Does pain, psychological distress and deteriorated family economy follow traumatic amputation among war casualties? A retrospective, cross-sectional study from Gaza

OBJECTIVES

The aim of this study was to explore determinants of psychosocial distress and pain in patients who have survived severe extremity amputation in Gaza.

SETTING

This study was conducted in a secondary care rehabilitation centre in Gaza, Palestine. The clinic is Gaza's sole provider of artificial limbs.

PARTICIPANTS

We included 254 civilian Palestinians who had survived but lost one or more limb(s) during military incursions from 2006 to 2016. We included patients with surgically treated amputation injuries who attended physical rehabilitation at a specialist prosthesis centre in Gaza. Amputees with injuries prior to 2006 or non-military related injuries were excluded.We assessed their pain and psychological stress using the General Health Questionnaire (GHQ-12). We used income, amputation severity scored by proximity to torso, current employment status, loss of family members and loss of home as independent variables.

RESULTS

The amputees median age was 23 years at the time of trauma, while a median of 4.3 years had passed from trauma to study inclusion. Nine of 10 were male, while 43 were children when they were amputated (17%≤18 years). One hundred and ninety-one (75%) were unemployed and 112 (44%) reported unemployment caused by being amputated. Pain was the most frequent problem, and 80 amputees (32%) reported to suffer from daily pain. Family income was significantly correlated with the physical pain (OR=0.54, CI 0.36 to 0.80, p=0.002). Psychological distress was higher among unemployed amputees (OR=1.36, CI 1.07 to 1.72, p=0.011). We found no association between psychological distress (GHQ-scores) and the extent of the initial amputation.

CONCLUSION

Pain and psychological distress following war-related extremity amputation of one or more limbs correlated stronger with deteriorated family economy and being unemployed than with the anatomical and medical severity of extremity amputations.

Factors Influencing Functional Outcomes and Return-to-Work After Amputation: A Review of the Literature

Purpose Amputation is a life changing event that can significantly impact an individual's physical and mental well-being. Our objective was to review literature exploring the impact of amputation upon a person's functioning and inclusion in the workplace. Methods Medline, CINAHL, and PsycINFO were searched using keywords related to amputation, employment and community reintegration. Eligible studies were published since 2000 and one of the following study designs: randomized controlled trial, non-randomized controlled trial, retrospective study, prospective study, concurrent cohort study, or cross sectional study. Studies for civilians with amputation as well as service members and Veterans with amputation were considered for inclusion. Results The search identified 995 articles, 25 of which met inclusion/exclusion criteria and were included in the review. While strong evidence for correlations and predictors of outcomes after amputation were limited, multiple factors were identified as contributing to physical functioning and employment after amputation. Conclusions Outcomes after amputation can vary widely with many potentially inter-related factors contributing. The factors identified may also serve to inform the development of interventions aiming to improve functional performance and reintegration after amputation. Furthermore, the review highlights the need for more high quality prospective studies.

Pain Phenotypes and Associated Clinical Risk Factors Following Traumatic Amputation: Results from Veterans Integrated Pain Evaluation Research (VIPER)

OBJECTIVE

To define clinical phenotypes of postamputation pain and identify markers of risk for the development of chronic pain.

DESIGN

Cross-sectional study of military service members enrolled 3-18 months after traumatic amputation injury.

SETTING

Military Medical Center.

SUBJECTS

124 recent active duty military service members.

METHODS

Study subjects completed multiple pain and psychometric questionnaires to assess the qualities of phantom and residual limb pain. Medical records were reviewed to determine the presence/absence of a regional catheter near the time of injury. Subtypes of residual limb pain (somatic, neuroma, and complex regional pain syndrome) were additionally analyzed and associated with clinical risk factors.

RESULTS

A majority of enrolled patients (64.5%) reported clinically significant pain (pain score ≥ 3 averaged over previous week). 61% experienced residual limb pain and 58% experienced phantom pain. When analysis of pain subtypes was performed in those with residual limb pain, we found evidence of a sensitized neuroma in 48.7%, somatic pain in 40.8%, and complex regional pain syndrome in 19.7% of individuals. The presence of clinically significant neuropathic residual limb pain was associated with symptoms of PTSD and depression. Neuropathic pain of any severity was associated with symptoms of all four assessed clinical risk factors: depression, PTSD, catastrophizing, and the absence of regional analgesia catheter.

