Utilization and Perception of Peer-Support After Lower Limb Loss in the United States: Potential Benefits on Mobility Outcomes

OBJECTIVE

To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes.

DESIGN

Quantitative and qualitative descriptive study with a cross-sectional design.

SETTING

National survey (distributed to 169 peer-support groups in 44 states in the US).

PARTICIPANTS

The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82).

MAIN OUTCOME MEASURES

A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M).

RESULTS

Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055).

CONCLUSION

Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility.

Fatigue, fear of being mobilized and residual limb pain limit independent basic mobility and physiotherapy for patients early after major dysvascular lower extremity amputation: A prospective cohort study

AIM

Early mobilization of patients with a major lower extremity amputation (LEA) is often a challenge because of lack of compliance. Therefore, we investigated factors limiting independent mobility and physiotherapy on the first day with physiotherapy (PTDay1) and the following 2 days after LEA.

METHODS

A total of 60 consecutive patients, mean age 73.7 years (SD 12.1 years), undergoing LEA were included over a period of 7 months. The Basic Amputee Mobility Score was used to assess basic mobility. Predefined limitations for not achieving independent mobility or not completing physiotherapy were residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea/vomiting, acute cognitive dysfunction or "other" factors reported on PTDay1 and the following 2 days after LEA.

RESULTS

Fatigue and fear of being mobilized were the most frequent limitations for not achieving independent mobility on PTDay1 and the following 2 days after LEA. Patients (n = 55) who were not independent in the Basic Amputee Mobility Score activity transferring from bed to chair on PTDay1 were limited by fatigue (44%) and fear of being mobilized (33%). A total of 21 patients did not complete planned physiotherapy on PTDay1, and were limited by fatigue (38%), residual limb pain (24%) and "other" factors (24%).

CONCLUSION

Fatigue and fear of being mobilized were the most frequent factors that limited independent mobility early after LEA. Fatigue, residual limb pain and "other" factors limited completion of physiotherapy. Geriatr Gerontol Int 2024; 24: 470-476.

Health-related quality of life in patients with extremity bone sarcoma after surgical treatment: a systematic review

PURPOSE

We conducted a systematic review of studies reporting on measurement of health-related quality of life (HRQoL), with a special focus on the use of the preference-weighted instruments, in patients with extremity bone sarcoma treated with limb-salvage surgery or amputation.

METHODS

We searched MedLine, Embase, Cochrane Library and Web of Science for English-language studies reporting on HRQoL of patients with bone sarcoma from inception to 28 August 2023. All records found were independently reviewed by two reviewers. We used the Newcastle-Ottawa Scale (NOS) and the CONSORT 2010 checklist to assess the quality of the cohort and randomised studies, respectively.

RESULTS

The search identified 1225 records, of which 16 studies were included for data extraction. Only one study used a preference-weighted instrument for measuring HRQoL in a small sample of patients (n = 28). Ten studies used the generic SF-36 questionnaire, but no preference-weighted HRQoL based on SF-6D was derived from the SF-36 scores. Most studies comparing HRQoL between amputation and limb-salvage surgery reported no significant differences. Twelve cohort studies scored six or more out of nine points based on the NOS. The only randomised study scored 54% on the CONSORT 2010 checklist.

CONCLUSIONS

The approaches used to measure HRQoL were inconsistent and outcome scores varied substantially. Only one study used preference-weighted instruments for HRQoL measurement. Future research into the surgical treatment of extremity bone sarcoma should consider the use of preference-weighted instruments to measure HRQoL, which will therefore enable economic evaluation for the growing orthopaedic armamentarium of novel surgical interventions.

REGISTRATION

This systematic review was registered with the PROSPERO International prospective register of systematic reviews (CRD42021282380).

Quality of life in lower limb amputees: a cross-sectional study from a tertiary care center of South India

BACKGROUND

Various literature have dealt with the physical aspect of amputation and the functional outcome after amputation. There are a few studies that give focused attention to the quality of life (QOL) of amputees. These studies are mostly from the developed countries. This study analyzed amputation as a whole and how it affects an individual physically, psychologically, emotionally, and socially, which would enable the health care providers to help the amputees to attain a better QOL.

STUDY DESIGN

Cross-sectional study.

MATERIALS AND METHODS

This cross-sectional study was conducted on lower limb amputees. Data were collected using a proforma for demographic details and two pretested questionnaires-the World Health Organization QOL-Bref and prostheses-specific Trinity Amputation and Prosthesis Experience Scales-Revised questionnaires. The data were analyzed using SPSS software, version 20.

RESULTS

Amputation significantly affects all domains of the QOL. Age was a significant determinant of QOL of amputees, and it was found that the QOL decreased with an increase in age. 48.1% of the amputees were using a prosthetic device, and they were found to have a significantly better QOL. The prevalence of residual limb pain and phantom limb pain was 52.9% and 37%, respectively.

CONCLUSION

Nearly half of the population perceived that their QOL was neither poor nor good. The QOL of the physical domain was better than the other domains. The most important factors that were found to be associated with QOL of amputees were age, duration since amputation, and use of prosthesis.

Structural validity and reliability of the patient experience measure: A new approach to assessing psychosocial experience of upper limb prosthesis users

Recent advances in upper limb prosthetics include sensory restoration techniques and osseointegration technology that introduce additional risks, higher costs, and longer periods of rehabilitation. To inform regulatory and clinical decision making, validated patient reported outcome measures are required to understand the relative benefits of these interventions. The Patient Experience Measure (PEM) was developed to quantify psychosocial outcomes for research studies on sensory-enabled upper limb prostheses. While the PEM was responsive to changes in prosthesis experience in prior studies, its psychometric properties had not been assessed. Here, the PEM was examined for structural validity and reliability across a large sample of people with upper limb loss (n = 677). The PEM was modified and tested in three phases: initial refinement and cognitive testing, pilot testing, and field testing. Exploratory factor analysis (EFA) was used to discover the underlying factor structure of the PEM items and confirmatory factor analysis (CFA) verified the structure. Rasch partial credit modeling evaluated monotonicity, fit, and magnitude of differential item functioning by age, sex, and prosthesis use for all scales. EFA resulted in a seven-factor solution that was reduced to the following six scales after CFA: social interaction, self-efficacy, embodiment, intuitiveness, wellbeing, and self-consciousness. After removal of two items during Rasch analyses, the overall model fit was acceptable (CFI = 0.973, TLI = 0.979, RMSEA = 0.038). The social interaction, self-efficacy and embodiment scales had strong person reliability (0.81, 0.80 and 0.77), Cronbach's alpha (0.90, 0.80 and 0.71), and intraclass correlation coefficients (0.82, 0.85 and 0.74), respectively. The large sample size and use of contemporary measurement methods enabled identification of unidimensional constructs, differential item functioning by participant characteristics, and the rank ordering of the difficulty of each item in the scales. The PEM enables quantification of critical psychosocial impacts of advanced prosthetic technologies and provides a rigorous foundation for future studies of clinical and prosthetic interventions.

Disability, pain, and wound-specific concerns self-reported by adults at risk of limb loss: A cross-sectional study using the World Health Organization Disability Assessment Schedule 2.0

Introduction

There has been limited study of patient-reported outcomes (PROs) in patients at risk of limb loss. Our primary objective was to estimate the prevalence of disability in this patient population using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0).

Materials and methods

We recruited patients referred to a limb-preservation clinic. Patients self-reported their disability status using the 12-domain WHODAS 2.0. Severity of disability in each domain was scored from 1 = none to 5 = extreme and the total normalized to a 100-point scale (total score ≥25 = clinically significant disability). We also asked patients about wound-specific concerns and wound-related discomfort or distress.

