Limb Deficiency and Prosthetic Management. 4. Comorbidities Associated With Limb Loss

4.1 Clinical Activity: To evaluate the functional outcome and prosthetic needs of a 63-year-old obese woman who has preexisting stable mild right hemiparesis and who presents with a new right transtibial amputation as a consequence of peripheral artery disease 

PERIPHERAL ARTERY DISEASE (PAD) is a common cause of amputation. The age-adjusted prevalence of PAD is estimated to be between 9% and 22% in men and between 9% and 27% in women.1 According to 2 large studies,2, 3 between 2% and 5% of women and 4% and 9% of men report symptomatic PAD (defined as intermittent claudication [IC]). Risk factors for symptomatic PAD include the presence of diabetes, hypertension, hyperlipidemia, advanced age, and a history of smoking.

The TransAtlantic Inter-Society Consensus group concluded that 1% to 2% of all people with IC will progress to major amputation.4 An international, multisite study showed that the rate of major amputation resulting from symptomatic peripheral vascular disease (PVD) ranged from 51% to 93% for men, with similar percentages for women in most geographic areas studied.5 In a recent analysis of U.S. hospital discharge data, Dillingham et al6 found that dysvascular amputations accounted for 82% of all limb-loss–related discharge diagnoses over a 9-year study period.

The incidence of major amputation rises steeply with age.5, 6 Two thirds of amputations occur in patients over the age of 60 years, and amputation rates are substantially higher in older men than in older women. For example, 1 U.S. study5 found an incidence of first major amputation for men between the ages of 60 and 79 years of 84.9 per 100,000 population per year, whereas the incidence for women of the same age range was 37.0. For people 80 years and older, the sex-related incidence of amputation varies depending on geographic location, but the incidence is higher in this age group overall.

This patient’s comorbid hemiparesis will likely confound her functional outcome.

Approximately 10% of elderly dysvascular amputees have at some time incurred a stroke.7 In those with PAD, the prevalence of lower-extremity amputation is increased on the hemiparetic side. O’Connell and Gnatz7 found in their study of stroke and amputations (“dual disability”) that hemiparesis occurred before amputation in 29 of 46 patients; amputation occurred initially in 10 patients, and the conditions occurred simultaneously in 7 patients. Decreased blood flow, impaired sensation with associated reduced awareness of local trauma, and disuse (decreased muscle fiber activation on the hemiparetic side) may all contribute to vascular compromise in the hemiparetic limb.8

Even a mild residual hemiparesis in conjunction with amputation presents a challenge to rehabilitation.7 Patients with a below-knee amputation and coexisting hemiparesis are more likely to walk after the amputation if they were ambulatory before the onset of the concurrent condition. However, independence in activities of daily living (ADLs) and transfers is equally as important as walking. O’Connell and Gnatz7 found that patients with moderate hemiparesis had difficulty transferring with 1 leg, and this limited their ADL performance. Neurologic status, measured as severity of hemiparesis and status of continence, can be used to predict ADL status and has been perceived as being the most important factor in rehabilitation outcome. Hand function on the hemiparetic side was particularly important for prosthetic training success among patients with concurrent stroke and amputation.7

There are various predictors of functional outcome related to amputation, including demographic, physical, and cognitive factors. Studies have shown that older age and higher level of leg amputation are typically associated with poorer functional outcome. Schoppen et al9 found that people over the age of 60 years with lower-limb amputations generally have a low level of functioning 1 year after amputation. Similarly, Fletcher et al10 found that only 36% of all unilateral vascular amputees over the age of 65 years were successfully fitted with a prosthesis. Successful prosthetic use dropped precipitously after the age of 85 years, primarily because of high mortality. Other reasons for failure of prosthetic use in older patients included above-knee amputations, reamputation, cerebrovascular disease, cognitive deficits, poor skin integrity, and fixed flexion contractures.10 Balance on the unaffected leg is a strong predictor for functional ability after amputation,9, 11 because it indicates the integrity of the muscular power of the sound limb, the existence of comorbidity, or comorbid balance problems related to older age.9

Memory appears to be the most important of the mental predictors for functional independence after amputation, because it may be important for relearning daily tasks9 and retaining this information. Testing of short-term and delayed memory can assist in prognostication.9 Other possible predictors of whether a person will be ambulatory with a prosthesis are a strong motivation to walk and level of physical fitness as measured by maximal oxygen consumption after amputation.11 One tool that can measure an amputee’s functional capabilities without a prosthesis to predict his/her ability to ambulate with a prosthesis is the Amputee Mobility Predictor.12 This instrument is designed to evaluate transfers, sitting and standing balance, and various gait skills.

