Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 4 , Pages 634-645, April 2009

Quality of Life of Persons With Lower-Limb Amputation During Rehabilitation and at 3-Month Follow-Up

  • Diana Zidarov, PT, MSc

      Affiliations

    • School of Rehabilitation, University of Montreal, Montreal, QC, Canada
    • Montreal Rehabilitation Institute, Montreal, QC, Canada
    • Corresponding Author InformationCorrespondence to Diana Zidarov, PT, MSc, 3600 Av Darlington, Montreal, QC, Canada, H3S 2J4
    • ,
  • Bonnie Swaine, PT, PhD

      Affiliations

    • School of Rehabilitation, University of Montreal, Montreal, QC, Canada
    • Montreal Rehabilitation Institute, Montreal, QC, Canada
    • Center for Interdisciplinary Research in Rehabilitation of Metropolitan Montreal, Montreal, QC, Canada
    • ,
  • Christiane Gauthier-Gagnon, PT, MSc

      Affiliations

    • School of Rehabilitation, University of Montreal, Montreal, QC, Canada

Article Outline

Abstract 

Zidarov D, Swaine B, Gauthier-Gagnon C. Quality of life of persons with lower-limb amputation during rehabilitation and at 3-month follow-up.

Objective

To describe and compare the quality of life (QOL) of persons with lower-limb amputation (LLA) at admission (T1), discharge (T2), and 3 months after rehabilitation discharge (T3) and to explore the relationships between QOL and demographic and clinical variables including body image.

Design

Longitudinal case series.

Setting

Inpatient rehabilitation facility.

Participants

Consecutive sample of 19 unilateral persons with LLA (14 men, mean age, 53.4±14.6y).

Intervention

Interdisciplinary rehabilitation.

Main Outcome Measures

Generic and specific QOL measures and perception of body image at T1, T2, and T3.

Results

Subjective QOL was relatively high at T1, T2, and T3 (0.87/2, 1.1/2, and 1.0/2, respectively) except for items related to physical functioning. There was no significant change over time for all but 1 QOL satisfaction measure (ability to go outside, P=.024). Prosthesis-related QOL was high at discharge and follow-up. Body-image disturbances were absent over the study period. QOL satisfaction and prosthesis satisfaction were strongly related to lower-limb pain and psychosocial factors (eg, body image).

Conclusions

QOL of persons with LLA was high and remained relatively stable during inpatient rehabilitation and 3 months after discharge.

Key Words: Amputation, Body image, Quality of life, Rehabilitation

List of Abbreviations: ABIS, Amputee Body Image Scale, ADLs, activities of daily living, ANOVA, analysis of variance, LLA, lower-limb amputation, NHP, Nottingham Health Profile, PEQ, Prosthesis Evaluation Questionnaire, QOL, quality of life, SF-36, Medical Outcomes Study 36-Item Short-Form Health Survey, SQLP, Subjective Quality of Life Profile, TF, transfemoral, TT, transtibial, VAS, visual analog scale

 

LOWER-LIMB AMPUTATION is a permanent surgical procedure that has important functional, psychologic, and social sequelae that can influence the QOL of the person with amputation.1, 2 Although rehabilitation aims to address these sequelae,3 measuring the effect of these interventions on rehabilitation outcomes of people who have had an LLA remains a challenge. The selected outcomes must be related to rehabilitation goals that are specific to each person and associated with premorbid function.1, 4, 5 There is currently no consensus on which outcomes to measure or how to measure them.4, 6, 7 This is surprising given that amputee rehabilitation programs have common goals to improve mobility and functioning through prosthetic fitting to assist community reintegration and to ultimately improve the overall QOL of persons with an LLA.

QOL is increasingly used to measure outcome in rehabilitation.8, 9, 10, 11, 12 QOL is complex, and there is no consensus regarding a single definition or about the domains that constitute QOL.10, 13, 14 There are 2 aspects that are included in almost all definitions: multidimensionality and subjectivity of QOL. Multidimensionality is taken into account in the numerous tools available to assess QOL because they cover various domains. These can include health status; physical, social, mental, and emotional function; pain; relationships; life satisfaction; and well-being.9, 10, 13, 15 The subjective aspect of QOL reflects the person's own perceptions based on his/her education, life experiences, values, expectations, and environment in which the person lives.11, 16, 17

Health-related QOL can be measured with generic or condition-specific instruments. Generic instruments are applicable to a wide range of patient populations including those without health conditions.13 An advantage resulting from this broad applicability is that generic questionnaires can provide populations norms or benchmarks of healthy populations to which populations with a specific condition can be compared.13 Furthermore, they also permit comparisons across populations with different conditions and across interventions.13 However, because they assess the broadest possible range of QOL dimensions, they are less sensitive to change and also to specific issues of concern to populations with a specific condition (eg, persons with an LLA).13, 18 In contrast, specific instruments are particular to a certain population and, as such, focus on areas of interest relevant for that population and may be closer to clinicians' interests and interventions.18 One disadvantage of condition-specific measures is that they do not allow for a comparison of people with disabilities to a general healthy population or among groups with different impairments.12, 18 Another disadvantage is that because of their narrower focus, they may miss measuring an unexpected finding (eg, sexual dissatisfaction, financial problems). Because of the complementarities and the different level of detail assessed by generic and specific instruments, some believe that it is best to use both to capture the majority of the dimensions of QOL.13 With persons with an LLA, the majority of outcome studies to date address mobility, functional abilities, and use of prosthesis as the most important measures to evaluate rehabilitation outcomes4, 19 despite the growing interest in patients' QOL.10 Outcomes studies addressing health-related QOL of persons with an LLA are relatively recent.20, 21, 22, 23, 24, 25, 26, 27 These studies have used mostly generic tools such as the Reintegration to Normal Living,28 the NHP,29 and the SF-36.30 In recent years, specific QOL tools, such as the PEQ31 and the Trinity Amputation and Prosthesis Experiences Scales,24 have been developed specifically for use with people with amputation.

