Psychological and Physical Health in Military Amputees During Rehabilitation: Secondary Analysis of a Randomized Controlled Trial

Reporting of Rehabilitation Outcomes in the Traumatic Lower Limb Amputation Literature: A Systematic Review

OBJECTIVE

To synthesize the outcomes reported in the rehabilitation and community literature for adults with traumatic lower limb amputation (LLA).

DATA SOURCES

The search strategy was conducted in 3 databases (Medline, EMBASE, and CINAHL) from inception to April 2022.

STUDY SELECTION

To be eligible, articles could be of any design but were required to have at least 50% adult individuals with traumatic LLA and had to report on interventions and outcomes in either a rehabilitation or community setting.

DATA EXTRACTION

The extracted outcomes were classified using Dodd's framework, which is designed for organizing research outcomes. Heterogeneity was observed in the outcome measures (OMs) used for evaluation. Two reviewers independently conducted the data extraction, which was verified by a third reviewer.

DATA SYNTHESIS

Of the 7,834 articles screened, 47 articles reporting data on 692 individuals with traumatic LLA, met our inclusion criteria. Four core areas encompassing 355 OMs/indicators were identified: life effect (63.4%), physiological/clinical (30.1%), resource use (5.1%), and adverse events (1.4%). Physical functioning (eg, gait, mobility) was the most frequently reported outcome domain across studies, followed by nervous system outcomes (eg, pain) and psychiatric outcomes (eg, depression, anxiety). Domains such as global quality of life and role/emotional functioning were seldomly reported.

CONCLUSION

The study provides a list of outcome indicators explicitly published for adults with traumatic LLA, highlighting inconsistent reporting of outcome indicators. The lack of a standardized set of OMs is a barrier to performing meta-analyses on interventions, preventing the identification of effective care models and clinical pathways. Developing a core outcome set that includes OMs relevant to the needs of the traumatic LLA population may address these issues.

A Comprehensive, Multidisciplinary Assessment for Knee Osteoarthritis Following Traumatic Unilateral Lower Limb Loss in Service Members

INTRODUCTION

Knee osteoarthritis (KOA) is a primary source of long-term disability and decreased quality of life (QoL) in service members (SM) with lower limb loss (LL); however, it remains difficult to preemptively identify and mitigate the progression of KOA and KOA-related symptoms. The objective of this study was to explore a comprehensive cross-sectional evaluation, at the baseline of a prospective study, for characterizing KOA in SM with traumatic LL.

MATERIALS AND METHODS

Thirty-eight male SM with traumatic unilateral LL (23 transtibial and 15 transfemoral), 9.5 ± 5.9 years post-injury, were cross-sectionally evaluated at initial enrollment into a prospective, longitudinal study utilizing a comprehensive evaluation to characterize knee joint health, functionality, and QoL in SM with LL. Presences of medial, lateral, and/or patellofemoral articular degeneration within the contralateral knee were identified via magnetic resonance imaging(for medically eligible SM; Kellgren-Lawrence Grade [n = 32]; and Outerbridge classification [OC; n = 22]). Tri-planar trunk and pelvic motions, knee kinetics, along with temporospatial parameters, were quantified via full-body gait evaluation and inverse dynamics. Concentrations of 26 protein biomarkers of osteochondral tissue degradation and inflammatory activity were identified via serum immunoassays. Physical function, knee symptoms, and QoL were collected via several patient reported outcome measures.

RESULTS

KOA was identified in 12 of 32 (37.5%; KL ≥ 1) SM with LL; however, 16 of 22 SM presented with patellofemoral degeneration (72.7%; OC ≥ 1). Service members with versus without KOA had a 26% reduction in the narrowest medial tibiofemoral joint space. Biomechanically, SM with versus without KOA walked with a 24% wider stride width and with a negative correlation between peak knee adduction moments and minimal medial tibiofemoral joint space. Physiologically, SM with versus without KOA exhibited elevated concentrations of pro-inflammatory biomarker interleukin-7 (+180%), collagen breakdown markers collagen II cleavage (+44%), and lower concentrations of hyaluronic acid (-73%) and bone resorption biomarker N-telopeptide of Type 1 Collagen (-49%). Lastly, there was a negative correlation between patient-reported contralateral knee pain severity and patient-reported functionality and QoL.