Obesity is another comorbidity that will likely complicate this patient’s functional outcome. One study of obese (body mass index ≥30kg/m2) but otherwise healthy women compared with healthy lean women found that exercise capacity decreased with obesity, and musculoskeletal pain was a significantly limiting factor.13 These findings, although not specific to amputees, are important for rehabilitation, as are prosthetic fitting and training. Assuming this patient has positive predictors of successful prosthetic use, a preparatory prosthesis should be prescribed when the residual limb is adequately healed and shaped and should be cleared for weight bearing. Adequate strength and range of motion of the other limbs and the residual limb facilitates prosthetic training. A trial in a preparatory device may also be considered in cases where it is questionable whether a person will use a prosthesis functionally.14 This patient will need a stable prosthesis that is easy to don and doff, because she has mild ipsilateral hemiparesis. If she had moderate hemiparesis involving the arm, assistance of a caregiver might be necessary for donning and doffing of the prosthesis.14 With severe hemiparesis, she likely would not be able to use a prosthesis for ambulation, although she may be able to use it for transfers.

It is recommended that an initial prosthetic device be a modular and adjustable system, because it permits socket changes, which are inevitable with fluctuations in size of the residual limb. Residual limb shape and size typically stabilize within 18 months after amputation.15 This patient would benefit from fabrication of a patellar tendon–bearing, lightweight socket. Full contact of the socket with the residual limb is important to control edema, avoid distal choking phenomenon, and minimize areas of focal pressure. A patellar tendon−bearing socket design distributes weight bearing to pressure-tolerant areas and accommodates dynamic forces occurring during the gait cycle.15 A lightweight device is preferable for a patient with balance difficulty or weakness caused by hemiparesis.14 This patient will require vigilant attention to proper socket fit and cushioning to prevent skin breakdown, particularly considering her underlying vascular disease and potentially impaired sensation from stroke.16

Options for the socket interface include an elastomeric liner or a soft foam insert liner. A silicone, urethane, or thermoplastic elastomeric liner offers greater cushioning than a soft foam liner and reduces friction. Dexterity and understanding are required to apply an elastomeric liner correctly, making it difficult to don and doff with an impaired hand and the cognitive functions associated with stroke. This type of liner is contraindicated when there is a residual limb ulceration, poor patient hygiene, or inconsistent patient participation in prosthetic rehabilitation.17 Elastomeric materials are also more costly than soft foam. A soft foam insert liner requires less care and is easier to don and doff than an elastomeric liner, especially if finger loops are added. Foam pads can be added to the insert liner to accommodate changes in residual limb size and shape, and they delay the need for a new liner and socket. Soft foam, however, provides less pressure relief, less conformance to skin, less cushioning, and less reduction of shear forces—especially with donning and doffing—compared with an elastomeric liner.17 Gel-filled socks can be used to add a cushioning effect when using a soft foam insert liner. For those few people who have previously tolerated a hard socket, a liner may not be necessary when they require a replacement prosthesis.

The choice of suspension for a prosthesis depends on residual limb length and shape, joint stability, limb volume stability, activity level, dexterity, prior suspension experience, and cosmetic requirements. For an amputee with an average to long transtibial residual limb length, the supracondylar suspension cuff, prosthetic sleeve, or elastomeric liner with locking mechanism are reasonable options.17 With a short transtibial residual limb, a patellar tendon−bearing supracondylar socket increases the surface area on which pressure is distributed, assists in the suspension of the prosthesis, and controls valgus and varus stresses on the knee.15, 17 A supracondylar suspension cuff is 1 of the easiest types of suspension for this patient to don, because she could potentially fasten the strap with a 1-handed technique. The cuff is also durable and adjustable, and it provides a kinesthetic reminder for knee extension control.17 However, the strap is not indicated for people with vascular compromise or knee instability, because it may cause constriction proximal to the knee joint and provides little medial or lateral support at the knee.17 A patellar tendon−bearing supracondylar and suprapatellar socket design may also help control the genu recurvatum, which is commonly present in patients with spastic hemiparesis.15 Foam pads incorporated into the soft foam insert or hard socket can assist with suspension and accommodate volume reduction.15 If significant physical activity is anticipated, an elastomeric liner with pin provides greater suspension through suction, friction, and a shuttle lock. A patellar tendon−bearing socket with a prosthetic sleeve for suspension may be indicated when a patient is significantly overweight or does not have prominent femoral condyles, because a supracondylar socket may neither fit properly nor provide adequate suspension. The patient’s degree of obesity may exceed the structural integrity of prosthetic components, which limits prosthetic options.