CONCLUSIONS

Most military service members in this cohort suffered both phantom and residual limb pain following amputation. Neuroma was a common cause of neuropathic pain in this group. Associated risk factors for significant neuropathic pain included PTSD and depression. PTSD, depression, catastrophizing, and the absence of a regional analgesia catheter were associated with neuropathic pain of any severity.

Functional outcome of patients with proximal upper limb deficiency–acquired and congenital

Objective: To investigate the functional outcome of patients with proximal upper limb deficiency – acquired and congenital (elbow disarticulation, transhumeral, shoulder disarticulation and forequarter level).

Design: Cohort observational study.

Subjects: All proximal upper limb amputees and patients with congenital upper limb absence currently registered with the Sheffeld Mobility and Specialised Rehabilitation Centre.

Methods: A self-administered postal questionnaire and medical records were used to collect data. The questionnaire obtained information about demographic details, dominancy of the amputated arm and independence and participation in activities of daily living (ADL), domestic and recreational activities. The prevalence of pain in the phantom limb and stump, and information regarding the remaining arm was also obtained. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the psychological state of the subjects.

Results: Trauma was the commonest cause of proximal upper limb loss (71.25%). Transhumeral amputation was the predominant level (78.75%). Although 73.2% returned to work following amputation, 66.6% had to change job. Overall rejection rate of prosthesis was 33.75%. Twenty-five per cent of patients found the prosthesis beneficial for driving and a small proportion used the prosthesis for employment and recreational activities, but the vast majority used the prosthesis primarily for cosmesis. Pain in the phantom limb was reported in 60% of our patients but there was no significant correlation between this and depression. Symptoms of overuse injury in the nonamputated limb were higher than expected in the normal population.

Conclusion: As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.

An exploration of the experiences of wound healing in military traumatic amputees and its impact on their rehabilitation

The aim of this study was to establish the effect that wounds had on the rehabilitation of traumatic amputees from the military patients' perspective. In particular it established which aspects of wound healing had the greatest impact in relation to living with a wound and the effect that military cohesion had on their recovery. The study was undertaken within the interpretivistic paradigm and followed an ethnographic design using semi-structured interviews. It contributes to the theoretical understanding of rehabilitation of the combat injured as no other study has been undertaken in this area in the UK. It captured the responses of this unique group as they reach the end of their journey through rehabilitation and detailed their reflections on the challenges they had faced and overcome. Analysis revealed that complications including infection, pain, foreign bodies and further surgery prevented the wounds from healing. The participants found this frustrating and they further highlighted time as an important factor in their journey. The military environment formed a culture in which patients learned from, and were supported by, each other. This was compared to a community of practice. In conclusion suggestions were made for practice, policy and education and further research in this area.

Replantation versus Prosthetic Fitting in Traumatic Arm Amputations: A Systematic Review

Background

Traumatic arm amputations can be treated with replantation or surgical formalization of the stump with or without subsequent prosthetic fitting. In the literature, many authors suggest the superiority of replantation. This systematic review compared available literature to analyze whether replantation is functionally and psychologically more profitable than formalization and prosthetic fitting in patients with traumatic arm amputation.

Methods

Functional outcome and satisfaction levels were recorded of patients with amputation levels below elbow, through elbow, and above elbow.

Results

Functional outcomes of 301 replantation patients and 172 prosthesis patients were obtained. In the replantation group, good or excellent functional scores were reported in 39% of above elbow, 55% of through elbow, and 50% of below elbow amputation cases. Nearly 100% of patients were satisfied with the replanted limb. In the prosthesis group, full use of the prosthesis was attained in 48% of above elbow and in 89% of below elbow amputation patients. Here, 29% of patients elected not to use the prosthesis for reasons including pain and functional superfluity. In both replantation patients and prosthesis wearers, a below elbow amputation yielded better functional results than higher amputation levels.

Conclusions

Replantation of a traumatically amputated arm leads to good function and higher satisfaction rates than a prosthesis, regardless of the objective functional outcome. Sensation and psychological well-being seem the two major advantages of replantation over a prosthesis. The current review of the available literature shows that in carefully selected cases replantation could be the preferred option of treatment.

[Replantation and reconstruction vs terminalization in the treatment of amputation of the digits]

MATERIAL AND METHODS

This study records the outcomes of the treatment of 21 patients, 19 men and two women, who sustained an amputation of the total of 35 digits (27 fingers and eight thumbs). Eleven patients received replantation or reconstruction maintaining the length of the digit, whereas ten had their digits terminalized.