CONCLUSIONS

While 37.5% of SM with LL had KOA at the tibiofemoral joint (KL ≥ 1), 72.7% of SM had the presence of patellofemoral degeneration (OC ≥ 1). These findings demonstrate that the patellofemoral joint may be more susceptible to degeneration than the medial tibiofemoral compartment following traumatic LL.

Depression and Anxiety Symptoms Among Lebanese Lower Limb Traumatic Amputees: Association with Education, Employment, Adjustment to Amputation and Prosthesis Satisfaction

ObjectiveTo examine and compare the association between the presence of depression and anxiety symptoms and different sociodemographic and clinical factors including the adjustment to amputation and prosthesis satisfaction among Lebanese individuals with lower limb amputation (LLA). Method: This cross-sectional study was conducted between December 2022 and May 2023 among 72 participants with LLA. Participants completed a questionnaire that included sociodemographic and clinical variables, the revised Trinity Amputation and Prosthesis Experience Scale (TAPES-R), and the Hopkins Symptom Checklist (HSCL-25). Result: Using the HSCL depression and anxiety cut-off, 25% of participants were categorized as having depression symptoms, with unemployment being significantly associated (p-value < .05) with depression. Similarly, 25% were classified as having anxiety symptoms, with both lower education and unemployment (p-value < .05) significantly linked to anxiety. TAPES-R subscales scores exhibited significant differences between non-depressed and depressed, as well as non-anxious and anxious participants (p-value < .05). Correlation analysis demonstrated significant relationship between HSCL scales and TAPES-R subscales; lower scores in adjustment to amputation and prosthesis satisfaction were moderately associated with increased rates of depression (r ranging between -0.331 and -0.500, p-values < .005) and increased rates of anxiety symptoms (r ranging between -0.362 and -0.441, p-values < .002). In addition, higher scores in activity limitation were moderately correlated to increased rates of depression and anxiety (r = 0.438 for anxiety and 0.490 for depression; p < .001). Conclusion: Mental health symptoms are associated with educational level, employment status, and adjustment to amputation and prosthesis satisfaction in Lebanese individuals with LLA. These findings should be considered to achieve optimal prosthetic rehabilitation.

The experience of self-managing from the perspective of persons with lower limb loss, prosthetists, and physical therapists

PURPOSE

Persons with lower limb loss (PwLLL) must self-manage their residual limb and their prosthesis to prevent self-management related complications (SMRC). However, the experience of PwLLL as it relates to self-management has not been reported. Thus, the purpose of this study was to explore the experience of self-management from the perspective of PwLLL, prosthetists, and physical therapists.

METHODS

This study had a qualitative design. Twenty-three participants were interviewed (PwLLL = 10, prosthetists = 7, physical therapists = 6). Interviews were transcribed and then coded using constant comparison.

RESULTS

Four prominent themes were developed from the transcripts: (1) embodying the duty of self-management, (2) being a vigilant self-advocate, (3) setting goals collaboratively, and (4) making informed decisions. Each of the four themes were influenced by the health beliefs of the PwLLL, specifically motivation and presence of an internal locus of control.

CONCLUSION

Clinicians should emphasize the therapeutic relationship, including open communication, collaborative goal setting, and promoting an internal locus of control in interactions with PwLLL, as it may play a role in decreasing SMRC and improving clinical outcomes.Implications for rehabilitationSelf-management is a crucial aspect of preventing secondary complications associated with limb loss and prosthesis use.Self-management requires an internal locus of control, problem-solving abilities, and foundational knowledgeClinicians can promote self-management through collaborative goal setting and systematic education.

Differences in quality-of-life scores across injury categories by mental health status among injured U.S. military service members and veterans

PURPOSE

Posttraumatic stress disorder (PTSD) and depression are strong predictors of poor health-related quality of life (HRQOL) among injured U.S. military service members (SMs). Patterns of HRQOL between injury categories and injury categories stratified by mental health (MH) symptoms have not been examined. Among deployment-injured SMs and veterans (n = 4353), we examined HRQOL and screening data for PTSD and/or depression within specific injury categories.

METHODS

Participants included those enrolled in the Wounded Warrior Recovery Project with complete data for HRQOL (SF-36) from June 2017 to May 2020. Injuries were categorized using the Barell Injury Diagnosis Matrix (Barell Matrix). Mean physical component summary (PCS) and mental component summary (MCS) scores were calculated for each injury category and stratified by the presence or absence of probable PTSD and/or depression.