With a modular and adjustable system, the pylon can accommodate a solid-ankle, cushioned-heel foot for training purposes, because this foot is durable, stable, and inexpensive. A flexible keel foot is recommended for patients with balance problems. This patient may require prosthetic socks to maintain socket fit, because the shape of her residual limb will likely change with prosthetic wear and weight bearing. A more definitive prosthesis can be prescribed after the residual limb shape and size have stabilized. If this patient is successful in ambulating with the preparatory prosthesis, a definitive prosthesis can be prescribed to meet her specific needs. A reasonable prosthetic prescription would have these 4 components: (1) a lightweight endoskeletal design; (2) a patellar tendon−bearing socket with foam insert liner; (3) supracondylar suspension; and (4) a fixed ankle with flexible keel foot.

If cost is not a limiting factor, this new amputee may optimally benefit from an elastomeric liner for skin protection and reduction of shear forces, particularly because of possible underlying sensory impairment. If she becomes more active, an elastomeric liner with pin and a dynamic response foot or multiaxial foot and ankle may be more appropriate.

4.2 Educational Activity: To anticipate the potential influence of complications from diabetes mellitus on the rehabilitation management of this patient 

As this patient ages with diabetes, she will have higher risks of contralateral limb loss, functional disability, persistent pain, depression, cognitive impairment, urinary incontinence, poly-pharmacy, injurious falls, cardiovascular disease (CVD), end organ damage, and premature death than if she were not diabetic.18

Worldwide, approximately 50% of all lower-extremity amputations are performed on people with diabetes.19 In a recent U.S. study, Aulivola et al20 found that 81% of 959 lower-limb amputations were performed on diabetic patients. In 1997, the Centers for Disease Control and Prevention reported that 67% of 131,218 nontraumatic lower-limb amputations performed in the United States were related to diabetes.21 Of all people with diabetes, 5% to 15% will undergo lower-extremity amputation,22 up to 55% will require amputation of the second leg within 2 to 3 years,23 and two thirds will die within 5 years after initial amputation.23

People with diabetes have an increased prevalence of CVD, peripheral neuropathy, obesity, visual deficits, and depression. One study of physically impaired elderly women showed that those with diabetes experienced greater mobility-related disability, and there was an association between diabetes and depression when adjusted for age.24

The most common diabetes-related complications in 1 study25 of elderly people were, in order of highest prevalence, ischemic heart disease, cerebrovascular accident, lower-extremity infection, acute myocardial infarction, hypoglycemia, ketoacidosis, gangrene, blindness, amputation, and hyperosmolar syndrome. Of these common comorbidities, CVD, including ischemic heart disease and acute myocardial infarction, had the highest mortality.18 Hypertension, another comorbidity of diabetes, is a major risk factor for both CVD and microvascular complications, such as retinopathy and nephropathy.18 Another factor that contributes to CVD is dyslipidemia, which has a high prevalence in diabetics.18 Diabetes accelerates atherogenesis and is an independent risk factor for coronary artery disease.22

Major cardiac stressors for this patient are walking, stair climbing, and transfers. The rate of metabolic energy expended while walking with a lower-limb prosthesis, up to the transfemoral level of amputation, is the same as walking without a limb deficiency, because walking speed is slower. Therefore, when this patient is allowed to walk at her self-selected speed, walking should not result in any undue cardiac stress.26 Exercise testing may be useful when designing a strengthening and endurance program, or a postprosthetic walking program.26 In the population with PVD, dipyridamole-thallium radionucleotide imaging may have a higher sensitivity and specificity than treadmill or arm ergometry exercise testing.26 Blood glucose monitoring will be important, because exercise-induced hypoglycemia may limit her exercise tolerance. Teaching her proper nutrition, monitoring her skin condition, and judicious control of her diabetes mellitus will maximize her rehabilitation outcome and minimize complications from diabetes.22