Nissen and Newman22 identified areas that were difficult with regards to the reintegration to normal living of 42 elderly persons with an LLA amputated several years previously. The most negatively affected areas in order of importance were participation in recreational activities, work activities, and community mobility. Another study using the NHP to measure the perceived health status of persons with an LLA (n=130, median time interval=38 months after limb amputation for peripheral arterial disease) found reintegration to be poor secondary to restricted mobility.32 Van der Schans et al20 investigated potential determinants of health-related QOL of persons with an LLA (n=437, median time since amputation=10y) and concluded that persons with phantom limb pain have poorer health-related QOL, as measured with the SF-36, than persons without pain. Furthermore, 28.7% of the variance of the mean SF-36 score was explained by 3 determinants: walking distance, stump pain, and diabetes. A recent study by Asano et al33 studied predictors of QOL with a large sample of 415 persons with a unilateral LLA (0 to >14y since amputation). Symptoms of depression accounted for 30% of the variance of QOL followed by prosthetic mobility (6% of the variance) and social support (2% of the variance). This study underscored the importance of psychosocial adaptation after an LLA and its impact on QOL. In contrast, Harness and Pinzur23 when using a condition-specific measure, the PEQ, with a sample of nontraumatic TT persons with amputation (on average 38.1mo after using their prosthesis), showed that the mobility and functional domains scores of the PEQ were lower than those of the psychosocial domains.

A few studies have investigated the relationships between body image of people with LLAs and QOL. Rybarczyk et al34 found that 53% of the variance of QOL was predicted by the person's perceived body image, social stigma, health, and time since amputation. Breakey35 developed the ABIS and found that the body image and psychosocial well-being (a component of QOL) of persons with an LLA was significantly correlated with QOL. The more negative the person's perception of his/her body image, the less satisfied he/she was with his/her QOL. Similar results were obtained by Miller36 with a sample of 51 vascular persons with an LLA; a person's perception of body image and self esteem predicted 63% of the variance of QOL.

Although these studies have improved our understanding of the QOL of persons with an LLA, they were all cross-sectional and conducted several months or years after the amputation. Furthermore, they used either a generic or specific tool, never both, except to validate a newly developed specific tool. Consequently, not all dimensions that may be of importance for a person with an LLA were assessed in a given period. Rehabilitation interventions have a holistic approach of the person, which all aim to impact on the QOL of patients. To determine whether this aim is attained, one must assess QOL at rehabilitation discharge. Moreover, QOL is an especially cogent measure of the performance of health care because it incorporates multiple domains that are addressed during the rehabilitation process, and, most of all, it involves the patient's own perception of his/her accomplishments during the process.12 To our knowledge, no study has yet investigated, using both generic and specific measurement tools, the overall QOL of persons with an LLA and whether it changes during and after rehabilitation.

The purposes of this study were to (1) describe and compare the QOL of persons with an LLA at admission, discharge, and 3 months after rehabilitation discharge and (2) explore the relationships between QOL and certain demographic and clinical variables, including body image.

Back to Article Outline

Methods 

Study Sample 

This exploratory longitudinal study was conducted with persons with an LLA who were consecutively admitted to the Montreal Rehabilitation Institute in Quebec, Canada, for inpatient rehabilitation between September 2005 and December 2006. Patients received an individualized program from a multidisciplinary team. This program includes daily physical therapy and occupational therapy for preprosthetic and prosthetic training and psychologic support to the patient and their family; additional family support and sociovocational orientation is provided by a social worker, and leisure activities are offered in and out of the rehabilitation center. Once a week, all patients meet with their rehabilitation team to set rehabilitation objectives for the upcoming week.

Inclusion criteria consisted of (1) being 18 years or older and having a unilateral TT or TF amputation from any cause except congenital, (2) having sufficient cognitive skills and French or English comprehension to be able to accurately respond to questionnaires, and (3) being admitted for a first rehabilitation for prosthetic training. The last criterion was chosen to minimize the effects of confounding variables (eg, multiple admissions to rehabilitation for subsequent amputation of the residual limb) so the results observed were specific to a first rehabilitation stay.

The research protocol was approved by the Research Ethics Committee of the Center for Interdisciplinary Research in Rehabilitation of which the Montreal Institute is a site. Subjects signed an informed consent form before participating.

Procedure 

Data were collected at 3 times: during the 7 days after admission to the inpatient rehabilitation program (T1), during the 7 days before discharge (T2), and at the 3-month follow-up (T3). All data were collected by using questionnaires that were either self-administered or administered during the interview depending on the participant's ability to answer (eg, no visual problems or difficulty in understanding certain questions). Interviews were conducted by the same evaluator (D.Z.), a senior physical therapist with over 10 years of experience. The following information was extracted from the patient's medical chart: age, highest level of completed education, level and date of amputation, duration of prosthetic training, length of stay (rehabilitation), associated medical conditions, and marital and employment status at the time of amputation.

Measurement Instruments 

Subjective Quality of Life Profile 

General QOL was measured with a generic tool, the SQLP.16, 37, 38 This questionnaire was selected, in part, because it was originally developed in French and the majority of patients admitted to the Montreal Rehabilitation Institute are French speaking. Furthermore, it allows respondents to report their level of satisfaction (satisfaction scale) with regards to each domain evaluated; to indicate the importance of each item and domains in their life (importance scale); and, most of all, to express the changes they expect to occur over time with regards to their rehabilitation services (anticipated change scale). Finally, this questionnaire has the advantage of being flexible in that it contains 27 core items as well as optional items (n=54) that can be added depending on the population studied. The core items cover 4 domains: functional life (physical and mental health), social life (relationships, social roles), material life (income), and spiritual life (religious experiences, ability to think, future expectations). The SQLP was used and validated with healthy subjects and with populations with psychiatric or somatic disorders39 but never with persons with an LLA. The convergent validity between the SQLP and the World Health Organization Quality of Life questionnaire was shown (r>.45).40 The SQLP was shown to have high internal consistency (Cronbach α=0.9) and moderate to fair test-retest reliability (Spearman ρ range, 0.3–0.5, P<.005).37

In the present study, we collected data for the 27 core items, and 9 additional questions from the optional list of the SQLP were added based on both our literature review and the authors' clinical experience. Participants were questioned about their eyesight, hearing, body weight, overall physical aspect, independence, future, relations and dependency on family, and feeling different from other people. For each item, 3 measures were obtained. The respondents rated their satisfaction/dissatisfaction level (–2, very unsatisfied; 0, indifference; 2, very satisfied). Next, they indicated the importance of each item (0, unimportant to 3, extremely important), and, finally, they reported the change they expected during their rehabilitation (–2, change very unfavorably; 0, no change expected; 2, change very favorably). Results are presented in the form of profiles; a mean score is calculated for each item and for each of the 3 global scores.