Results

We included 162 patients. Reasons for clinic referral included arterial-insufficient (37.4%), postoperative (25.9%), and mixed etiology (10.8%) wounds. The mean WHODAS 2.0 disability score was 35.0 (standard deviation = 16.0). One-hundred-and-nineteen (73.5%) patients had clinically significant disability. Patients reported they had the greatest difficulty walking a long distance (mean score = 4.2), standing for long periods of time (mean score = 3.6), taking care of household responsibilities (mean score = 2.7), and dealing with the emotional impact of their health problems (mean score = 2.5). In the two-weeks prior to presentation, 87 (52.7%) patients expressed concern over their wound(s) and 90 (55.6%) suffered a moderate amount or great deal of wound-related discomfort or distress. In adjusted ordinary least squares regression models, although WHODAS 2.0 disability scores varied with changes in wound volume (p = 0.03) and total revised photographic wound assessment tool scores (p<0.001), the largest decrease in disability severity was seen in patients with less wound-specific concerns and wound-related discomfort and distress.

Discussion

The majority of people at risk of limb loss report suffering a substantial burden of disability, pain, and wound-specific concerns. Research is needed to further evaluate the WHODAS 2.0 in a multicenter fashion among these patients and determine whether care and interventions may improve their PROs.

Falls in unilateral lower limb amputees living in the community. A Portuguese study

INTRODUCTION

Lower limb amputees present a high risk of falling. This study aims to characterise fall history in unilateral lower limb amputees that are autonomous in the community, identifying differences between transfemoral and transtibial amputees and assessing fear of falling between fallers and non-fallers.

MATERIAL AND METHODS

Descriptive, cross-sectional study of consecutive community-dwelling unilateral lower limb adult amputees of any aetiology, attending outpatient consultation in a Portuguese Physical and Rehabilitation Medicine central and university hospital department.

INCLUSION CRITERIA

a prior 12 week individualised rehabilitation program for prosthesis training; regular prosthesis use for more than one year with autonomous gait; and a Functional Independence Measure® score equal to or greater than 100. Injury severity was classified according to the National Database of Nursing Quality Indicators® injury falls measure. In order to assess walking performance over short distances and fear of falling we used the 10-meter walk test and the Falls Efficacy Scale, respectively.

RESULTS

In a sample of 52 lower limb amputees, mainly men (80.8%) and of traumatic aetiology (63.5%), with a mean age of 57.21 ± 11.55 years, 36.5% reported at least one fall in the previous 12 months, all classified as minor injuries. Transfemoral amputees (n = 23) presented a higher number of falls (2.22 ± 3.23, p = 0.025) and lower gait velocity (0.77 ± 0.26 m per second, p < 0.001). Regarding fear of falling, we found no significant differences between fallers and non-fallers.

DISCUSSION

The prevalence of falls was low and of minor severity. Transfemoral amputees fell more often and were slower. There were no reported differences in fear of falling between groups.

CONCLUSION

This paper contributes information about Portuguese lower limb amputees, whose studies are scarce and are rarely dedicated to falling.

Effects of microprocessor-controlled prosthetic knees on self-reported mobility, quality of life, and psychological states in patients with transfemoral amputations

OBJECTIVE

This study aimed to determine the effects of the microprocessor-controlled prosthetic knee (MPK) joint on self-mobility, body perceptions, depression, and quality of life in patients with unilateral transfemoral amputations (TFAs).

METHODS

Thirty consecutive patients (28 males, mean age=38.5 years, age range=22-57) who had previously used non-MPKs and who were approved to use swing and stance phase-control MPKs were included in this 12-week clinical study. Before the MPK use and after the three-month follow-up, prosthetic use and locomotor capabilities were evaluated using the Houghton Scale and the Locomotor Capabilities Index (LCI-5), respectively. Body perception was assessed using the Amputee Body Image Scale (ABIS). The depressive symptoms and quality of life were evaluated using the Beck Depression Inventory (BDI) score and the 36-Item Short- Form Health Survey (SF-36), respectively.

RESULTS

After MPK use, statistically significant ameliorations were observed in all outcome measures. The basic and advanced LCI-5 increased from 26.7±2.2 and 24.8±5.2 to 27.6±1.2 (p=0.007) and 27±2.1 (p=0.004), respectively. Houghton scores improved from 9±1 to 10.3±0.8 (p=0.000). The ABIS and BDI scores decreased from 43.2±10.9 and 5.7±6.6 to 37.1±8.9 (p=0.000) and 3.8±4.5 (p=0.015), respectively. Also, the SF-36 physical function and vitality subscales increased from 71.2±24.0 and 75.5±14.6 to 85.6±16.6 (p=0.001) and 81.7±14.1 (p=0.015), respectively.

CONCLUSION

MPK use provides significant improvements in the locomotor capabilities, quality of life, and activities of daily living to patients with TFAs as well as improves their body image perceptions and depressive symptoms.

LEVEL OF EVIDENCE

Level III, Self controlled study.

Impedance Control Strategies for Enhancing Sloped and Level Walking Capabilities for Individuals with Transfemoral Amputation Using a Powered Multi-Joint Prosthesis

INTRODUCTION

Powered prostheses are a promising new technology that may help people with lower-limb loss improve their ability to perform locomotion tasks. Developing active prostheses requires robust design methodologies and intelligent controllers to appropriately provide assistance to the user for varied tasks in different environments. The purpose of this study was to validate an impedance control strategy for a powered knee and ankle prosthesis using an embedded sensor suite of encoders and a six-axis load cell that would aid an individual in performing common locomotion tasks, such as level walking and ascending/descending slopes.

MATERIALS AND METHODS

Three amputees walked on a treadmill and four amputees walked on a ramp circuit to test whether a dual powered knee and ankle prosthesis could generate appropriate device joint kinematics across users.

RESULTS

Investigators found that tuning 2-3 subject-specific parameters per ambulation mode was necessary to render individualized assistance. Furthermore, the kinematic profiles demonstrate invariance to walking speeds ranging from 0.63 to 1.07 m/s and incline/decline angles ranging from 7.8° to 14°.

CONCLUSION

This work presents a strategy that requires minimal tuning for a powered knee & ankle prosthesis that scales across a nominal range of both walking speeds and ramp slopes.

Qualitative study exploring patients experiences of being diagnosed and living with primary bone cancer in the UK

OBJECTIVE

The aim of this study is to explore the experiences of patients with primary bone cancer.

DESIGN

Qualitative study design using semistructured interviews and focus groups.

SETTING

Hospitals across the UK and recruitment through UK sarcoma charities and support groups.

METHODS

Semistructured telephone/face-to-face interviews and focus groups with a purposive sample of 26 participants. Data were analysed using Framework Analysis.

PARTICIPANTS

Patients (n=26) with primary bone cancer aged 13-77 years. The majority were male (69%), white (85%); diagnosed within 4 years (54%); and had lower limb sarcoma (65%). Ten participants had undergone an upper/lower limb amputation (39%).