Diabetes impedes wound healing, which may delay prosthetic fitting in this patient.22 The presence of neuropathy and the associated sensory impairment make this patient vulnerable to skin breakdown on her residual limb, particularly with weight bearing. Diabetic retinopathy is strongly related to the duration of disease.18 It is estimated to be the most frequent cause of new blindness in 20- to 74-year-old adults.18 Low vision would limit this patient’s potential for successful use of a prosthesis, interfering with successful donning and doffing of the prosthesis and increasing fall risk. However, visual impairment may not be a contraindication to prosthetic use if the person has a caregiver to don and doff the prosthesis and monitor the residual limb. This patient’s remaining foot is at risk for development of diabetic neuropathic osteoarthropathy, the most common cause of Charcot’s arthropathy. This can cause deformity, bone and joint destruction, and increased risk of ulceration because of pressure redistribution. Presentation is classically a warm, swollen erythematous foot without open wounds. Early diagnosis is the key to management, which is immobilization23 and unloading of the joint. This patient is also at risk for development of diabetic neuropathic pain. The pain may be epicritic (burning, dysesthetic) or protopathic (deep, gnawing). Early in the course of disease, epicritic pain is often experienced and may spontaneously resolve; later, protopathic pain may appear. Topical and oral medications and transcutaneous electrical stimulation may be helpful in controlling diabetic neuropathic pain.23 Diabetic amyotrophy, another complication of diabetes, is typically associated with prominent pain in the affected limb and atrophy of the proximal limb muscles. It is most commonly found in older men but has been documented in women. If present, it would likely inhibit ambulation efforts.

Diabetes also predisposes this patient to skin injuries from unrecognized trauma, as well as to skin disorders such as necrobiosis lipidica diabeticorum, diabetic dermopathy, lipodystrophy, diabetic hand syndrome, diabetic bullae, nail problems, and plantar xerosis. The presence of these skin disorders in the residual limb and the intact limb can prohibit or hamper prosthetic use and mobility.

The primary conditions predisposing a patient to lower-limb ulceration are diabetes, lower-extremity arterial disease, and venous valve insufficiency, or combinations of the above.27 Diabetic foot ulcers most commonly result from neuropathy, infection, ischemia, mechanical stress, and even minor trauma. Faulty wound healing also plays an important role.23 In diabetics, the 2 most common types of neuropathies are distal symmetric sensory motor neuropathy and autonomic neuropathy.23 Lack of protective sensation allows for unrecognized trauma, fractures, and neuropathic joint disease, as well as tissue ischemia with resultant ulceration.23 Motor neuropathy causes foot deformities because of intrinsic foot muscle weakness and associated muscle imbalance. This, in turn, can produce areas that are prone to skin breakdown because of abnormal pressure.23 Autonomic neuropathy leads to impaired sweat and sebaceous glands and dry, cracked skin, which is an entry site for bacteria. Another reported association with ulceration and neuropathic joint disease is the arteriovenous shunting that results from autonomic dysfunction.23 In addition to the ulceration risks from autonomic neuropathy, there may be associated orthostatic hypotension and exercise-induced hypotension, which adversely affects rehabilitation efforts.22 Diabetic microangiopathy is a manifestation of vascular disease in the diabetic population and is the second most common cause of diabetic foot lesions. Ischemic ulcers are typically on the dorsum of the foot and toes.23 Infection is an inherent risk of diabetes, because of impaired leukocytosis and because healing is compromised secondary to ischemia-related impairment of antibiotic perfusion.23 Foot ulcerations can also result from mechanical stress because of impaired sensation, ischemia, and repetitive motion with abnormal pressure or abnormal gait. The evaluation and management of diabetic foot ulceration has been previously reviewed.22 Assessment of the patient’s understanding of her disease and risk of complications is necessary. Patient education is paramount to foot ulcer prevention and must take place at every patient contact. Instruction should be given on mobility exercises and appropriate footwear. Routine foot care should be performed by a health professional if sensation is impaired. For an excellent outline of footcare instructions for patients, refer to Pandian et al.23