Prosthesis Evaluation Questionnaire 

The PEQ31 was used to evaluate the function of a lower-limb prosthesis and the prosthesis-related QOL of the persons with an LLA. It contains 82 items grouped into 9 validated independent subscales: ambulation, appearance of the prosthesis, residual limb health, perceived responses, frustration, social burden, prosthetic sounds, utility, and well-being. It also includes additional questions (not contained in the subscales) about satisfaction with the prosthesis, pain, transfers, prosthetic care, self-efficacy, and other aspects of the prosthesis. The PEQ subscales and the subscales of the SF-36, the Sickness Impact Profile, and the Profile of Mood States–short form were found to be significantly correlated (r=.49–.61).31 The PEQ has also shown good to excellent internal consistency (Cronbach α varies from .73 to .89 for each of the 9 subscales) and moderate to excellent test-retest reliability for a mean retest period of 30 days (intraclass correlation coefficient=.56–.90, for the 9 subscales).31

In this study, we used only 4 of the 9 subscales: appearance, utility, sounds, and well-being. The questions addressing satisfaction with prosthesis (n=1) and self-efficacy (n=3) were also included for a total of 21 items. Patients indicated their responses on a VAS (10-cm line) with the 2 boundaries representing extremes of possible answers (eg, never or all of the time). A score for each subscale was calculated by computing the arithmetic mean of all the questions that were applicable to each respondent within the particular subscale. The PEQ was administrated only at discharge and at the 3-month follow-up because patients do not have their prosthesis on admission.

Amputee Body Image Scale 

The ABIS35 assessed persons' perception of their body image with and without prosthesis. It contains 20 items measured with a 5-level Likert scale ranging from none of the time to all of the time. A total score can be calculated that ranges from 0 to 100, where low scores indicate the relative absence of body image concern. The internal consistency was shown to be high (Cronbach α=.88).35 Although there is a lack of information regarding the tool's other psychometric properties, to our knowledge, the ABIS is the only tool developed to specifically address body image with persons with an LLA.

Data Analysis 

Descriptive statistics were computed for the questionnaires scores as well as for the sociodemographic and clinical characteristics. Mean and SD were used for the continuous data and frequencies and percentages for the categoric data. The differences between the means of each item of the SQLP at the 3 evaluation times were tested with a 1-way repeated-measures ANOVA with time of measurement as a within-subjects factor. When significant results were obtained (P<.05), post hoc comparisons were performed by using the Bonferroni correction for multiple comparisons. Paired t tests were used to test differences in means between discharge and the 3-month follow-up for the PEQ and ABIS questionnaires. Independent t tests were used to examine the influence of sex, level and cause of amputation on duration of stay, duration of prosthetic training, and ABIS scores at discharge and at follow-up. Pearson correlation coefficients were used to test relationships between clinical, sociodemographic, and questionnaire scale or subscale variables regrouped under 4 categories (appendix 1). The significance level was set at .05 for all analyses. All analyses were performed with SPSS, version 14.0 for Windows.a

Back to Article Outline

Results 

Demographic and Clinical Variables 

Of the 114 persons with an LLA admitted to the program during the study period, only 29 (26%) met the eligibility criteria. Of the 85 remaining, 30% were readmissions, 34% had a bilateral amputation, 11% insufficiently understood French or English, 16% had important cognitive or psychiatric problems, and 9% were not considered as potential prosthetic wearers. Of the 29 eligible subjects, 6 (21%) refused to participate, 1 died at follow-up, and 3 had an unplanned discharge. Data for the 3 evaluation times were obtained for 19 participants. Table 1 summarizes their clinical and demographic characteristics. The main cause of amputation was peripheral vascular disease (63%) with or without diabetes. They suffered from several associated medical conditions; 52.6% had high blood pressure, 42.1% had visual problems, 21.1% had hearing problems, and 26.3% had chronic kidney failure. The mean time between amputation and admission to rehabilitation did not significantly differ (P>.05) according to the level or cause of amputation. The same results were obtained for the mean duration of stay and the mean duration of prosthetic training.

Table 1. Clinical and Demographic Characteristics of the Sample
VariablenFrequency (%)
Cause of amputation
Vascular1263.2
Traumatic315.8
Tumor210.5
Infection210.5
Level of amputation
TT1684.2
TF315.8
Sex
Men1473.7
Women521.7
Marital status
Married/committed947.4
Single526.3
Divorced/widowed526.3
Education
Primary210.5
Secondary1052.7
Post secondary736.8
Employment status at the amputation
Employed1263.2
Retired736.8
VariableMean ± SDRange
Time since amputation (d)73.3±87.77–384
Duration of rehabilitation stay (d)84.3±23.359–146
Duration of prosthetic training (d)49.2±19.229–105
Age (y)53.4±14.626–78

Subjective Quality of Life Profile 

The mean global satisfaction scores of the SQLP at admission, discharge, and follow-up were 0.87, 1.10, and 1.01, respectively (fig 1). At admission, the items for which the lowest satisfaction was expressed were the ability to go outside (.26) and overall fitness (.26). The most satisfaction was reported for items relating to relationships with other people (1.7) and material conditions (1.65). At discharge, sexuality (.42) and body weight (.42) had the lowest scores, whereas ability to think (1.79) and relationships with others (1.74) were the highest. At follow-up, the items with the highest scores were the same as those at discharge, and sexuality (.37) and physical abilities (.42) scored the lowest.

With regards to the patients' importance of the various domains of life, the mean global scores for the 3 evaluation times were all 1 or more, indicating that they were perceived as very important (fig 2). In general, the importance slightly decreased from admission to follow-up. At admission, the ability to think (2.52) and independence (2.43) were the most important items, whereas spirituality (.61) and surrounding world (.96) were the least important. At discharge, eyesight (2.21) followed by independence, going outdoors, sleep, and ability to think (2.16) were the most important items for the persons with an LLA. Group participation (.63) and surrounding world were the least important (.79). At the 3-month follow-up, the same items were rated as unimportant, whereas going outdoors (2.16) and companionship (2.11) were judged the most important.