RESULTS

The average follow-up time that participants were surveyed after injury was 10.7 years. Most participants were male, non-Hispanic White, served in the Army, and enlisted rank. Mechanism of injury for 77% was blast-related. Mean PCS and MCS scores across the entire sample were 43.6 (SD = 10.3) and 39.5 (SD = 13.3), respectively; 50% screened positive for depression and/or PTSD. PCS and MCS scores were significantly lower within each injury category among individuals with probable PTSD and/or depression than those without.

CONCLUSION

Among deployment-injured SMs, those with probable PTSD and/or depression reported significantly lower HRQOL within injury categories and HRQOL component (i.e., physical or mental) than those without. Findings are consistent with prior reports showing mental health symptoms to be strongly associated with lower HRQOL and suggest integration of mental health treatment into standard care practices to improve long-term HRQOL.

Social and Psychological Rehabilitation of War Veterans

The subject of the study is determined by the need for effective rehabilitation of war veterans and the presence of many problems of sociopsychological recovery after being in the zone of active combat operations, and the need to develop an effective rehabilitation programme for this category of people. The purpose of the study is to conduct a comprehensive analysis of the features of socio-psychological rehabilitation, identify the relationship of physiological states with individual psychological components of the individual’s functioning in specific conditions of life, determine which measures are most effective for the establishment of areas of work in the aspect of socio-psychological rehabilitation of war veterans. The basis of the methodological approach in this study is the analysis and generalisation based on the results of the examination of scientific and theoretical material, which determines the establishment of conclusions and recommendations in the field under study. The following methods of scientific knowledge are used: dialectical, logical-semantic, system-structural, functional, and logicalnormative. The study proves the direct connection between the presence of a person in a war zone and their psychoemotional state. It is considered which psychophysiological disorders can be caused by involvement in armed conflicts. The conclusion is formulated that participants in military operations need social and psychological rehabilitation, and problematic issues and prospects for rehabilitation are outlined. Specific medical and socio-psychological aspects are highlighted, the avoidance or generation of which will help in the process of rehabilitation of military personnel and their families. It was identified that although psychological rehabilitation is generally conducted, it requires more government support, popularisation, and wider involvement of both war veterans and experts. Ways to improve approaches to providing psychological assistance to military personnel and their families in Ukraine are proposed. The conclusions of the study are of substantial importance for psychologists and social workers, psychology students and teaching staff of psychology faculties as a doctrinal basis for the educational process

The War after War: Volumetric Muscle Loss Incidence, Implication, Current Therapies and Emerging Reconstructive Strategies, a Comprehensive Review

Volumetric muscle loss (VML) is the massive wasting of skeletal muscle tissue due to traumatic events or surgical ablation. This pathological condition exceeds the physiological healing process carried out by the muscle itself, which owns remarkable capacity to restore damages but only when limited in dimensions. Upon VML occurring, the affected area is severely compromised, heavily influencing the affected a person’s quality of life. Overall, this condition is often associated with chronic disability, which makes the return to duty of highly specialized professional figures (e.g., military personnel or athletes) almost impossible. The actual treatment for VML is based on surgical conservative treatment followed by physical exercise; nevertheless, the results, in terms of either lost mass and/or functionality recovery, are still poor. On the other hand, the efforts of the scientific community are focusing on reconstructive therapy aiming at muscular tissue void volume replenishment by exploiting biomimetic matrix or artificial tissue implantation. Reconstructing strategies represent a valid option to build new muscular tissue not only to recover damaged muscles, but also to better socket prosthesis in terms of anchorage surfaces and reinnervation substrates for reconstructed mass.

Health Outcomes Used to Determine Facets of Health-related Quality of Life for Post-9/11 Veterans Using Assistive Technology for A Combat-related Mobility Impairment: A Literature Review

INTRODUCTION

Novel rehabilitation methods, including distribution and adoption of assistive technology for lower extremity impairments, are becoming crucial to ensure positive quality of life in all individuals. The quality of life of post-9/11 combat veterans is not well understood, in comparison to research on other populations. The following essay describes a review on health outcomes used to determine health-related quality of life (HR-QoL) among combat-injured service members who require mobility-related assistive technology.

MATERIALS AND METHODS

Reviews pooled data from research on PubMed, EMBASE, CINAHL, and PsycINFO published after September 11, 2001, and included service members who sustained a mobility impairment because of involvement in a post-9/11 combat operation. Basic descriptors were extracted in addition to health outcomes used, which were then categorized and summarized by six domains for HR-QoL as defined by the World Health Organization.