Diabetic nephropathy is present in 20% to 40% of people with diabetes and is the single leading cause of end-stage renal disease (ESRD). In a study of a Medicare ESRD population, the rate of lower-limb amputation was 10 times greater in diabetic patients with ESRD than in diabetic patients without ESRD.28 Mortality rates for patients with ESRD who undergo amputation have been reported to be 48% to 51% within 1 year, 67% within 2 years, and 86% within 5 years.20, 28 These statistics vary with age and presence of diabetes. For example, older people with ESRD have higher mortality rates after amputation. In contrast, people with ESRD caused by diabetes actually have slightly lower mortality rates than those with ESRD from other causes.28

4.3 Educational Activity: To discuss the differential diagnosis and management of limb pain in this 63-year-old woman 6 weeks after transtibial amputation 

Pain after amputation may be complex and functionally limiting. It is important to determine the type and intensity of pain experienced by the patient to initiate appropriate management. The sources of the pain may originate from the residual limb or may be referred from other anatomic sites. Additionally, pain may emanate from the phantom limb. Phantom limb and residual limb pain are common after a lower-limb amputation. In 10% to 25% of people, this pain may be so severe it is disabling.29 In a recent study29 of amputees 6 or more months after amputation, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. In a Dutch study30 with a large sample, health-related quality of life (QOL) was significantly poorer in amputees with phantom pain compared with those without phantom pain. The most important amputation-specific determinants of health-related QOL described by the participants in this study were “walking distance” and “stump pain”.30

Phantom limb pain can occur in any “portion” of the amputated limb. It has been described as intermittent cramping, squeezing, and burning or sharp, shooting pain of variable intensity.14, 29 The cause of phantom limb pain continues to be debated. However, it has been associated with older age, female sex, transfemoral amputation, lack of social support before the amputation, and the presence of comorbidities.31 Onset of phantom limb pain can be immediate or delayed after an amputation.14 Numerous treatments have been tried for management of phantom limb pain, but none have had universal success. Medications and physical modalities used to treat phantom limb pain were discussed in detail in the 2001 Study Guide.32 Phantom limb pain differs from phantom limb sensation, which is an awareness of the missing part of the limb occasionally accompanied by nonnoxious sensations such as pruritis, numbness, or tingling.14

Residual limb pain involves identifiable areas of the stump such as prominent bone, adherent scar, or an area of erythema or skin breakdown.14 Residual limb pain has been described as aching, sharp, throbbing, burning, tingling, and shock-like29 and has been associated with traumatic amputation, above-knee amputation, the presence of comorbidities, and low levels of adjustment to limitation.31, 33 A residual limb can change with age, walking, climate, and blood flow,31 and a poorly prescribed or poorly fitted prosthesis can contribute to pain and wound development. Ill-defined pain in the residual limb can signal poor socket fit as a result of fluctuation in distal limb size. For example, edema management is critical in people with ESRD, because limb volume may fluctuate from dialysis, and this leads to a poorly fitting prosthetic socket. Problems created by lack of total contact can be avoided by diligent and often-repeated evaluation by the prosthetist of the residual limb’s fit within the socket. These issues underscore the importance of having excellent communication between the patient and rehabilitation team.14

Claudication, another etiology of residual limb pain, may present as worsening pain with activity, which resolves with rest. The patient’s physical examination findings may be consistent with arterial insufficiency, including pallor, cool limb, and reduced pulses. Presence of ischemia may be determined using measures of temperature, segmental pressure, pulse, volume, Doppler waveforms,23 and transcutaneous oxygen tension. The residual limb may require revision or bypass surgery if the patient has intractable pain or severely limited function.

Incomplete resolution of infection in the soft tissues or bone may result in reoccurrence of infection and residual limb pain. Further, constitutional signs of infection such as cognitive or functional decline, low-grade fever, poorly controlled blood sugar levels, malaise, or lethargy may exist. Treatment may include revision, incision and drainage, or long-term antibiotic therapy.