The mean scores for the anticipated changes indicated that persons with an LLA expected a fairly favorable change in the various domains of life during rehabilitation (fig 3). Mean scores slightly decreased from admission to follow-up. At admission, the greatest changes were expected in the ability to go outside and independence (1.43), and the least change was expected in spirituality (.09), hearing, and relationships (family and relatives=.13). At discharge, going outdoors, overall fitness, and view of the future (1.32) were expected to change the most, whereas hearing (0.11), relations with others, and meals (.21) were not. At follow-up, participants still expected their physical abilities (1.05) and their overall fitness (.89) to improve, whereas spirituality and meeting friends (.11) were not expected to change.

The change in subjective QOL was analyzed item by item for each measurement scale (satisfaction, importance, anticipated change) by using a repeated-measures ANOVA. Pair-wise comparisons (Bonferroni correction applied) were performed for comparisons reaching significance (table 2) to determine when the differences occurred. After applying the Bonferroni correction, 5 were still significant (see table 2). There was a significant increase in patients' mean total satisfaction score concerning the ability to go outside between admission and discharge (F2,34=5.77, P=.007). The importance perceived concerning ADLs significantly decreased between admission and discharge (F2,34=3.89, P=.03). The importance attributed to the ability to think and concentrate also decreased between admission and follow-up (F2,34=5.39, P=.009). Change anticipated with rehabilitation decreased significantly from admission to follow-up concerning the ability to go outside (F2,34=5.09, P=.012) and sleep (F2,34=4.80, P=.015).

Table 2. Change of Subjective QOL for Each Measurement Scale Using Repeated-Measures ANOVA
VariableMean Difference (T2–T1) (P)95% CIMean Difference (T3–T2) (P)95% CIMean Difference (T3–T1) (P)95% CI
Satisfaction scale
Ability to go outside1.00(.024)0.12to1.89NSNSNSNS
Importance scale
ADLs−0.50(.024)−0.94to−0.06NSNSNSNS
Ability to thinkNSNSNSNS−0.61(.022)−1.14to−0.08
Anticipated change scale
Ability to go outsideNSNSNSNS−0.67(.019)−1.24to−0.10
SleepNSNSNSNS−0.61(.005)−1.05to−0.17

Abbreviations: CI, confidence interval; NS, not significant.

Prosthesis Evaluation Questionnaire 

In general, patients' overall perception was very favourable, with no significant differences found between scores at discharge and follow-up (P>.05) for the 4 selected PEQ subscales (table 3). The mean prosthesis satisfaction scores were also high, indicating greater satisfaction with the prosthesis at discharge and at follow-up (7.4 and 7.0, respectively), and these scores did not differ significantly. Patients indicated that if the fit and the comfort of their prosthesis were both poor at discharge, they completed on average 55% of their daily activities. Results were similar at the 3-month follow-up, and there were no significant differences between scores at discharge and at follow-up. Regarding the amount of activities performed without the prosthesis, on average, patients performed significantly less activities without their prosthesis at follow-up than at discharge (t17=3.43, P=.003).

Table 3. Mean Scores for the PEQ Subscales, Prosthesis Satisfaction, Self-Efficacy Questions, and the ABIS at Discharge and Follow-Up
VariablePossible ScoreMean at Discharge ± SDRange at DischargeMean at Follow-Up ± SDRange at Follow-UpP⁎
PEQ subscales
Well-being0–108.0±1.35.6–10.07.9±1.53.5–10.739
Appearance0–106.8±1.63.6–8.87.5±1.82.1–10.0.235
Utility0–107.5±1.34.4–9.67.5±1.53.4–9.5.825
Sounds made by prosthesis0–108.7±1.73.6–10.07.9±2.41.6–10.0.111
Satisfaction with prosthesis0–107.4±1.54.9–10.07.0±1.73.1–9.1.498
Self-efficacy questions
Fit of prosthesis0–105.5±1.51.8–7.75.6±2.32.0–10.0.776
Comfort of prosthesis0–105.5±2.30–5.95.2±2.70–10.0.416
Daily activities done without prosthesis0–106.9±1.74.4–104.6±2.70–9.4.003
ABIS0–10029.0±15.31.3–68.829.1±19.36.3–73.8.819

⁎P associated with ANOVA. Significant results indicate differences between the 3 evaluation periods.

Amputee Body Image Scale 

The mean ABIS score at discharge was low, and it did not differ significantly from that at follow-up (see table 3). Subgroup analyses revealed that at discharge persons with a TF LLA (47.5±22.6) reported a significantly poorer perception of body image compared with that of persons with a TT LLA (25.5±11.4, t17=–2.63, P=.017). At the 3-month follow-up, women (50.9±24.7) had a significantly higher body image disturbance compared with men (23.3±13.3, t17=–3.088, P=.007).

Relationship Between Patient/Clinical Variables and Quality of Life and Prosthesis Satisfaction 

At discharge, strong and significant relationships were found between QOL satisfaction and bothersome pain in the nonamputated leg, adaptation to amputation, presence of phantom limb pain, and adaptation to prosthesis (table 4). At the 3-month follow-up, QOL satisfaction was significantly correlated with the PEQ's well-being and utility subscales, adaptation to amputation, body image, and adaptation to prosthesis. At discharge, prosthesis satisfaction was strongly correlated with the perception of the utility of the prosthesis and the frequency of back and residual limb pain (table 5). At 3 months, prosthesis satisfaction was still strongly associated with the utility of the prosthesis and prosthesis adaptation and body image.