RESULTS

The results were assessed at a mean of 5 years after injury. Patients with finger stumps had stronger grip than those with replanted digits (72% vs 48% of strength of the healthy hand). Hand function as assessed by quickDASH score (29 vs 33), quality of life as assessed by SF-36 score (63 vs 67) and number of patients experiencing cold sensitivity (7 vs 7) were similar in both groups. Patients after terminalization returned to work significantly earlier than those after replantation or reconstruction (6 vs 12 months).

CONCLUSIONS

These results show that - considering function of the hand - replantation or advanced reconstruction offers the patient less benefit than simple terminalization.

Patient-specific prosthetic fingers by remote collaboration--a case study

The concealment of amputation through prosthesis usage can shield an amputee from social stigma and help improve the emotional healing process especially at the early stages of hand or finger loss. However, the traditional techniques in prosthesis fabrication defy this as the patients need numerous visits to the clinics for measurements, fitting and follow-ups. This paper presents a method for constructing a prosthetic finger through online collaboration with the designer. The main input from the amputee comes from the Computer Tomography (CT) data in the region of the affected and the non-affected fingers. These data are sent over the internet and the prosthesis is constructed using visualization, computer-aided design and manufacturing tools. The finished product is then shipped to the patient. A case study with a single patient having an amputated ring finger at the proximal interphalangeal joint shows that the proposed method has a potential to address the patient's psychosocial concerns and minimize the exposure of the finger loss to the public.

Acute stress disorder and post-traumatic stress disorder following traumatic amputation

Traumatic amputations are important causes of acute stress disorder and post-traumatic stress disorder. In this study, we aimed to find out the occurrence rate of symptoms of acute and post-traumatic stress disorder after traumatic amputations and according to this, to assess the psychiatric status of the patients in the postoperative period. Twenty-two patients with traumatic limb amputation who were treated in our institution were retrospectively evaluated. During the early post-traumatic period, the patients were observed to determine whether they needed any psychiatric supportive treatment. During the follow-up period, after the sixth month from the trauma, the patients were referred to the psychiatry department and they were evaluated to determine whether they needed any psychiatric supportive treatment, by clinical psychiatric examination and use of the 'post-traumatic stress disorder scale' (Clinician Administered Post traumatic Scale, or CAPS). Twenty-one (95.5%) of 22 patients were male, one (4.5%) female. Mean age of the patients was 40.8 years (range: 15 to 69). During the early posttraumatic period, 8 (36.3%) of these patients consulted the psychiatry clinic following the orthopaedists' observations. Five (22.7%) of these patients needed psychiatric supportive treatment for acute stress disorder. After the 6th month (6 months to 5 years), 17 (77.2%) had chronic and delayed post-traumatic stress disorder and needed psychiatric supportive treatment. Patients who have sustained a traumatic amputation may need psychiatric supportive treatment in the late period after the trauma. As we orthopaedic surgeons treat these patients surgically, we should be aware of their psychiatric status.

Sex differences in pain and psychological functioning in persons with limb loss

Sex differences in pain are frequently reported in the literature. However, less is known about possible sex differences in the experience of pain secondary to a disability. The current study explored these issues in persons with limb loss (n = 335, 72% men) who were recruited as part of a postal survey. Participants provided ratings of phantom limb pain (PLP), residual limb pain (RLP), and general pain intensity. Participants also completed measures of pain-related interference, catastrophizing, coping, and beliefs. Results indicated that a greater proportion of males than females (86% vs 77%, respectively) reported the presence of PLP; however, this difference was no longer prominent when cause of limb loss was controlled. No sex differences were found in the presence of RLP, or in average intensity ratings of PLP or RLP. In contrast, females reported greater overall average pain intensity and interference than males. Females also endorsed significantly greater catastrophizing, use of certain pain-coping strategies, and beliefs related to several aspects of pain. This study did not find prominent sex differences in pain specific to limb loss. However, several sex differences in the overall biopsychosocial experience of pain did emerge that are consistent with the broader literature.

PERSPECTIVE

The current study contributes to the literature on sex differences in the experience of pain. Although males and females with limb loss did not significantly differ in their disability-specific pain, sex differences in their broader experience of pain were significant and are worthy of future clinical and empirical attention.