Terminal or spindle neuromas may cause residual limb pain, especially when large or superficial and vulnerable to repetitive trauma.14, 34 Neuromas typically develop within 1 to 12 months postamputation.34 After nerve transection, proliferation is expected to occur at the distal end, forming a terminal neuroma. In contrast, a spindle neuroma develops proximally and distant to the nerve ending and may be caused by abrupt stretching of the nerve or chronic compression by scar tissue. Clinically, a terminal neuroma is often asymptomatic, whereas a spindle neuroma is often symptomatic.34 Neuromas buried deep in soft tissue are typically not painful. Very large neuromas may cause significant pain but may also be asymptomatic, particularly when a prosthetic socket is properly fit.35

Physical examination results in the presence of a neuroma may be normal or may identify a focal, soft-tissue mass and reproducible pain with palpation or percussion. A local anesthetic injection may confirm the diagnosis and provide pain relief.34 Radiographic studies can help localize the source for a painful residual limb.34 Magnetic resonance imaging is optimal for detecting a neuroma but is of limited value when there are surgical clips or metallic fragments. If the neuroma measures less than 1cm, it is usually difficult to detect on imaging studies.34

There are several techniques used to manage neuroma pain. Surgical scar mobilization techniques can help prevent adherence of the scar to underlying tissues causing neuronal compression. Conservative therapy, including oral and topical analgesics, corticosteroid injections, electric stimulation, and socket reshaping, may also be successful in relieving neuroma pain. Resection of a neuroma is an option but can result in scar extension and new painful neuroma generation.34

Bone spurs and complex regional pain syndrome can also be sources of pain after amputation and require a high index of suspicion for accurate diagnosis. Musculoskeletal causes such as spine, hip and knee osteoarthritis, trochanteric or prepatellar bursitis, patellar tendinopathy, enthesopathy, medial or lateral collateral ligamentous sprain, meniscal injury, or other intra-articular pathology can cause additional pain and limit functional use of a prosthesis. Addressing the underlying etiology of the pain can help alleviate the pain.

4.4 Clinical Activity: Her husband reports during the clinic visit that she seems depressed. Evaluate the potential psychosocial issues that arise after amputation 

Implementing physical therapy before surgery may help prepare patients both physically and mentally to undergo the amputation and may enhance postoperative recovery. A psychologic consultation before the amputation is also appropriate, because unprepared and depressed patients may experience more physical and psychosocial difficulties afterward.36

After amputation, a comprehensive, interdisciplinary treatment plan that addresses medical, social, psychologic, and financial issues is critical to decreasing postoperative psychologic and social morbidity.36 Assessment of functional outcome may be difficult, because there are a multitude of assessment instruments and procedures used to identify the variably defined terms “optimal” or “successful” outcome after amputation.37 Functional outcome can be improved by appropriately addressing psychosocial factors, because loss of the ability to relate psychologically, vocationally, avocationally, sexually, and socially after amputation may have more impact on QOL than the loss of the limb itself.36

Patients who have lost a limb often have a predictable course of psychologic adjustment, regardless of the cause of amputation. An initial period of grieving is expected, often with disbelief, blunted emotions, preoccupation with the loss, anger, tearfulness, and insomnia.36 Later, there may be a period of sadness, hopelessness, and emotional lability.36 Vague somatic complaints are not unusual. Patients may sense that their independence and future goals are not attainable.36 Denial may also be a limiting factor in recovery, and patients with traumatic amputation are more likely to use avoidance as a coping strategy compared with those with disease-related amputation.33 Eventually, an adjustment phase takes place.33

The ultimate adjustment to amputation and perceived QOL are influenced by a patient’s age, level of maturity, past experiences, temperament, inner strength, personality traits, coping strategies, social support, comorbidities, site and cause of amputation, length of time since amputation, and comprehensiveness of care.33, 36, 37, 38 Nissen and Newman’s study38 showed that patients’ psychosocial and physical functioning after amputation are negatively affected by the presence of comorbidities. Vascular amputation may be related to greater physical disability and social isolation, and older age may be related to more limited mobility.37 Prolonged pain, regardless of the cause, may impair general, vocational, social, and emotional functioning and health-related QOL.33, 34, 35, 36, 37

People with limb loss perceive that they are participating less in recreational activities, are more dissatisfied at work, and are more impaired in community mobility relative to their premorbid status.38, 39 In fact, a person’s mobility and engagement in social activity is directly related to his/her confidence in his/her balance when using a prosthesis.40 Social discomfort, greater activity restrictions, and lower levels of perceived social support are associated with lower QOL ratings and higher levels of depression.37