RESULTS

The health-related quality-of-life domains of physical, emotional and social well-being and healthcare professionals' role were the overarching themes of analysis. The physical domain anchored patient experiences. The intensity and length of treatment, the severity of side-effects, the level of disability after surgery and the uncertainty of their prognosis had an impact on patient's self-image, confidence, mood and identity, and caused disruption to various aspects of the patients' social life, including their relationships (emotional and sexual) and participation in work/school and leisure activities. Adaptation was influenced by the way patients dealt with stress and adversity, with some finding a new outlook in life, and others struggling with finding their 'new normal'. Family and friends were the main source of support. Healthcare professional's expertise and support was critical. Rehabilitation services had a considerable role in patient's physical and emotional well-being, but inequitable access to these services was apparent.

CONCLUSIONS

This study described the impact of primary bone cancer on patients' well-being and adjustment over time with the identification of influencing factors of better/worse experiences. It showed that impact was felt after end of treatment and affected patients at different life stages. Holistic models of survivorship care are needed.

Time-related changes in quality of life in persons with lower limb amputation or spinal cord injury: protocol for a systematic review

BACKGROUND

Experiencing a lower limb amputation (LLA) or spinal cord injury (SCI) is a life-changing event, affecting physical and systemic function as well as having psychological and social impacts. However, the severity of the physical impairment and/or motor disability demonstrates a poor relationship with patient-reported quality of life, suggesting that other factors determine such outcomes. As such, holistic health-related quality of life (QoL) assessment is an important tool to monitor long-term outcomes. While there are some studies that have assessed the influence of variables such as age at time of injury occurrence and time since injury on changes in QoL, there are no systematic reviews which synthesise this evidence.

METHODS/DESIGN

All follow-up study designs will be included, where data from multiple time points are presented. Searches will target both SCI and LLA populations where a validated measure of QoL has been used: Medical Outcome Study Short-Form 36/12 or the World Health Organization Quality of Life instruments 100 and BREF. Studies must include adult participants (≥ 18 years at time of injury) and detail time since injury event and patient age. The primary objective is to establish the effects of participant age and time since injury on QoL scores. Secondary objectives include determining between-group effects (i.e. LLA vs. SCI). We will search PubMed, Embase and Web of Science databases, supplemented by hand-searching references within existing review articles and experimental studies. Reviewer pairs will conduct screening and quality assessment of included papers. Results will be stratified by impairment, QoL tool, age/time since injury and additional variables such as sex, race, comorbidity or disease aetiology, as appropriate. If sufficient high-quality data exist, a meta-analysis will be conducted.

DISCUSSION

The results of this systematic review will summarise evidence of how QoL changes across the life course, relative to both patient age and time since injury, for both LLA and SCI populations. By enabling a direct comparison of different chronic conditions, disability-specific differences in QoL changes over the life course can be identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018096633 .

Quality of Life in Individuals With Peripheral Arterial Disease Who Underwent Toe Amputations: A Descriptive, Cross-sectional Study

Studies have shown above- or below-the-knee amputation has a profound impact on physical, mental, and emotional health; the impact of having a toe(s) amputated is unknown.

PURPOSE

This descriptive research study measured health-related quality of life (HRQoL) using the Vascular Quality-of-Life Questionnaire-6 (VascuQol-6) among persons with peripheral arterial disease (PAD) who had undergone toe amputations.

METHODS

A list of 127 patients discharged from the hospital in 2016 with a diagnosis of PAD and toe amputation was provided to the investigator. The independent variables of age (subsequently divided into groups of persons <65 and ≥65 years of age), gender, race, diabetes mellitus, and time of PAD diagnosis (within the year or 2 to 7 years before 2016) were abstracted from the patient charts. A letter was mailed to potential participants that explained the study and the VascuQol-6 tool, along with a prepaid envelope to return the completed tool. The VascuQol-6 tool is a valid and reliable instrument for assessing HRQoL that covered the different aspects of quality of life (QoL) affected by PAD. The tool contains six 4-point Likert scale questions about activity, symptoms, pain, emotional status, and social life, resulting in a total score between 6 and 24. Higher values indicate better perceived quality of life. Variables were analyzed using frequencies, percentages, means, and standard deviations, and a standard t test was used to compare interval scale items. Statistical significance was noted when P <.05.

RESULTS

Thirty-eight (38) completed surveys were returned (30% completion rate). The mean total score was 15.5 ± 3.93 (range 7-24), and the mean overall score of the 6 items was 2.66 ± 0.90 (range 1-4). In addition to a low overall QoL score, the data showed QoL was negatively affected in every area assessed, but some participants were strongly affected whereas others were not affected at all. No significant differences in QoL scores were noted concerning age groups, gender, race, the presence of diabetes mellitus, or time since PAD diagnosis.

CONCLUSION

In this study, patients with PAD and toe amputations had low QoL scores related to their disease. Additional research is needed to better understand HRQoL related to PAD to facilitate education of patients considering toe amputation.

Psychosocial factors associated with poor outcomes after amputation for complex regional pain syndrome type-I

Background

Amputation for longstanding therapy resistant complex regional pain syndrome type-I (CRPS-I) is controversial. Reported results are inconsistent. It is assumed that psychological factors play a role in CRPS-I.

Objective

To explore which psychological factors prior to amputation are associated with poor outcomes after amputation in the case of longstanding therapy resistant CRPS-I.

Methods

Between May 2008 and August 2015, 31 patients with longstanding therapy resistant CRPS-I were amputated. Before the amputation 11 psychological factors were assessed. In 2016, participants had a structured interview by telephone and filled out questionnaires to assess their outcome. In case of a perceived recurrence of CRPS-I a physician visited the patient to examine the symptoms. Associations between psychological factors and poor outcomes were analysed.

Results

Four of the 11 psychological factors were associated with poor outcomes. Regression analyses showed that change in the worst pain in the past week was associated with poor social support (B = 0.3, 95% confidence interval: 0.1;0.6) and intensity of pain before amputation (B = 2.0, 95% confidence interval 0.9;3.0). Patients who reported important improvements in mobility (n = 23) had significantly higher baseline resilience (median 79) compared to those (n = 8) who did not report it (median 69)(Mann-Whitney U, Z = -2.398, p = 0.015). Being involved in a lawsuit prior to amputation was associated with a recurrence in the residual limb (Bruehl criteria). A psychiatric history was associated with recurrence somewhere else (Bruehl criteria).

Conclusion

Poor outcomes of amputation in longstanding therapy resistant CPRS-1 are associated with psychological factors. Outstanding life events are not associated with poor outcome although half of the participants had experienced outstanding life events.

Towards functional restoration for persons with limb amputation: A dual-stage implementation of regenerative agonist-antagonist myoneural interfaces

While amputation has traditionally been viewed as a failure of therapy, recent developments in amputation surgery and neural interfacing demonstrate improved functionality and bidirectional communication with prosthetic devices. The agonist antagonist myoneural interface (AMI) is one such bi-directional neural communication model comprised of two muscles, an agonist and an antagonist, surgically connected in series within the amputated residuum such that contraction of one muscle stretches the other. By preserving agonist-antagonist muscle dynamics, the AMI allows proprioceptive signals from mechanoreceptors within both muscles to be communicated to the central nervous system. Preliminary human evidence suggests that AMIs have the capacity to provide high fidelity control of a prosthetic device, force feedback, and natural proprioception. However, AMIs have been implemented only in planned amputations and require healthy distal tissues, whereas the majority of amputations occur in patients who do not have healthy distal tissues. Through the use of a dual-stage surgical procedure which leverages existent tissues, this study proposes a revision model for implementation of the AMI in patients who are undergoing traumatic amputation or have already undergone a standard amputation. This paper validates the resulting AMI's physiology, revealing robust viability and mechanical and electrophysiological function. We demonstrate the presence of H-waves in regenerative grafts, indicating the incorporation of the AMI into physiological reflexive loops.