Quality of life-oriented evaluation of late functional results of hand replantation

BACKGROUND

Forearm amputation in different zones via a similar mechanism in a group of patients of similar age is associated with different possibilities of functional recovery. The degree of postoperative recovery of function is invariably partial compared to pre-amputation function; this kind of trauma inevitably leads to disability. The patients adapt to their new circumstances to a different extent. That is why a quality of life evaluation should be included in the assessment of replantation outcomes. The aim of the study was to evaluate functional outcomes in patients after replantation at the metacarpal, wrist and mid-forearm level with regard to the quality of life of this patients.

MATERIAL AND METHODS

Thirty patients (29 men, 1 woman) of an average age of 41 years who had had replantation or revascularization surgery of an upper limb at different levels took part in a randomized study. The patients were divided into 3 groups depending on the level of amputation: metacarpal, wrist, mid-forearm, with 10 patients in each group. Amputations had been done by a circular saw (21) or via a guillotine mechanism (9). The patients were evaluated on average 4.2 years postoperatively. The following parameters were assessed: total range of active motion (the long finger with the greatest range of motion was assessed) (TAM), grip strength, and sensation; patients performed the Nakamura-Tamai test (modified). Overall functional outcomes were assessed according to Chen's classification. The quality of life (QoL) was measured with the SF-36 questionnaire (0-136 points). The correlation of functional and QoL results was assessed by Spearman's non-parametric test.

RESULTS

Average TAM was: 167 degrees in metacarpal, 174 degrees in wrist, 114 degrees in mid-forearm group; grip strength was 0.7 N, 0.9 N and 0.6 N respectively. All patients had at least protective sensation, whereas a 2PD of less then 10 mm was present in 4 patients in the metacarpal group, and 6 patients in the wrist group. In Chen's classification 5 patients in metacarpal group were rated as grade I and II, compared to 7 in the wrist group, and 2 in the forearm group. QoL scores were 98.9, 104 and 82 respectively. A strong QoL-function correlation was confirmed in the wrist and forearm groups (0.73 - 0.81 respectively), and in the metacarpal group it was weak (0.43).

CONCLUSION

The quality of life of patients of the designated groups was correlated with their functional results.

A study of the physical rehabilitation and psychological state of patients who sustained limb loss as a result of terrorist activity in Northern Ireland 1969 – 2003

OBJECTIVE

To benchmark the psychological state and physical rehabilitation of patients who have sustained limb loss as a result of terrorist activity in Northern Ireland and to determine their satisfaction with the period of primary prosthetic rehabilitation and the artificial limb.

METHOD

All patients who sustained limb loss as a result of the Troubles and were referred to our rehabilitation centre were sent a questionnaire. The main outcome measures were the SIGAM mobility grades, the General Health Questionnaire (GHQ12) and three screening questions for Post Traumatic Stress Disorder (PTSD).

RESULTS

Out of a 66% response rate, 52 (69%) patients felt that the period of primary prosthetic rehabilitation was adequate; 32 (54%) lower limb amputees graded themselves SIGAM C or D; 45 (60%) patients stated that they were still having significant stump pain. Significant stump pain was associated with poorer mobility. Nine (56%) upper limb amputees used their prosthetic limb in a functional way; 33 (44%) patients showed "psychiatric caseness" on the GHQ 12 and 50 (67%) had symptoms of PTSD.

CONCLUSIONS

Most patients felt that the period of physical rehabilitation had been adequate; those who did not were more likely to be having ongoing psychological problems. A high percentage of patients continue to have psychological problems and stump pain.

Why traumatic leg amputees are at increased risk for cardiovascular diseases

BACKGROUND

Post-traumatic lower limb amputees have an increased morbidity and mortality from cardiovascular disease. Risk factors for this amplified morbidity and the involved pathophysiologic mechanisms have not been comprehensively studied.

METHODS

The MEDLINE database was reviewed, with case-controlled studies and nested in cohort studies eligible for inclusion in this analysis.

RESULTS

Insulin resistance, psychological stress and patients' deviant behaviors are prevalent in traumatic lower limb amputees. Each of these factors may have systemic consequences on the arterial system and may contribute to the increased cardiovascular morbidity in traumatic amputees. Abnormalities of arterial flow proximal to the amputation site may hold the explanation for the linkage between the extent of leg amputation and the magnitude of the cardiovascular risk: proximal leg amputation is associated with greater risk than distal amputation and bilateral amputation with greater risk than unilateral amputation. This review focuses on hemodynamic culprits (shear stress, circumferential strain, reflected waves), hemodynamic consequences in proximity to the occluded femoral artery and hemodynamic consequences at a distance.