Rates of clinical depression range from 18% to 35% among amputees, depending on the timeframe studied and the instrument used to assess for depression after amputation.33, 37, 41 A review of the literature fails to support elevated levels of anxiety in amputees compared with the general public.37 Rates of depressive symptoms may be elevated in the early postoperative and rehabilitation phases, but symptoms tend to diminish over time, reflecting the variability of adjustment to amputation.37 The cause of amputation does not appear to be related to depressive symptomatology.37 However, people with amputation-related pain are more prone to depression.33 Adequate postoperative pain control may favorably alter symptoms of anxiety and depression and may facilitate better participation in rehabilitation.36 The expected grief response, postoperative adjustment disorder, anger with social withdrawal/constricted affect, and cognitive disorders (delirium and/or dementia) may be difficult to distinguish from major depression, but an accurate diagnosis is crucial to providing of appropriate treatment.36

Because this patient has diabetes, it is important to note that up to one third of people with diabetes have depressive symptoms and approximately 10% have major depression.42 According to a recent meta-analysis,42 there is a 2-fold increase in the likelihood of depression in diabetics compared with nondiabetics. The increased incidence of depression was found to be similar between people with type 1 and type 2 diabetes. Women with diabetes are more likely to develop depression than are men with diabetes.42 Further, in a recent, large-population study, subjects with diabetes and comorbid depression reported significantly more functional disability than those with diabetes or depression alone.43 Surtees et al44 found that depression and anxiety reduce function independent of 4 chronic medical illnesses (diabetes, stroke, myocardial infarction, and cancer). Seven percent of women with chronic medical conditions in this study had either major depressive disorder or generalized anxiety disorder. With the exception of stroke, chronic anxiety had a greater impact on function than either chronic depression or the aforementioned comorbidities.44 Pharmacologic treatment of depression should be tailored to the patient. Age-specific treatment of depression is an important consideration. Effective medications used for older patients include selective serotonin reuptake inhibitors (SSRIs), venlafaxine and mirtazapine.45 This patient’s concomitant stroke also merits attention, because depression commonly occurs after such an event. Antidepressant drugs are effective for treatment of poststroke depression and may contribute to additional functional or cognitive recovery.46 The SSRIs, noradrenaline reuptake inhibitors, and tricyclic antidepressants (TCAs) appear to be effective in treating poststroke depression, but TCAs have a higher side-effect profile.46, 47 Of the SSRIs, sertraline and citalopram both have been used successfully to reduce emotional lability and are recommended for use in poststroke depression.46, 47 It is important to consider sex-specific treatment of depression as well. A recent literature review suggested that there may be increased rates of remission from depression related to menopause when estrogen replacement therapy is used.48 There is some debate over whether estrogen has any value in augmenting the efficacy of antidepressants.48

Sexuality is also affected by amputation.36 The presence of depression, performance anxiety, altered body image, positioning difficulties, and loss of range of motion may all result in sexual difficulties.36 These issues are especially prominent with chronic disease states such as diabetes.36

The psychosocial evaluation should include assessment of driving competency and skills to reduce the probability of an accident associated with a newly acquired amputation. This patient would benefit from screening of her vision, visuospatial perception, speed of visual search, attention, mental adaptability, and motor and sensory function.49, 50, 51 A formal driving evaluation is highly recommended. Amputation of a lower extremity may require adaptation of the vehicle, because use of a prosthesis on the foot pedals is not safe because there is no sensory feedback.51 Patients with a new amputation can greatly benefit from counseling with a trained peer who has experienced a similar amputation. This interaction may help patients acquire a greater understanding of the implications of their amputations, help alleviate anxiety, and offer insight regarding employment and social and recreational opportunities. Education and early involvement with an amputee support group can be useful for patients with new amputations or who have difficulty reintegrating into the community.36 Information on national peer support groups is available on the Internet at such sites as http://www.amputee-coalition.org. Accessibility information for people with disabilities is available on the Health and Human Services website http://www.hhs.gov. A disability and health team at the U.S. Centers for Disease Control and Prevention is available for information at http://www.cdc.gov.