Quality of life of diabetes amputees following major and minor lower limb amputations

INTRODUCTION

Minor amputation was performed as a salvage procedure because most of the patients were not able to ambulate and become dependent following major amputation. Minor amputation is defined as amputation at the level of ankle joint and below while major amputation is defines by amputation above the ankle joint. The aim of this study was to compare the quality of life among diabetes patients following major and minor amputations.

METHODS

A total of 94 diabetes patients were reviewed six months following amputation. Their walking ability, dependency status and quality of life were evaluated, using the Malay translated version of the Short Form Health Survey 36 (SF-36) questionnaire.

RESULTS

During the follow up only three patients (8.3%) following major amputation were dependant compared to 30 patients (51.7%) following minor amputation. Forty-nine (84.5%) of minor amputation and only 15 (41.7%) of major amputation patients were ambulating independently. Patients with minor amputation have significantly better Physical functioning, Role - physical, General health, Role - emotional, and Mental health score (p<0.001). However, they have worse BP and SF score than those following major amputation (p<0.001). The VT score of both groups were not significantly different.

CONCLUSION

Patients with minor amputation are more independent, ambulatory and had better quality of life than those with major amputation. Despite the risk of persistent infection and amputation stump complication, minor amputation should be attempted in diabetes patients.

Pain Support for Adults with a Diabetes-Related Lower Limb Amputation: an Empirical Phenomenology Study

BACKGROUND

Chronic pain after lower extremity amputation surgery has been reported in up to 80% of patients. Amputations are among the most debilitating chronic complication of diabetes with a variety of consequences including depression, inability to perform daily activities, and change in quality of life.

AIMS

This study sought to understand the lived experience of chronic pain support among those who have undergone a diabetes-related lower limb amputation.

METHOD

Researchers used a qualitative empirical phenomenology design. Private, semistructured interviews were conducted on a purposive sample (N = 11). Codes were identified for each participant separately and then across participants for common themes.

RESULTS

Three major themes emerged from the research: (1) Phantom pain is nontreatable pain; (2) support systems were nonempathetic; and (3) participants experienced identification of a new normal. Participants did not understand that neuropathic (phantom) pain was part of the total pain experience. Further, they felt that there was no help from family or providers for alleviation of this pain.

CONCLUSIONS

Phantom pain was identified as something the participants had to tolerate when it occurred. They did not feel that family or providers understood their pain. Further, they wanted a means of controlling their pain using nonpharmacologic therapies.

Bicycling participation in people with a lower limb amputation: a scoping review

BACKGROUND

To review literature on bicycling participation, as well as facilitators and barriers for bicycling in people with a lower limb amputation (LLA).

METHODS

Peer-reviewed, primary, full text, studies about bicycling in people with a LLA from midfoot level to hemipelvectomy were searched in Pubmed, Embase, Cinahl, Cochrane library, and Sportdiscus. No language or publication date restrictions were applied. Included full-text studies were assessed for methodological quality using the Effective Public Health Practice Project tool. Data were extracted, synthesized and reported following Preferred Reporting Items for Systematic Review.

RESULTS

In total, 3144 papers were identified and 14 studies were included. The methodological quality of 13 studies was weak and 1 was moderate. Bicycling participation ranged from 4 to 48%. A shorter time span after LLA and a distal amputation were associated with a higher bicycling participation rate particularly for transportation. In people with a transtibial amputation, a correct prosthetic foot or crank length can reduce pedalling asymmetry during high-intensity bicycling. People with limitations in knee range of motion or skin abrasion can use a hinged crank arm or a low profile prosthetic socket respectively.

CONCLUSION

People with a LLA bicycled for transportation, recreation, sport and physical activity. Adaptation of prosthetic socket, pylon and foot as well as bicycle crank can affect pedalling work and force, range of motion, and aerodynamic drag. Because the suggestions from this review were drawn from evidences mostly associated to competition, prosthetists should carefully adapt the existing knowledge to clients who are recreational bicyclists.

Prosthesis satisfaction in lower limb amputees: A systematic review of associated factors and questionnaires

BACKGROUND

Factors influencing patient satisfaction with a transtibial prosthesis have been studied fragmentarily. The aims of this systematic review were to review the literature regarding factors of influence on patient satisfaction with a transtibial prosthesis, to report satisfaction scores, to present an overview of questionnaires used to assess satisfaction and examine how these questionnaires operationalize satisfaction.

METHODS

A literature search was performed in PubMed, Embase, PsycInfo, CINAHL, Cochrane, and Web of Knowledge databases up to February 2018 to identify relevant studies.

RESULTS

Twelve of 1832 studies met the inclusion criteria. Sample sizes ranged from 14 to 581 participants, mean age ranged from 18 to 70 years, and time since amputation ranged from 3 to 39 years. Seven questionnaires assessed different aspects of satisfaction. Patient satisfaction was influenced by appearance, properties, fit, and use of the prosthesis, as well as aspects of the residual limb. These influencing factors were not relevant for all amputee patients and were related to gender, etiology, liner use, and level of amputation. No single factor was found to significantly influence satisfaction or dissatisfaction. Significant associations were found between satisfaction and gender, etiology, liner use, and level of amputation.

CONCLUSION

Relevance of certain factors for satisfaction was related to specific amputee patient groups. Questionnaires assessing satisfaction use different operationalizations, making comparisons between studies difficult.

Function and quality of life among primary osteosarcoma survivors in Iran: amputation versus limb salvage

PURPOSE

This study aimed to evaluate the psychometric properties of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) in Iranian osteosarcoma patients and apply this to compare the functional level, quality of life, symptoms and financial burden of the patients who underwent amputation and limb-salvage operations.

METHODS

This study was conducted at the main referral orthopedic centers in the southwest of Iran from 2006 to 2016. After complete review of medical records, 48 patients were invited to attend the outpatient clinic and participate in the study via initial telephone interview. All data were entered in the Statistical Package for the Social Sciences version 15.0, and p values <0.05 were considered statistically significant.

RESULTS

In total, 48 patients with extremities osteosarcoma completed the study. Of these, 31 had been treated with limb-salvage operation and 17 had undergone amputation. In functioning subscale, all the mean score of items, except social function, were higher in the limb salvage group than the amputee group. The mean scores (SD) of global health and quality of life were 64.5(13.2) and 61.2± 12.4 in the limb salvage and amputee groups, respectively. In the financial impact subscale, the mean score (SD) in the limb salvage group was 68.8± (29.7) compared to 74.5(25.0) in the amputee group.

CONCLUSION

Results support the responsiveness of the EORTC QLQ-C30 for Iranian osteosarcoma patients. Applying this questionnaire revealed similar functional outcome, quality of life, symptoms and financial burden between amputation and limb-salvage groups.

'If I can walk that far': space and embodiment in stories of illness and recovery

Illness and recovery transform embodied experience, and transform the experience of space. Space, in turn, is a valuable resource in the telling of an illness narrative. Starting from a phenomenological perspective that takes the body to be the centre of experience, and hence of selfhood and storytelling, this article offers an argument for and an approach to analysing space as a narrative resource in stories about illness and recovery. Using a case study of one woman's stories about her amputation, it demonstrates how both narrated space and narrating space can be used as devices to structure the narrative and position its characters and interlocutors to construct the narrator's embodied experiences and identities. The article reveals intersections between embodied experience, space, and narrative identity construction, offering a new way of attending to illness narratives and a new way of engaging with narrative space.