Table 4. Correlation Coefficients Between Mean Total QOL Satisfaction Score as Measured by the SQLP and Patient/Clinical Variables Measured at Discharge and at 3-Month Follow-Up
VariablesPearson Correlation CoefficientnP
Discharge
Bothersomeness of pain in the nonamputated leg0.7059.034
Adaptation to amputation0.74119<.001
Phantom limb pain−0.49719.031
Adaptation to prosthesis0.46019.048
3-month follow-up
PEQs well-being scale0.73319<.001
PEQs utility scale0.68519.001
Adaptation to amputation0.68419.001
Total score ABIS−0.60419.006
Adaptation to prosthesis0.60219.006
Table 5. Correlation Coefficients Between Satisfaction With the Prosthesis as Measured by the PEQ and Patient/Clinical Variables Measured at Discharge and at 3-Month Follow-Up
VariablesPearson Correlation CoefficientnP
Discharge
PEQs utility scale0.61519.005
Frequency of back pain−0.55219.014
Frequency of residual limb (stump) pain−0.46119.047
3-month follow-up
PEQs utility scale0.65319.002
Adaptation to prosthesis0.64519.003
ABIS total score−0.48819.034

Back to Article Outline

Discussion 

This is the first study to document the QOL of persons with an LLA and to determine whether it changes during and after a period of intensive inpatient rehabilitation. Results obtained with the SQLP showed that at admission persons with an LLA tended to be mostly unsatisfied with items related to their health and physical functioning (eg, ADLs, going outside, overall fitness, independence, physical abilities). These domains were judged very important to the subjects, and they were associated with the highest expectations for favorable change during inpatient interdisciplinary rehabilitation. Again at discharge and follow-up, items related to physical functioning (physical abilities, overall fitness, personal future) were still perceived as unsatisfactory and important, and participants expected improvements before discharge and in the months to come.

These results are difficult to compare directly with those obtained by others mainly because of the differences in the intervals of time between the completion of rehabilitation and the evaluations and the tools used to measure QOL. Studies were conducted months or years postrehabilitation and used primarily a single-item question33 or generic tools providing either a total or subscale scores.20, 21, 22, 25, 32 The SQLP provided a more detailed profile (item by item) in relation to 3 measurement scales: satisfaction, importance, and anticipated change. Nonetheless, in general, our results are comparable with those of others who found that physical functioning20, 21 and mobility32 were problematic months and even years after an amputation.

When our results are compared with the mean total SQLP satisfaction scores of nondisabled persons (.77),39 we find that the mean total satisfaction scores of persons with an LLA are generally higher at admission (.87), discharge (1.10), and at follow-up (1.01). The participants satisfaction profile concerning interpersonal relationships was similar to that obtained with a normal sample.39 Surprisingly, physical appearance was perceived more satisfactory at all 3 evaluation periods by persons with an LLA compared with the normal sample. However, items related to health and physical functioning, such as independence, physical abilities, and dependence on family, were scored lower by the participants than by healthy individuals. Sexual satisfaction was also scored lower by the participants in all 3 evaluation periods when compared with the normal sample. Moreover, observed sexual satisfaction scores were lower than those of other persons with an LLA who reported being moderately satisfied with their sexual behavior.41

Concerning the evolution of the subjective QOL, few results were significant. This may indicate that the SQLP is not sensitive to change or that another phenomenon, not specifically measured in this study, may have occurred. Here, we refer to a response shift. A response shift has been defined as a change in internal standards, a change in importance of values, and reconceptualization of a subjective concept, such as QOL, after a modification of a peron's health status.42 A response shift may explain how persons with an LLA maintain or improve their QOL after a major disability that has an important physical, psychologic, and social impact.43 In our study, the relatively high satisfaction scores recorded at all 3 evaluations and the lack of significant differences observed over time may indicate that the rehabilitation interventions were effective in promoting a healthy response shift44 or that the amputation itself may have alleviated some of the subjects' physical and psychologic suffering.

The Importance Attributed Scale of the SQLP could provide a means to measure an aspect of response shift because it identifies participants' personal values and the changes related to them during a certain timeframe.16 In our study, the mean total importance scores tended to decrease slightly during the 3 evaluation periods. The significant changes in personal values observed could reflect a reduction in the importance attributed to ADLs and the ability to think and concentrate.

A change in expectations is also an indication that a response shift may have occurred.42 Our results showed that the total mean anticipated change scores tended to decrease from admission to follow-up and that significant results were obtained with regards to the ability to go outside and to sleep. These results indicate that patients' perceptions about their reality and their expectations converge over time. In other words, it is likely that a response shift occurred indicating that ultimately persons with an LLA did report some improvement in their QOL.

The authors of another very recent study,33 with a much larger sample of participants with LLA (n=415), also hypothesized that a response shift could possibly explain the relatively high QOL scores they observed (mean score, 7.4±2.1 out of 10). It is interesting to note that time since amputation of their sample varied from 0 to more than 14 years and QOL scores tended to improve (but not significantly) with time. In contrast, the perception of QOL in our sample tended to decrease once the person returned home. One could argue that in the months after discharge, people may experience different real-life situations that make them realize their limitations, which consequently can lower their perception of their QOL. On the other hand, the relatively high QOL satisfaction of our participants may be caused by the relatively short period between the amputation and their admission to rehabilitation (77.3d) when their QOL was first evaluated. In fact, for persons with amputations of vascular causes, the amputation of a leg that may have caused pain and a low level of functioning for months previously may be seen as a relief and may have contributed to the high satisfaction responses observed.45 Among persons who sustained an amputation after a trauma, the elevated QOL scores may be because of their happiness of having survived their injury.

Prosthesis-Related Quality of Life 

Concerning results obtained with the PEQ, participants' satisfaction with the prosthesis and their perception about the appearance, utility, and sounds made by the prosthesis were equally high at discharge and at the 3-month follow-up. This may indicate that the quality of the delivered prosthesis was adequate at discharge and that the timing of delivering a definitive prosthesis was well targeted by the rehabilitation team in relation to residual limb issues (maturation, wound healing, and so on). The high mean PEQ subscale scores obtained in our study are similar to those obtained by Legro,31 Harness,23 and colleagues in their cross-sectional studies. However, in contrast to our results (8.0 at discharge and 7.9 at follow-up), these authors reported lower well-being subscales scores (7.2 and 6.7, respectively) when assessed several years after prosthetic rehabilitation. These differences may be because of the fact that well-being is a dynamic concept. A person's perception may change according to his/her life experiences as they are influenced by the person's physical and social environment, personality, or new health problems.14, 40 This may explain, in part, the slight decrease in well-being or QOL after an LLA that occurs later. It remains unclear, however, when this change occurs and what factors are associated with this event. Nevertheless, our results, as well those studies discussed here, indicate that the perceived well-being of persons with an LLA is consistently high after their amputation.