RESULTS

This review found health outcomes that fit in the pain and discomfort, negative emotions, mobility, social relations, access to and quality of healthcare services, and religious/spiritual/personal beliefs subdomains. The categorized results detailed their application to track and model HR-QoL health states in those with mobility impairments using mobility-based assistive technology.

CONCLUSIONS

The research on combat-induced mobility impairments indicates assistive technology improves otherwise poor health states. The results model these domains and subdomains to determine overall HR-QoL and the quality of a healthcare intervention, though additional research is needed as only one study was identified to be experimental in design.

Telerehabilitation for Amputee Care

Patients with amputation have unique characteristics and needs that must be considered when services are being provided through a virtual platform. The types of amputation rehabilitation services that can be provided virtually are numerous and vary from a full clinical team evaluation to individual therapy services. Whether services are being provided in person or through a virtual platform, rehabilitation of the person with amputation ideally involves a collaborative interdisciplinary team. The potential benefits of providing amputation rehabilitation care through a virtual platform include enhanced access to specialized services, reduced travel burden, and improved continuity of care.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation

PURPOSE

Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes.

MATERIALS AND METHODS

Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status.

RESULTS

Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning.

CONCLUSIONS

Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

Benchmarking Residual Limb Pain and Phantom Limb Pain in Amputees through a Patient-reported Outcomes Survey

More than 75% of major limb amputees experience chronic pain; however, data on severity and experience of pain are inconsistent. Without a benchmark using quantitative patient-reported outcomes, it is difficult to critically assess the efficacy of novel treatment strategies. Our primary objective is to report quantitative pain parameters for a large sample of amputees using the validated Patient-reported Outcomes Measurement System (PROMIS). Secondarily, we hypothesize that certain patient factors will be associated with worse pain.

METHODS

PROMIS and Numerical Rating Scales for residual limb pain (RLP) and phantom limb pain (PLP) were obtained from a cross-sectional survey of upper and lower extremity amputees recruited throughout North America via amputee clinics and websites. Demographics (gender, age, race, and education) and clinical information (cause, amputation level, and time since amputation) were collected. Regression modeling identified factors associated with worse pain scores (P < 0.05).

RESULTS

Seven hundred twenty-seven surveys were analyzed, in which 73.4% reported RLP and 70.4% reported PLP. Median residual PROMIS scores were 46.6 [interquartile range (IQR), 41-52] for RLP Intensity, 56.7 (IQR, 51-61) for RLP Behavior, and 55.9 (IQR, 41-63) for RLP Interference. Similar scores were calculated for PLP parameters: 46.8 (IQR, 41-54) for PLP Intensity, 56.2 (IQR, 50-61) for PLP Behavior, and 54.6 (IQR, 41-62) for PLP Interference. Female sex, lower education, trauma-related amputation, more proximal amputation, and closer to time of amputation increased odds of PLP. Female sex, lower education, and infection/ischemia-related amputation increased odds of RLP.

CONCLUSION

This survey-based analysis provides quantitative benchmark data regarding RLP and PLP in amputees with more granularity than has previously been reported.

Impact of C-LEG on mobility, satisfaction and quality of life in a multicenter cohort of femoral amputees

BACKGROUND

In some countries, the microprocessor-controlled C-LEG knee joint is reimbursed by the national health insurance for transfemoral amputees under certain conditions. However, whether users really benefit from such a technology in their daily life is unknown.

OBJECTIVE

To observe the performance of active C-LEG users in terms of locomotor ability and activities, satisfaction and quality of life after 6 months of wearing the prosthesis in real-life conditions.

METHODS

This multicenter observational study investigated locomotor ability [Locomotor Capability Index 5 (LCI-5)], satisfaction [Quebec User Evaluation of Satisfaction with Assistive Device 2.0 (QUEST 2.0)] and quality of life [Medical Outcomes Study Short Form 36 (SF-36)] at the beginning (T0) and end (T1) of the C-LEG test period and at 6 months (T2) after the confirmed prescription of the C-LEG. Information was also collected on the use of walking aids, daily wear of the prosthesis, falls and adverse events.

RESULTS

We enrolled 102 participants; 81 were assessed at T1 (62 had a previous prosthesis) and 56 were followed up after 6 months (45 had a previous prosthesis). For participants who had previously been fitted with a prosthetic knee, which was mechanical in almost all cases, as compared with baseline, the use of C-LEG significantly improved locomotor ability (LCI-5 52.6 vs. 46.7, P<0.001), satisfaction (QUEST score 4.6 vs. 3.7, P<0.001) and physical quality of life (SF-36 physical component summary score 51.1 vs. 45.3, P<0.001). In addition, daily use of the prosthesis was higher and use of walking aids and frequency of falls were lower as compared with the previous period.