Clinical Experience with Psychological Aspects in Pediatric Patients Amputated for Malignancies

Aims and background

Amputation surgery in pediatric patients suffering from malignant tumors is less common than in the past, but has a great emotional impact on patients and their families as well as on the medical team. Studies addressing the psychological aspects of limb amputation in childhood cancer are still relatively limited, and the results have sometimes been contradictory.

Methods

At the Pediatric Oncology Unit of the Istituto Nazionale Tumori of Milan psychological support was provided to candidates for amputation and their families, involving medical oncologists, a clinical psychologist, and social assistants. Twenty-two patients were analyzed and 16 underwent mutilating surgery.

Results

Different emotional reactions were observed. Surgery proved to be easier to accept when the tumor caused pain and functional loss. Specialist medical psychological support was needed in case of defense mechanisms (eg, splitting and projection) and depressive reactions evolving into isolation or intolerance.

Conclusions

The reported experience could be helpful in providing adequate support to children with tumors requiring mutilating surgery.

[The endo-exo prosthesis treatment concept : Improvement in quality of life after limb amputation]

Osseointegrated, percutaneous implants as the force bearer for exoprosthetics after limb amputation have been used in individual cases for clinical rehabilitation of amputees during the past years. Most experience in this field in Germany has been accumulated at the Sana Klinik in Lübeck with the so-called endo-exo prosthesis (EEP) system. The two-step implantation procedure can now be considered as reliable. Following a well-documented learning curve initial soft tissue problems concerning the cutaneous stoma can now be regarded as exceptions. The retrospective examination of the results concerning by now more than 100 patients provided with an endo-exo femoral prosthesis (EEFP) showed a very satisfying outcome concerning objective as well as subjective values, such as duration of daily use and wearing comfort of the exoprosthesis. Regaining the ability of osseoperception due to the intraosseous fixation is described by the patients as a great advantage. The step from a socket prosthesis to an EEP is felt to be a big increase in quality of life by nearly all patients included into the follow-up. Nearly all of the patients questioned would choose an endo-exo prosthesis again. Meanwhile, the success of the EEP resulted in the broadening of indications from above-knee amputations to transtibial as well as transhumeral amputations. The results are likewise encouraging. The use of EEP for the upper limbs leads to substantial improvement in the range of motion of the shoulder joint with the intramedullary anchored percutaneous implant. Furthermore, new pathbreaking possibilities in the fixation of myoelectrically controlled arm prostheses may arise from the EEP technique.

Perceived Concerns of Patients at Risk for Lower Extremity Amputation

Despite a good understanding of risk factors for amputation and the development of multidisciplinary amputation prevention teams, thousands of lower limb amputations are performed on a daily basis. These amputations are often transformative events in the lives of patients with functional, psychological, social, and economic implications.

OBJECTIVE

The objective of this investigation is to qualitatively and quantitatively explore the perceived concerns of patients with chronic wounds at risk for lower extremity amputation.

MATERIALS AND METHODS

A guided, physician-administered survey was completed by consenting participants. The survey consisted of both open-ended questions and a 10-point scale for specific questions on a variety of potential patient concerns.

RESULTS

Although some questions resulted in relatively high and low mean scores, 9 of the 13 specific questions produced a range of responses on a 10-point modified Likert scale. This indicates that there are not necessarily universal patient concerns and that every patient is different and should be treated as such. With that being said, however, the highest levels of concern (mean measurements ≥ 7/10) had to do with recurrence, function, walking, and self-sufficiency. The lowest levels of concern (mean measurement ≤ 5/10) had to do with pain, shoe gear considerations, cost, and cosmetic appearance of an amputation.

CONCLUSIONS

It is the authors' hope that this investigation provides wound care professionals with information that will benefit their approach to the education and treatment of patients at risk for amputation as well as lead to future investigations into the emotional and psychological state of patients with chronic lower extremity wounds.

The quality of life analysis of knee prosthesis with complete microprocessor control in trans-femoral amputees

Objective

The aim of this study was to analyze the patient demographics, etiology of limb loss as well as reporting SF-36 scores for microprocessor prosthesis users in Turkish population.

Methods

We reviewed 72 patients (61 male and 11 female; mean age: 37.7 ± 10.7) with uni-lateral, above knee amputation and a history of regular and microprocessor prosthesis use. All patients were called back for a last follow-up and they were asked to fill a self-administered general health status questionnaire (SF-36).

Results

According to the SF-36 results; physical component score (PCS) score was 46 ± 7.3 and mental components summary (MCS) score was 46.5 ± 9.1. These scores have statistical similarity with Turkish healthy controls, except SF (social functioning) sub-dimension. PCS score for women microprocessor users were significantly lower than men (43.3 vs. 48.7, p = 0.03), but MCS scores were similar in between genders (46 vs. 48.2, p = 0.13). Conventional prostheses usage time was positively correlated with physical function (PF) scores (r = 0.322, p = 0.010). Microprocessor prosthesis usage time was negatively correlated with role limitations due to emotional problem (RE) scores (r = −0,313, p = 0.009).

Conclusion

The quality of life surveys were showed that the loss of an extremity have higher physical and psychological impact on women's physical scores. Overall, SF-36 results were similar in microprocessor using amputee's and Turkish normal controls.

Level of evidence

Level IV, therapeutic study.

Long-term consequences of landmine injury: A survey of civilian survivors in Bosnia-Herzegovina 20 years after the war

INTRODUCTION

Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals.

OBJECTIVE

The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being.

METHODS

Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care."

RESULTS

42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work.

CONCLUSION

The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide.

When to biomechanically examine a lower-limb amputee: A systematic review of accommodation times

BACKGROUND

Hundreds of investigations examining biomechanical outcomes of various prostheses have been completed, but one question remains unanswered: how much time should an amputee be given to accommodate to a new prosthesis prior to biomechanical testing?

OBJECTIVE

To examine the literature for accommodation time given during biomechanical investigations to determine whether consensus exists.

STUDY DESIGN

Systematic review.

METHODS

A systematic search was completed on 7 January 2016 using PubMed and Scopus.

RESULTS

The search resulted in 156 investigations. Twenty-eight studies did not provide an accommodation or were unclear (e.g. provided a "break in period"), 5 studies tested their participants more than once, 25 tested only once and on the same day participants received a new prosthesis (median (range): above-knee: 60 (10-300) min; below-knee: 18 (5-300) min), and 98 tested once and gave a minimum of 1 day for accommodation (hip: 77 (60-180) days; above-knee: 42 (1-540) days; below-knee: 21 (1-475) days).

CONCLUSION

The lack of research specifically examining accommodation and the high variability in this review's results indicates that it remains undecided how much accommodation is necessary. There is a need for longitudinal biomechanical investigations to determine how outcomes change as amputees accommodate to a new prosthesis. Clinical relevance The results of this review indicate that little research has been done regarding lower-limb amputees accommodating to a new prosthesis. Improper accommodation could lead to increased variability in results, results that are not reflective of long-term use, and could cause clinicians to make inappropriate decisions regarding a prosthesis.

Preparing youth with cancer for amputation: A systematic review

Children and adolescents who require limb amputation as part of cancer treatment face many physical and emotional challenges. Preparatory interventions may serve to facilitate positive coping and improve long-term adjustment during pediatric cancer treatment, including decreasing anxiety and postoperative distress. This review aimed to examine and identify the type and degree of psychosocial preparation provided to the child with cancer and family prior to amputation. Electronic databases including Embase, PubMed, and PsycINFO were searched for relevant research articles. Five studies were identified that satisfied inclusion criteria and revealed common themes for preparatory interventions, but results were limited by a lack of empirical approaches and revealed little consensus on pre-operative support prior to amputation. These findings demonstrate that there is a lack of studies to date that have adequately addressed psychosocial preparation prior to amputation for pediatric oncology patients. Future research on preparatory interventions is needed using prospective and quantitative research to establish evidence-based recommendations for interventions to support this vulnerable population.