Body Image 

One major finding was that participants were not very concerned with their body image at the 3 evaluation periods. The median ABIS score observed in our study was lower at discharge (23.8) and at the 3-month follow-up (21.3) compared with those reported in other studies using this tool.35, 36, 46 Breakey35 reported body image perturbation among males with traumatic amputation of a similar age to be 33.5, whereas Miller36 obtained a score of 53 among nontraumatic persons with an LLA suggesting that older and vascular amputees may be more concerned about their body image than younger traumatic amputees. Others have, however, reported higher ABIS scores among persons with amputations of mixed causes (eg, 57.5).46 Comparisons between studies are difficult because of the differences in sample composition and the timing of the evaluations. In fact, time since amputation may play a role in the development of body image disturbance. In our study, mean time since amputation was very short (73.3±87.7d) compared with those reported in Breakey's (17.0±13.5y) and Miller's studies (5y). It seems that with the passage of time, persons with an LLA tend to develop a concern for their body image. However, more longitudinal studies are needed to clarify when this occurs and to determine the contributing factors. Concerning the potential influence of sex and level of amputation on perception of body image, in contrast to our findings, Breakey35 did not find a significant difference between persons with a TT and TF LLA and Miller36 did not find significant differences between males and females. Significant results in our study may reflect a tendency toward women having a greater concern about their body image once being back home.

Relationship Between Patient/Clinical Variables and Qualtiy of Life and Prosthesis Satisfaction 

The present study explored whether a relationship exists between demographic, clinical, prosthetic, pain sensation, and psychologic well-being variables and QOL and prosthesis satisfaction. Our findings suggest that participants' perception of their QOL satisfaction is more related to pain sensation, prosthetic factors, and psychosocial well-being (adaptation to amputation, prosthesis, body image) than to clinical or demographic variables such as age, sex, level, or cause of amputation. In a sample of 77 persons with an LLA, higher amputation-related pain was associated with lower QOL.41 Matsen et al47 showed a significant correlation between QOL and the condition of the contralateral limb and found significant correlations ranging from .47 to .60 between QOL and the ability of persons with an LLA to walk in confined space or walk while carrying a load. Similar to our results, they did not find age, sex, or level of amputation to be significantly related to the perception of QOL. Van der Schans et al,20 while investigating the potential determinants of health-related QOL among 437 persons with an LLA by using the SF-36, found that respondents with phantom limb pain had a poorer health-related QOL compared with those without phantom limb pain. Although psychologic well-being and adjustment to an amputation were not measured directly, anxiety and depression, social support, phantom limb pain intensity, concerns with self-esteem, and body image were associated with their measure.35, 48, 49 In another study,33 symptoms of depression accounted for 30% of the variance in QOL of a sample of 415 persons with an LLA and factors predicting long-term adjustment to an LLA such as phantom limb pain and psychosocial variables such as catastrophizing, perceived control over pain, and coping and social support were found to be important contributors to adjustment to an amputation.49 Furthermore, greater levels of social support, 1 month after an LLA, were related to greater levels of life satisfaction50 and social support explained 2% of the variance of perceived QOL.33 Callaghan and Condie27 validated the Patient Generated Index, a generic QOL measure, by using the Medical Outcomes Study Short Form-12 with 42 unilateral TF amputees who had been fitted with a prosthesis at least 1-year postrehabilitation and found a stronger relationship between mental health and QOL life than between physical health and QOL.

At discharge, prosthetic satisfaction seems to be mostly associated with pain and prosthetic variables, whereas at follow-up prosthetic variables and psychosocial variables play a role. The reduction of residual limb pain is an important rehabilitation goal. Residual limb pain may impede the use of the prosthesis and is associated with lower physical functioning.51 Furthermore, a recent study found that acute residual limb pain (assessed at 4 and 5 days postamputation) was the best predictor of development of chronic residual limb pain in persons with an LLA.52 Bilodeau et al2 found that pain and the risk of injuries were the main causes of dissatisfaction with the prosthesis among persons with LLA and that prosthesis satisfaction explained 46% of the variance of prosthesis use. In a survey of 44 persons with LLA investigating prosthesis satisfaction, body image, and phantom pain, Murray and Fox46 found that higher levels of prosthesis satisfaction were significantly correlated with lower levels of body image disturbance (r=–.52) and that the number of hours of prosthetic use was significantly related to prosthesis satisfaction (r=.39). However, prosthesis satisfaction was not significantly related to pain (r=–.019).

Study Limitations and Clinical Implications 

There are a few limitations to this study. Our sample was small; hence, we were not able to detect significant differences over time for all variables. All subjects were inpatients in the same rehabilitation facility and were candidates for prosthetic fitting. As such, our results may not be generalizable to the total population of persons with LLA including those who never received a prosthesis, who have bilateral amputation, and who have severe cognitive disorders. Indeed, correlational analyses do not allow one to conclude any causal relationship between functional rehabilitation and QOL; however, the observed significant correlation coefficients, despite the small sample size, underscore the importance of the relationship between the two.

Despite these limitations, there are important points to be learned from this study. The SQLP, as a measure of subjective QOL, appears to provide valuable information about rehabilitation QOL outcomes and patients' perceptions in different domains of life that may help the multidisciplinary rehabilitation team identify a particular client's objectives and treatment plan. Individualized selection of objectives and treatment promote patient involvement in the rehabilitation process.53 However, the use of the SQLP in routine clinical practice may be difficult because of practicability issues. The mode of administration, frequently by interview, is lengthy (≈30min), and clinicians may feel that therapy is more useful to the patient than administration of a questionnaire even if the responses provide them with useful information. Furthermore, generating and interpreting the satisfaction profiles can be complex and time-consuming for daily practice. Ideally, more methodologic work is needed to shorten and simplify QOL tools in order to be routinely used in rehabilitation clinical settings.11, 14, 15, 53

The specificity of the PEQ provides practitioners with the perceptions of persons with an amputation regarding aspects important to their QOL such as satisfaction, appearance, and usefulness of their definitive prosthesis. This information can serve as benchmark criteria when delivering a definitive prosthesis before discharge. The only practicability issue with regards to using the PEQ routinely was that some older participants found it difficult to understand the VAS and to complete the questionnaire by themselves.