CONCLUSIONS

Active transfemoral amputees with prescription of the C-LEG knee joint showed improved function, satisfaction and physical quality of life after 6 months of wear as compared with their previous prosthesis.

A UV damage-sensing nociceptive device for bionic applications

Artificial limbs have been widely investigated in the past several decades, and multifuncional bionic limbs have already been constructed. However, due the lack of nociceptive systems, amputees still cannot feel ubiquitous noxious stimuli through bionic limbs. The construction of artificial nociceptors can bring bionic limbs closer to real flesh and bone. In daily life, UV irradiation is an invisible potential noxious stimulus to human skin and eyes. Furthermore, it is well known that the synthetic polymers widely used in bionic limbs can be degraded by UV radiation, accelerating their aging. Based on the above, UV damage-sensing nociceptors could be a feasible strategy to solve these existing problems. Here, azobenzene-functionalized gold nanoparticles (Azo-Au NPs) are embedded in insulating poly(methyl methacrylate) (PMMA) to construct a two-terminal memristor. With UV irradiation as a light damage medium, major nociceptive behaviors such as "threshold", "relaxation" and "sensitization" are successfully emulated, demonstrating its potential application as a nociceptive system.

Characterization of disability following traumatic through knee and transfemoral amputations

INTRODUCTION

The purpose of this study is to characterize through knee and transfemoral amputations following severe traumatic injuries.

METHODS

A retrospective review of all transfemoral and through knee amputations sustained by United States military service members from 1 October 2001 to 30 July 2011 was conducted. Data from the Department of Defense Trauma Registry, the Armed Forces Health Longitudinal Technology Application, inpatient medical records and the Physical Evaluation Board Liaison Offices were queried in order to obtain characteristics related to injury sustained, demographics, treatment, and disability/mental health outcome data.

RESULTS

A total of 1631 amputations in 1315 patients were identified. Of these there were 37 through knee and 296 were transfemoral amputations. Adequate records for detailed analysis were available on 140 and 25 transfemoral and through knee amputations respectively. There were no significant differences in demographic information, injury mechanism, initial injury severity score, or associated injuries, to include contralateral amputations. There was no significant difference in average disability rating (67.9% vs 78.3%, p = 0.46) or number of service members determined to be fully disabled (42.2% vs 28.6% p = 0.33) between the transfemoral and through knee amputation groups. Whereas there was no difference between groups preoperatively, the knee disarticulation group displayed a higher rate of mental health diagnoses post-amputation (96% vs 72%, p < 0.001) and a higher preponderance of anxiety related disorders than the transfemoral amputees (26.92% vs 12.96%, p = 0.0129).

DISCUSSION/CONCLUSION

Among this military amputee through knee and transfemoral amputees displayed similar physical disability profiles. However, the through knee amputees displayed a higher level of anxiety related disorders and mental health diagnosis overall. While we don't believe this relationship to be causal in nature, this finding reflects the importance of paying particular attention to mental health in the final disposition of traumatic lower extremity amputees.

Brazilian Portuguese Version of the Amputee Body Image Scale: Cultural Adaptation and a Psychometric Analysis

Body image adjustments after a limb loss are essential to rehabilitation. This study evaluated the psychometric properties of the Brazilian Portuguese version of the Amputee Body Image Scale (ABIS). We analyzed data from a nonprobability sample of 100 participants (71% men, mean age 48.26 ± 18.35 years) by using a confirmatory factor analysis with partial least square path modeling. We evaluated the structural model by using Pearson's coefficient of determination, path coefficients, indicator of Stone-Geisser, and Cohen's indicator. We evaluated item factor loadings and average variance extracted for model measurement. We tested the internal consistency with Cronbach's α test and composite reliability and evaluated the discriminant validity by adopting Fornell and Larcker (1981) criteria. We tested the original and a new three-factor model and performed correlational and variance analyses as additional tests. The new three-factor theoretical model had stronger structural support and better discriminant and convergent validities than the original three-factor model. The ABIS total score was inversely correlated with body appreciation. There were significant body image score differences between the groups of sedentary and physically active amputees and among those with differences in years since amputation, but there were no differences between those with different causes of amputation nor for those with different amputated limbs.