End-Stage Renal Disease Negatively Affects Physical Quality of Life in Patients With Diabetic Foot Complications

The aim of this study was to evaluate the impact of end-stage renal disease (ESRD) on health-related quality of life (QOL) in patients with diabetic foot disease. We compared a group of 30 diabetic patients with ESRD requiring dialysis to a group of 60 diabetic patients without ESRD. Both groups consisted of patients with active diabetic foot disease (ulcer, Charcot, infection) and were matched with regard to age and gender. Self-reported QOL was assessed using the Short Form-36 (SF-36) physical and mental component summary (PCS and MCS) scores and the region-specific Foot and Ankle Ability Measure (FAAM). Diabetic foot patients with ESRD requiring dialysis were found to have significantly higher creatinine levels, lower hemoglobin levels, lower albumin levels, higher rates of peripheral arterial disease, and lower rates of Charcot neuroarthropathy than patients without ESRD. The median PCS was significantly lower in the ESRD group; however, no significant difference was found when comparing the median MCS and FAAM. Patients who ultimately died had a tendency to report lower PCS scores at baseline compared with those patients who did not die ( P = .07). Patients who ultimately required major amputation also reported lower PCS scores at baseline. ESRD negatively affects physical QOL to a greater degree than mental QOL in patients with diabetic foot disease. The SF-36 may not be sensitive enough to capture impaired mental QOL because both groups had relatively high MCS scores. Low physical QOL may be associated with mortality and the eventual need for major amputation.

Perceived social support moderates the relationship between activities of daily living and depression after lower limb loss

OBJECTIVE

This study examined the moderating influence of perceived social support on the prospective relationship between baseline levels of activities of daily living (ADL) and depressive symptoms during the 1st year following amputation.

METHOD

Participants included 73 veterans with new/first unilateral lower extremity amputation due to vascular disease or diabetes. Baseline levels of perceived social support, ADL function, and mobility were assessed by retrospective recall 6 weeks after amputation. Depressive symptoms were measured at 6 weeks and 12 months following surgery.

RESULTS

Perceived social support moderated the relationship between baseline ADL functioning and depressive symptoms at 12 months (β = -0.27, p < .001) after controlling for 6-week depressive symptoms and sociodemographic and physical/functional variables. Lower levels of baseline ADL function were associated with depressive symptoms at 12 months among those who reported lower levels of perceived social support.

CONCLUSION

These data allowed us to identify those participants with both low ADL function at baseline and low social support as being at higher risk for depression symptoms postamputation. The findings support the stress buffering hypothesis and suggest that perceived social support may be an important modifiable target of intervention among individuals with lower levels of functioning. (PsycINFO Database Record

[Limb salvage or amputation after severe trauma to the lower extremities : Evidence from the LEAP Study]

Deciding between reconstruction and primary amputation after severe high-energy trauma to the lower extremities is difficult and consequential. The Lower Extremity Assessment Project (LEAP) prospectively included and investigated patients with severe, limb-threatening injuries below the femur, with third-grade open fractures, defined soft-tissue damage and amputation wounds. This paper aims to review the key results of the LEAP study, which were published in several parts, in due consideration of the newer relevant literature, and to deduce the consequences for clinical practice. The main results are as follows: No score is sufficiently reliable to predict the success of reconstruction. Loss of muscle seems to be more momentous than loss of bone. Any accompanying injuries that should be taken into account in the individual treatment concepts are crucial to the results, in addition to comorbidities and other individual patient-related factors, such as alcoholism, smoking, insurance, and social background. Psychological impairment is frequent after these injuries and should therefore be addressed regularly with regard to rehabilitation.

Psychological Adjustment To Amputation: Variations On The Bases Of Sex, Age And Cause Of Limb Loss

BACKGROUND

Amputation is the removal of a limb or part of a limb by a surgical procedure in order to save the life of a person. The underlying reasons behind the occurrence of this tragic incidence may be varied. However, irrespective of its cause limb loss is associated with wide range of life challenges. The study was done to investigate the psychological sequel of an individual after losing a limb and to know the level of strain and pressure they experience after this traumatic event. It also attempts to examine the moderating role of some demographic traits such as age, sex and cause of limb loss in psychosocial adjustment to amputation.

METHODS

The study includes 100 adult amputees of both genders and the data was collected from major government and private hospitals of Peshawar district. Demographic data sheet was constructed in order to know the demographics traits of amputees and a standardize Psychological Adjustment Scale developed by Sabir (1999) was used to find out the level of psychological adjustment after limb loss.

RESULTS

Nearly all the amputees' exhibit signs of psychological maladjustment at varying degrees. Males showed much greater signs of maladjustment than women and young adults were much psychologically shattered and disturbed as a result of limb loss. Amputation caused by planned medical reasons leads to less adjustment issues as compared to unplanned accidental amputation in which patient were not mentally prepare to accept this loss.

CONCLUSIONS

Psychological aspect of amputation is an important aspect of limb loss which needs to be addressed properly in order to rehabilitate these patients and helps them to adjust successfully to their limb loss.

A Comparison of Four-Year Health Outcomes following Combat Amputation and Limb Salvage

Little research has described the long-term health outcomes of patients who had combat-related amputations or leg-threatening injuries. We conducted retrospective analysis of Department of Defense and Department of Veterans Affairs health data for lower extremity combat-injured patients with (1) unilateral amputation within 90 days postinjury (early amputation, n = 440), (2) unilateral amputation more than 90 days postinjury (late amputation, n = 78), or (3) leg-threatening injuries without amputation (limb salvage, n = 107). Patient medical records were analyzed for four years postinjury. After adjusting for group differences, early amputation was generally associated with a lower or similar prevalence for adverse physical and psychological diagnoses (e.g., pain, osteoarthritis, posttraumatic stress disorder) versus late amputation and/or limb salvage. By contrast, early amputation was associated with an increased likelihood of osteoporosis during the first year postinjury. The prevalence of posttraumatic stress disorder increased for all patient groups over four years postinjury, particularly in the second year. The different clinical outcomes among combat extremity injured patients treated with early amputation, late amputation, or limb salvage highlight their different healthcare requirements. These findings can inform and optimize the specific treatment pathways that address the physical and psychological healthcare needs of such patients over time.

Health Related Quality of Life in Patients with Single Lower Limb Amputation

OBJECTIVE

To determine the effects of age, cause of amputation, and anatomic level of amputation on the health related quality of life (HRQOL) in individuals with unilateral lower limb amputation.

STUDY DESIGN

Across-sectional survey.

PLACE AND DURATION OF STUDY

The Armed Forces Institute of Rehabilitation Medicine, from August 2014 to February 2015.

METHODOLOGY

Short Form-36 (SF-36) health related quality of life (HRQOL). Survey questionnaire was used to collect data. The responses were scored by using the quality metric health outcomes™ scoring software 4.5. The scores were entered and analysed in SPSS version 21.