The ABIS is the only tool we are aware of that measures the perception of body image of people with an LLA. Although we did not report body image disturbances over the study period, we believe that certain subgroups of participants, such as persons with TF LLA or women, may start developing body image issues during rehabilitation. This hypothesis needs to be tested with larger samples. To be able to intervene in a timely manner, rehabilitation programs should provide regular follow-up to persons with an LLA to detect a potential problem, including body image, and to be able to provide the necessary services.

Finally, future research should include more longitudinal QOL studies extending beyond 3 months postdischarge with larger samples that also include persons with a unilateral and bilateral LLA and candidates and noncandidates for prosthetic training. This type of research should have sufficient power to determine the factors that positively or negatively impact QOL. Such studies should also take into consideration the possible influence of response shift that could occur when someone experiences a major change in his/her life.

Back to Article Outline

Conclusions 

Subjective QOL of persons with an LLA is relatively high during and 3 months after the rehabilitation process except for items related to their physical functioning. Furthermore, persons with LLA have a high prosthesis-related QOL in relation to the global satisfaction of their prosthesis and their perception of the appearance and the utility of their prosthesis. Although participants did not seem to have a body image disturbance during the study period, body image perception was found to be highly related to the perception of QOL. Although the rehabilitation process is mainly focused on the physical functioning including prosthetic fitting, our findings underscore the importance of also focusing care on pain issues and particularly psychosocial issues such as body image and adaptation to amputation and the prosthesis during the rehabilitation process. This holistic approach should enhance the QOL of persons with LLA.

Supplier

Back to Article Outline

Appendix 1: Variables Used in Correlation Analyses 


Demographic and clinical variables

Age at admission

Sex

Level of amputation

Cause of amputation


Prosthetic variables

Satisfaction with prosthesis

Appearance of prosthesis

Utility of prosthesis

Sounds made by prosthesis

Number of associated medical conditions
Time since amputation
Duration of stay
Duration of prosthetic training

Pain sensation variables

Frequency, intensity, and bothersomeness of:

