. The Hospital Anxiety and Depression Scale (HADS) was used to assess anxiety and depression, and the ankle-brachial index (ABI) was used to assess PAD.

Results

The prevalence of anxiety in these patients was 24.4%, with associations between anxiety and monthly family income, smoking, and SAH. The prevalence of depression was 27.6%, with associations between depression and the female gender, being married or in a stable relationship, living on a family income of one minimum wage or less, not being an alcoholic, and having hypertension.

Conclusions

There are high prevalence rates of anxiety and depressive disorders among patients with PAD, which are underdiagnosed and, hence, not properly treated.