RESULTS

Atotal of 52 patients were inducted with mean age of 30.71 ±7.50 years. Mean physical component summary (PCS) was lower than mental component summary (MCS) (38.7 vs. 44.8). RP and RE scores were found to be significantly associated with gender (p=0.024 and p=0.003, respectively). Age group was also significantly associated with RP(p=0.037) and SF (p=0.041). When SF-36 domains were compared with level of amputation (i.e. trans-tibial and transfemoral), none of the domains showed any statistically significant results.

CONCLUSION

Age and indication affect different aspects of quality of life but level of amputation did not. If these are known and anticipated before any type of rehabilitation, this could help in anticipation of health consequences and prevention accordingly.

Factors Affecting Disability-Related Depression in Patients with Lost Limbs: A Mediational Model

The objective of the present study was to determine the mediating role of self-efficacy between religiosity, social support, and depression in patients with lost limbs. We sampled 67 male and 33 female disabled patients who had lost limbs in accidents or amputations from four public hospitals in Lahore, Pakistan, and used Religiosity Index (Farooq and Imam, in The effect of religiosity on locus of control. Department of Psychology, Govt College University, Lahore, 1997), General Self-efficacy Scales (Tabassum et al., in Urdu adaptation of the general self-efficacy scale. Retrieved from http://userpage.fu-berlin.de/~health/urdu.htm , 2003), Berlin Social Support Scale (Schwarzer and Schulz, in Berlin Social Support Scales. Retrieved online from http://userpage.fuberlin.de/~gesund/skalen/Language_Selection/Turkish/BerlinSocialSupportScales/berlin_social_support_scales.htm , 2000), and Siddiqui-Shah Depression Scale (Siddiqui and Shah, in Pychol Dev Soc 9(2):245-262, 1997), and used a correlation matrix and mediational analyses along with other inferential statistics to develop a model that suggested self-efficacy mediated between religiosity, social support, and depression with negative correlations that partially mediated this relationship. The findings suggest that low level of religiosity, social support, and self-efficacy may play a role in the onset and continuation of depression or its symptoms. We found no significant differences in gender, education, and cause of disability in patients with lost limbs. Results have implications for clinical psychologists, counselors, and health psychologists to develop a treatment plan for such patients with depression focusing on the factors implicated above.

Shape alterations of basal ganglia and thalamus in xenomelia

Xenomelia is a rare condition characterized by the persistent desire for the amputation of physically healthy limbs. Associations with morphological alterations such as reduced cortical thickness and surface area. Nothing is known, however, about the potential involvement of subcortical structures. The thalamus and basal ganglia process, relay, and integrate sensorimotor information and are involved in the preparation and execution of movements. Moreover, both of these structures house somatotopic representations of all body parts. We therefore investigated subcortical correlates of xenomelia by assessing basal ganglia and thalamus by means of vertex-wise shape analyses. For that purpose, we compared the shape of the thalamus, putamen, caudate nucleus, and the pallidum in 13 men suffering from xenomelia, all desiring a leg amputation, compared to 13 healthy control men. We hypothesised that the target leg is misrepresented in subcortical structures of individuals with xenomelia, especially in locations with a somatotopic representation. Shape analyses showed thinning of bilateral dorsomedial putamina, left ventromedial caudate nucleus and left medial pallidum associated with xenomelia. This was accompanied by thickening of bilateral lateral pallida and the left frontolateral thalamus. These shape differences were mainly located in sensorimotor areas of somatotopic leg representations. The present study provides strong evidence for shape differences in striatal, pallidal, and thalamic subregions housing subcortical body part representations. It adds to previously described neural correlates of a condition one can barely empathize with and invites future connectivity analyses in cortico-subcortical networks.

Rehabilitation of the Combat Casualty: Lessons Learned from Past and Current Conflicts

The field of rehabilitation is deeply rooted in military medicine, especially in promoting the restoration of function and community reintegration of injured service members returning from war. Since military operations began in Iraq and Afghanistan over a decade ago, rehabilitative care programs have been integral in supporting the Military Healthcare System in providing high quality comprehensive care for combat casualties and their families, particularly those with complex blast injuries resulting in conditions such as amputation and other limb dysfunction, traumatic brain injury, and spinal cord injury. Fundamental to a successful rehabilitation program is the coordination of interdisciplinary care that not only crosses multiple medical specialties and disciplines, but also promotes ongoing education, research, quality improvement and readiness. This brief article is intended to highlight some of the most important lessons learned from current and past conflicts in delivering the highest quality rehabilitative care to our nation's heroes.

An exploratory phenomenological study exploring the experiences of people with systemic disease who have undergone lower limb amputation and its impact on their psychological well-being

BACKGROUND

Amputation is a life-changing event accompanied by challenges for the affected person with time-dependent depression often used to quantify its level of impact on their psychological well-being. There are varied factors that contribute to this and its persistence. The aim of this study was to explore the experiences over time of people with diabetes and/or peripheral vascular disease following an amputation and the impact on their psychological well-being.

OBJECTIVES

To develop an understanding of the experience of living with an amputation and a chronic condition in order to help clinicians identify those in need of counselling support.

STUDY DESIGN

A qualitative study utilising an iterative approach in line with the philosophy of interpretive phenomenology.

METHODS

Six participants who had experienced a lower limb amputation associated with peripheral vascular disease/diabetes were interviewed on two occasions (baseline and 4 months). An interpretative phenomenological approach was utilised for both data collection and analysis.

RESULTS

For these participants, amputation was part of the chronology of their chronic disease. It was the individual's variable experience of health which impacted their psychological well-being rather than the length of time since amputation.

CONCLUSIONS

The multivariable experience of amputation means that individually tailored counselling/psychological support is recommended.

CLINICAL RELEVANCE

An understanding of how the experience of living with an amputation and a chronic condition may change over time will help clinicians to identify the ongoing need for counselling support.

The Evaluation of Daily Life Activities after Application of an Osseointegrated Prosthesis Fixation in a Bilateral Transfemoral Amputee: A Case Study

Individuals with a transfemoral amputation (TFA) may experience limitations in daily life due to reduced mobility and prosthesis-related problems. An osseointegrated prosthesis fixation (OPF) procedure in amputees might contribute to a solution for patients with short stumps or socket-related problems. To date, no study has specifically described the application of an OPF procedure in individuals with a TFA. This study evaluated the level of daily life activities of a 21-year old service member with a bilateral TFA and cerebral trauma. Due to a short stump length and coordination problems, an OPF procedure was deemed the most suitable option.The result of this procedure and the rehabilitation program showed an increased mobility and satisfaction as obtained by the assessment of life habits questionnaire (LIFE-H) and lower extremity functional scale. The participant was able to walk short distances and the Genium knee provided a stance position. Stair ambulation is impossible because of inadequate muscle capacity.In this specific case we conclude that the quality of life improved through the use of an OPF. However, OPF might not be the appropriate device for every individual with TFA, due to varying bone compositions, co-morbidities, and limited clinical experience and unknown long-term effects.

Overview: Mechanism and Control of a Prosthetic Arm

Continuous growth in industrialization and lack of awareness in safety parameters the cases of amputations are growing. The search of safer, simpler and automated prosthetic arms for managing upper limbs is expected. Continuous efforts have been made to design and develop prosthetic arms ranging from simple harness actuated to automated mechanisms with various control options. However due the cost constraints, the automated prosthetic arms are still out of the reach of needy people. Recent data have shown that there is a wide scope to develop a low cost and light weight upper limb prosthesis. This review summarizes the various designs methodologies, mechanisms and control system developed by the researchers and the advances therein. Educating the patient to develop acceptability to prosthesis and using the same for the most basic desired functions of human hand, post amputation care and to improve patient's independent life is equally important. In conclusion it can be interpreted that there is a wide scope in design in an adaptive mechanism for opening and closing of the fingers using other methods of path and position synthesis. Simple mechanisms and less parts may optimize the cost factor. Reduction in the weight of the prosthesis may be achieved using polymers used for engineering applications. Control system will remain never ending challenge for the researchers, but it is essential to maintain the simplicity from the patients perspective.