• Phantom pain

• Residual limb pain

• Nonamputated leg pain

• Back pain


Psychologic well-being variables

Body image

Adaptation to amputation

Adaptation to prosthesis

Back to Article Outline

References 

  1. Geertzen JH, Martina JD, Rietman HS. Lower limb amputation part 2: rehabilitation– a 10 year literature review. Prosthet Orth Int. 2001;25:14–20
  2. Bilodeau S, Hebert R, Desrosiers J. Lower limb prosthesis utilisation by elderly amputees. Prosthet Orth Int. 2000;24:126–132
  3. Kuiken TA, Miller L, Lipschutz R, Huang ME. Rehabilitation of people with lower limb amputation. In:  Braddom RL,  Buschbacher RM editor. Physical medicine and rehabilitation. Philadelphia: Saunders Elsevier; 2007;p. 282–318
  4. Kent R, Fyfe N. Effectiveness of rehabilitation following amputation. Clin Rehabil. 1999;13(Suppl 1):43–50
  5. Jelic M, Eldar R. Rehabilitation following major traumatic amputation of lower limbs– a review. Crit Rev Phys Rehabil Med. 2003;15:235–252
  6. Miller WC, Deathe AB, Speechley M. Lower extremity prosthetic mobility: a comparison of 3 self-report scales. Arch Phys Med Rehabil. 2001;82:1432–1440
  7. Condie E, Scott H, Treweek S. Lower limb prosthetic outcome measures: a review of the literature 1995 to 2005. Proceedings of the State-of-the-Science-Conference. Chicago: Lipincott Williams and Wilkins; 2005;
  8. Wilson IB, Cleary PD. Linking clinical variables with health-related quality of life. JAMA. 1995;273:59–65
  9. Renwick R, Nourhaghighi N, Manns PJ, Rudman DL. Quality of life for people with physical disabilities: a new instrument. Int J Rehabil Res. 2003;26:279–287
  10. Macduff CC. Respondent-generated quality of life measures: useful tools for nursing or more fool's gold?. J Adv Nurs. 2000;32:375–382
  11. Jette AM. Using health-related quality of life measures in physical therapy outcomes research. Phys Ther. 1993;73:528–537
  12. Andresen EM, Meyers AR. Health-related quality of life outcomes measures. Arch Phys Med Rehabil. 2000;81(12 Suppl 2):S30–S45
  13. Cella D, Nowinski CJ. Measuring quality of life in chronic illness: the functional assessment of chronic illness therapy measurement system. Arch Phys Med Rehabil. 2002;83(12 Suppl 2):S10–S17
  14. Wood-Dauphinee S. Assessing quality of life in clinical research: from where have we come and where are we going?. J Clin Epidemiol. 1999;52:355–363
  15. Fitzpatrick R, Fletcher A, Gore S, Jones D, Spiegelhalter D, Cox D. Quality of life measures in health care (I: applications and issues in assessment). BMJ. 1992;305:1074–1077
  16. Dazord A, Boissel JP. Subjective quality of life assessement in therapeutic trials: presentation of a new instrument in France. In:  Orley J,  Kuyken W editor. Measurement of quality of life in health care settings. Berlin: Springer-Verlag; 1994;p. 185–195
  17. In:  Béthoux F,  Calmels P editor. Guide des outils de mesure et d'évaluation en médecine physique et de réadaptation. Paris: Frison-Laroche; 2003;
  18. Finch E, Brooks D, Stratford PW, Mayo NE. Physical rehabilitation outcome measures. 2nd ed.. Baltimore: Lippincott Williams and Wilkins; 2002;
  19. Gallagher P, MacLachlan M. The trinity amputation and prosthesis experience scales and quality of life in people with lower-limb amputation. Arch Phys Med Rehabil. 2004;85:730–736
  20. Van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. Phantom pain and health-related quality of life in lower limb amputees. J Pain Symptom Manage. 2002;24:429–436
  21. Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related amputations. Arch Phys Med Rehabil. 2000;81:292–300
  22. Nissen SJ, Newman WP. Factors influencing reintegration to normal living after amputation. Arch Phys Med Rehabil. 1992;73:548–551
  23. Harness N, Pinzur MS. Health related quality of life in patients with dysvascular transtibial amputation. Clin Orthop Relat Res. 2001;(383):204–207
  24. Gallagher P, MacLachlan M. Development and psychometric evaluation of the trinity amputation and prosthesis experience scales (TAPES). Rehabil Psychol. 2000;45:130–154
  25. Demet K, Martinet N, Guillemin F, Paysant J, Andre JM. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil. 2003;25:480–486
  26. De Godoy JM, Braile DM, Buzatto SH, Longo O, Fontes OA. Quality of life after amputation. Psychol Health Med. 2002;7:397–400
  27. Callaghan BG, Condie ME. A post-discharge quality of life outcome measure for lower limb amputees: test-retest reliability and construct validity. Clin Rehabil. 2003;17:858–864
  28. Wood-Dauphinee S, Opzoomer M, Williams J, Marchand B, Spitzer W. Assessment of global function: the reintegration to normal living index. Arch Phys Med Rehabil. 1988;69:583–590
  29. Hunt SM, McKenna SP, McEven J. The Nottingham Health Profile: subjective health status and medical consultation. Soc Sci Med. 1981;15:221–229
  30. Ware J, Sherbourne C. The MOS-36-Item Short-Form Health Survey (SF-36): I (Conceptual framework and item selection). Med Care. 1992;30:473–481
  31. Legro MW, Reiber GD, Smith DG, Del Aguila M, Larsen J, Boone D. Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life. Arch Phys Med Rehabil. 1998;79:931–938
  32. Pell JP, Donnan PT, Fowkes FG, Ruckley CV. Quality of life following lower limb amputation for peripheral arterial disease. Eur J Vasc Surg. 1993;7:448–451
  33. Asano M, Rushton P, Miller WC, Deathe AB. Predictors of quality of life among individuals who have a lower limb amputation. Prosthet Orthot Int. 2008;32:231–243
  34. Rybarczyk BD, Nyenhuis DL, Nicholas JJ, Cash SM, Kaise J. Body image, perceived social stigma, and the prediction of psychosocial adjustment to leg amputation. Rehabil Psychol. 1995;40:95–110
  35. Breakey JW. Body image: the lower-limb amputee. J Prosthet Orthot. 1997;9:58–66
  36. Miller CA. The relationship between body-image, self-esteem, level of depression, and quality of life in elderly persons following lower limb amputation [dissertation]. Minneapolis: Walden Univ; 2001;
  37. Gerin P, Dazord A, Cialdella P, Leizorovicz A, Boissel JP. Le questionnaire Profil de la Qualité de Vie Subjective (PQVS): premiers éléments de validation. Therapie. 1991;46:131–138
  38. Gerin P, Dazord A, Boissel JP, Hanauer Th M, Moleur P, Chauvin F. L'évaluation de la qualité de vie dans les essais thérapeutiques: aspects conceptuels et présentation d'un questonnaire. Therapie. 1989;44:355–364
  39. Navez M, Dazord A, Perrin AM, Gerbaud L, Clavelou P, Laurent B. Qualité de vie des patients migraineux. Douleur et analgésie. 2002;15:147–153
  40. Bonomi AE, Patrick DL, Bushnell DM, Martin M. Validation of the United States' version of the World Health Organization Quality of Life (WHOQOL) instrument [see comment]. J Clin Epidemiol. 2000;53(1):1–12Comment in: J Clin Epidemiol 2000;53:19-23.
  41. Walters AS, Williamson GM. Sexual satisfaction predicts quality of life: a study of adult amputees. Sex Disabil. 1998;16:103–115
  42. Sprangers MA, Schwartz CE. Integrating response shift into health-related quality of life research: a theoritical model. Soc Sci Med. 1999;1507–1515
  43. Tierney DK, Facione N, Padilla G, Dodd M. Response shift - a theoritical exploration of quality of life following hematopoietic cell transplantation. Cancer Nurs. 2007;30:125–138
  44. Schwartz CE, Andresen EM, Nosek MA, Krahn GL. Response shift theory: important implications for measuring quality of life in people with disability. Arch Phys Med Rehabil. 2007;88:529–536
  45. Racy JC. Psychological adaptation to amputation. In:  Smith DG,  Michael JW,  Bowker JH editor. Atlas of amputations and limb deficiencies: surgical, prosthetic and rehabilitation principles. 3th ed.. Rosemont: American Academy of Orthopaedic Surgeons; 2004;p. 727–737
  46. Murray CD, Fox J. Body image and prosthesis satisfaction in the lower limb amputee. Disabil Rehabil. 2002;24:925–931
  47. Matsen SL, Malchow D, Matsen FA. Correlations with patients's perspectives of the result of lower-extremity amputation. J Bone Joint Surg. 2000;82-A:1089–1095
  48. Horgan O, MacLachlan M. Psychosocial adjustment to lower-limb amputation: a review. Disabil Rehabil. 2004;26:837–850
  49. Hanley MA, Jensen MP, Ehde DM, Hoffman AJ, Patterson DR, Robinson LR. Psychosocial predictors of long-term adjustment to lower-limb amputation and phantom limb pain. Disabil Rehabil. 2004;26:882–893
  50. Williams RM, Ehde DM, Smith DG, Czerniecki JM, Hoffman AJ, Robinson LR. A two-year longitudinal study of social support following amputation. Disabil Rehabil. 2004;26:862–874
  51. Pohjolainen T, Alaranta A. Predictive factors of functional ability after lower limb amputation. Ann Chir et Gynaecol. 1991;80:36–39
  52. Hanley MA, Jensen MP, Smith DG, Ehde DM, Edwards WT, Robinson LR. Preamputation pain and acute pain predict chronic pain after lower extremity amputation. J Pain. 2007;8:102–109
  53. Johnston MV, Miklos CS. Activity-related quality of life in rehabilitation and traumatic brain injury. Arch Phys Med Rehabil. 2002;83(Suppl 2):S26–S38
  • a SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.

 Supported by the Montreal Rehabilitation Institute Foundation, the Fonds de la recherche en santé du Québec, the Ordre professionnel des physiothérapeutes du Québec, and the Faculté des études supérieures of the Université de Montréal.

 No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

 Reprints not available from the author.

PII: S0003-9993(09)00077-X

doi:10.1016/j.apmr.2008.11.003

Archives of Physical Medicine and Rehabilitation
Volume 90, Issue 4 , Pages 634-645, April 2009

Article Tools

* Image Usage & Resolution