The Role of Interprofessional Teams in the Biopsychosocial Management of Limb Loss

Heterogeneous trajectories of depression and resilience following limb amputation

OBJECTIVE

To identify longitudinal trajectories of depression in the first 6 months following limb loss and to explore baseline predictors of trajectories, including pain and demographic factors. A secondary aim was to evaluate whether trajectories of depression were associated with elevated symptoms of posttraumatic stress (PTS) at 6 months.

DESIGN

Secondary longitudinal data analysis of an inception cohort study of persons with new-onset limb loss. Participants completed assessments at three intervals (initial, 3 months, and 6 months).

SETTING

Hospitalized care, acute rehabilitation, ambulatory care, and community.

PARTICIPANTS

Participants were recruited from consecutive cases of amputation surgery in a metropolitan hospital system over a period of 4 years (2002-2007). The final sample (n = 203) was predominantly White (79.3%) and male (78.8%) with an average age of 49.4 years (standard deviation [SD] = 14.6).

MAIN OUTCOME MEASURE(S)

Depression was assessed via the Patient Health Questionnaire-9 (PHQ-9); posttraumatic stress symptoms were measured via the PTSD checklist- Civilian Version (PCL-C).

RESULTS

Four trajectories of depression were identified via Latent Growth Mixture Modeling: Resilience (73.2%), Chronic Depression (11.2%), Emerging Depression (8.9%), and Recovery (6.7%). Average pain intensity significantly predicted trajectory membership. Membership in the Chronic Depression class predicted elevated 6-month PTS compared to all other classes; membership in the Resilience class predicted lower PTS than in the Chronic and Emerging Depression classes but did not differentiate from the Recovery trajectory.

CONCLUSIONS

Findings reveal that the course of depression post-amputation is heterogenous, with varying profiles of symptom development, maintenance, and remission. A majority of individuals were classified as Resilient, whereas a substantial minority of individuals developed clinically significant depression between 3 and 6 months (Emerging Depression), suggesting that early screening during acute care may be insufficient. We detected a significant prospective relation between depression trajectories and distal PTS, advancing the potential clinical utility of trajectory modeling as a risk surveillance tool.

Risk Factors for Underreporting of Life-Limiting Comorbidity Among Adults With Lower-Limb Loss

Peripheral neuropathy (PN) and peripheral arterial disease (PAD) are life-limiting comorbidities among adults with lower-limb loss that may not be adequately addressed in current care models. The objective of this study was to evaluate underreporting of PN and PAD among adults with lower-limb loss. We conducted a secondary analysis of a cross-sectional dataset of community-dwelling adults with unilateral lower-limb loss seen in an outpatient Limb Loss Clinic (n = 196; mean age = 56.7 ± 14.4 years; 73.5% male). Individuals participated in standardized clinical examinations including Semmes-Weinstein monofilament testing to assess for PN and pedal pulse palpation to assess for PAD. Bivariate regression was performed to identify key variables for subsequent stepwise logistic regression to discern risk factors. Clinical examination results indicated 16.8% (n = 33) of participants had suspected PN alone, 15.8% (n = 31) had suspected PAD alone, and 23.0% (n = 45) had suspected PN and PAD. More than half of participants with clinical examination findings of PN or PAD failed to self-report the condition (57.7% and 86.8%, respectively). Among adults with lower-limb loss with suspected PN, participants with dysvascular amputations were at lower risk of underreporting (odds ratio [OR] = 0.2, 95% CI: 0.1-0.6). For those with suspected PAD, those who reported more medication prescriptions were at lower risk of underreporting (OR = 0.8, 95% CI: 0.7-1.0). Adults with lower-limb loss underreport PN and PAD per a medical history checklist, which may indicate underdiagnosis or lack of patient awareness. Routine assessment is highly recommended in this population and may be especially critical among individuals with non-dysvascular etiology.

"I Wish I Could Have My Leg": A Qualitative Study on the Experiences of Individuals With Lower Limb Amputation

Amputation is commonly regarded as a lifesaving procedure. However, the loss of a body part can lead to permanent disability that can impact patients physically, psychologically, and socially. The aim of this study was to describe and understand the perspectives of patients with lower limb amputation (LLA) about their condition. The study uses a descriptive phenomenological design. Data were collected from 12 patients. The researchers conducted interviews using semi-structured questions. MAXQDA was used for qualitative software support in managing the interview data. Data were transcribed. The participants were aged 61.3 ± 10.8 years. Three themes emerged from the qualitative data: (i) losing control over one's own life, (ii) dreams versus the realities of life, and (iii) future perceptions. Most of the participants emphasized that they face undesirable experiences in their post-amputation lives. The findings of the present study provide novel insight into how individuals subjectively experience life after LLA.