[Trauma and chronic pain: echoes and amplifications of physical and emotional suffering]

Chronic pain often presents following a traumatic event, or alternatively, patients attribute pain to a trauma, whether this link is established or not. The psychological impact of trauma can significantly complicate the treatment of chronic pain. This article aims to review the known interactions between trauma and chronic pain. Following this review, it discusses therapeutic avenues suited to these complex situations, underlining the specific contributions of the different members of a multidisciplinary team.

Transcultural validation of the SIGAM mobility grades in French: The SIGAM-Fr

BACKGROUND

The main French language scales evaluating functioning after lower-limb amputation have not undergone exhaustive psychometric validation.

OBJECTIVE

A transcultural validation of the Special Interest Group in Amputee Medicine (SIGAM) mobility grades questionnaire, with 21 closed questions, as an administered questionnaire.

METHODS

The questionnaire translation, back-translation and original-author validation was followed by a pretest with 5 patients to check comprehension. The psychometric properties of the scale were validated with 49 patients at the definitive prosthesis stage by an investigator via telephone. Criterion validity was evaluated by comparison with the Houghton Scale score and construct validity by correlation between the questionnaire scores and convergent dimensions (performing everyday activities and performing transfers on a numerical rating scale [NRS], 2-min walk test) and divergent dimensions (managing medication and stump skin care on an NRS). Internal consistency was assessed by the Kuder-Richardson Formula 20 (KR-20) coefficient and test-retest reproducibility by the Cohen kappa coefficient.

RESULTS

The resulting questionnaire was validated by the original author after the back-translation. It showed good psychometric properties when administered by an investigator as a self-reporting questionnaire, excellent criterion validity (r=0.89, P<0.01), excellent reproducibility (kappa coefficient 0.87) and satisfactory construct validity. The KR-20 coefficient was 0.67.

CONCLUSION

The French version of the SIGAM mobility grades questionnaire (SIGAM-Fr) has satisfactory psychometric properties and can be administered in clinical practice.

Acupuncture for the treatment of phantom limb pain in lower limb amputees: study protocol for a randomized controlled feasibility trial

BACKGROUND

Phantom limb pain is a prevalent condition that is difficult to manage, with a lack of robust evidence to support the use of many adjunctive treatments. Acupuncture can be effective in the management of many painful conditions but little is known about its effectiveness in treating phantom limb pain. The aim of this study is to explore the feasibility of conducting a randomized controlled trial comparing acupuncture and routine care in a group of lower limb amputees with phantom limb pain.

METHODS/DESIGN

An unstratified, pragmatic, randomized, two-armed, controlled trial of parallel design comparing acupuncture and usual care control will be conducted. A total of 20 participants will be randomly assigned to receive either usual care or usual care plus acupuncture. Acupuncture will include eight 1 hour treatments delivered pragmatically over 4 weeks by practitioners trained in traditional Chinese medicine. As outcome measures, the Numerical Pain Rating Scale, short-form McGill Pain Questionnaire 2, EQ-5D-5 L, Hospital Anxiety and Depression Scale, 10-Item Perceived Stress Scale, Insomnia Severity Index, and Patient Global Impression of Change will be completed at baseline, weekly for the duration of the study and at 1 month after completion of the study. After completion of the trial, participants will provide feedback though semi-structured interviews. Feasibility will be determined through the ability to recruit to the study, success of the randomization process, completion of acupuncture intervention, acceptability of random allocation and completion of outcome measures. Acceptability of the acupuncture intervention will be determined through semi-structured interviews with participants. The appropriateness of outcome measures for a future trial will be addressed through completion rates of questionnaires and participant feedback.

DISCUSSION

Data generated on effect size will be used for future sample size calculations and will inform the development of an appropriate and feasible protocol for use in a definitive multicentre randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02126436.

Conversion From Limb Salvage to Late Amputation: Lessons Learned From Recent Battlefields With Application to Civilian Trauma

Battlefield injuries and high-energy civilian trauma present orthopaedic surgeons with treatment challenges. Despite efforts at limb salvage, some patients elect late amputation. This article reviews risk factors that predispose to late amputation. Using a MEDLINE search, English language peer-reviewed articles from 1993 to 2013 having data on late amputation following limb salvage were included. Late lower extremity amputation after limb salvage varied from 3.9% to 40% in civilian patients and from 5.2% to 15.2% in military patients. Factors influencing a patient's decision to undergo late amputation included a combination of complex pain symptoms with neurologic dysfunction, infection, a desire for improved limb functionality, and unwillingness to endure an often complicated and lengthy course of treatment. In military patients, rank was a significant risk factor since officers were 2.5 times more likely to elect late amputation (p < .05) than enlisted personnel. Despite often extraordinary efforts towardlimb salvage, results maybe disappointing.

The psychosocial impact associated with diabetes-related amputation

AIMS

Research has suggested that the additional impact of a diabetes-related amputation is associated with poorer physical functioning, poorer psychosocial outcome and greater body image disturbance. However, no study to date has compared patients with diabetes with and without amputation and adequately controlled for additional medical morbidity often found among individuals with an amputation. The aim of this study was to statistically control for any group differences on medical and demographic variables to examine the isolated psychosocial impact of diabetes-related amputation.

METHODS

Individuals with diabetes with an amputation (n = 50) were compared to a control sample (individuals with diabetes without an amputation; n = 240). All participants completed a demographic and medical questionnaire, as well as measures of psychological distress, quality of life and body image.

RESULTS

The results indicated that, in univariate analyses, depression, physical quality of life and body image disturbance were all poorer in the amputee group. These differences remained for body image disturbance (P = 0.005), but were no longer significant for depression or physical quality of life in multivariate analyses controlling for important demographic and medical variables.

CONCLUSIONS

The present study found that the impact of diabetes-related amputation was significant for body image disturbance. However, it appears that other psychosocial outcomes are better accounted for by medical co-morbidities common in this group rather than the amputation itself. This research certainly highlights that clinicians must assess for and address all potential medical contributors to psychosocial outcomes, rather than assuming that people will experience poorer outcomes following amputation.

The role of expectations in pain after dysvascular lower extremity amputation

OBJECTIVE

The objective was to determine the relationship between pain expectations assessed prior to surgery and satisfaction with pain 4 and 12 months after major dysvascular lower extremity amputation.

RESEARCH METHOD

The study included a prospective cohort of male (n = 19) veterans experiencing their first lower extremity amputation due to complications of diabetes mellitus or peripheral arterial disease. Measures included presurgical expectations of pain at 4 and 12 months postamputation, actual average pain and satisfaction with pain at 4 and 12 months postamputation, and agreement between expected and actual pain.

RESULTS

Sixty-eight percent of participants expected to experience no or minimal pain at 4 months; 95% expected to experience no or minimal pain at 12 months. Thirty-two percent and 58% of participants had more pain than they expected at 4 and 12 months, respectively. Participants whose pain expectations were met reported higher satisfaction with their actual level of pain at 12 months postamputation, even after adjusting for current pain levels.

CONCLUSION

The results underscore the potential value of fostering realistic expectations about the degree to which amputation may impact average pain.