CONCLUSION

Coronary risk in lower limb amputees may be substantially greater than predicted by available algorithms, given that neither hemodynamic nor psychological factors concern the current prediction models. It seems reasonable to take early prophylactic measures in lower limb amputees by discouraging smoking, excessive alcohol consumption and adherence to a low fat diet. Studies are needed to evaluate the optimal intensity of physical exercise effects on reflected pulse waves and their possible long-term consequences. Guidelines for optimal blood pressure, blood glucose and lipid control in amputees need to be convened.

Traumatic below-elbow amputations

Prehension, intelligence, and erect posture distinguish humans from lower animals. Hands are instrumental for our survival and welfare. We use our hands when we work, recreate, and communicate. A handshake, a touch, a sign, or signal has significant social and communicative meanings. Hands play a major role in defining the skill level of our activities and our level of social expression and integration. Indeed, refined psychomotor precision of hand function may distinguish some individuals among us, gifting society with its more skilled craftsmen, surgeons, artisans, musicians, athletes, and the like in a highly digital world. For others, their hands are critical in providing and caring for their families. Injury severity scores may identify the majority of patients that require amputation; however, injury severity scoring system predictions in individual patients may be problematic and should be used with caution. Amputees require comprehensive multidisciplinary treatment and compassion so that they can successfully overcome their losses. Ultimately, the patients must change, adjust, and adapt to successfully reintegrate themselves into their families, peer groups, job settings, and society as a whole. Early amputation may decrease the incidence and severity of phantom pain compared to amputation after the failure of reconstruction. Early prosthetic fitting, training, and physical rehabilitation; early psychological and sociological support; and early return to work facilitate successful functional recovery. Psychological recovery may be a more arduous and extended process than physical recovery. We must teach our amputees from the outset to use their losses as an incentive for success, assist them to regain their quality of life, and encourage them to act as role models for and to educate others.

Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations

OBJECTIVE

This study investigated the prevalence of symptoms of depression and anxiety in a sample of predominantly elderly males with acquired upper limb amputations (n=138) and examined the contribution of coping strategies to the prediction of psychosocial adjustment.

METHOD

One hundred and thirty-eight men with injury-related upper limb amputations completed self-report questionnaires assessing coping strategies, symptoms of anxiety and depression, and psychosocial adaptation to prosthesis use.

RESULTS

Prevalence of significant depressive symptoms was 28.3% [Hospital Anxiety and Depression Scale, Depression subscale (HADS-D) score > or =8]. Prevalence of significant anxiety symptoms was 35.5% [HADS Anxiety subscale (HADS-A) score > or =8]. Coping styles emerged as important predictors of psychosocial adaptation. In particular, avoidance was strongly associated with psychological distress and poor adjustment.

CONCLUSIONS

These findings suggest the potential benefits of interventions to reduce reliance on avoidant coping and stimulate more problem-focused approaches to coping with difficulties and challenges in order to facilitate adaptation and prevent problems in psychosocial functioning postamputation.

Types of psychological reactions in patients with lower-extremity amputations

The aim of this study was to establish types of psychological reactions and conditions in patients with lower-extremity amputations. Apart from using psychological interviews, detection was performed using psychometric tests: Minnesota Multiphasic Personality Inventory and Beck Depression Inventory. Psychometric parameters were analyzed in a group of 20 examinees treated at the Medical Rehabilitation Clinic in Novi Sad. Out of the whole sample, 45% of patients presented with adaptive reactions to amputation and consequent disability, whereas 55% presented with maladaptive responses. The registered psychopathological symptoms included nosologic categories: reaction to stressful events and adjustment disorder (predominantly affecting other emotions; mixed disorder of conduct and emotions; prolonged depressive reaction) and dysthymia. When working with lower-extremity amputees, apart from adaptive, nonpathological forms of behavior, one also encounters maladaptive responses with predomination of mood disorders due to severe somatic stress.

Genital self-mutilation

A 53-year-old man was brought to the emergency department having removed both testicles and amputated his penis using a bread knife. Examination of the amputated penis showed it to be unsuitable for an attempted replant procedure. The patient was taken to theatre where the perineal wound was debrided and the remaining urethra brought down as a perineal urethrostomy, with a local cutaneous flap rotated to provide coverage for the urethra. Discussed herein are the incidence, predisposing factors, management and complications of genital self-mutilation in the adult male, and the existing literature is reviewed on the subject.

Check list of symptoms SCL-90-R at persons with extremities amputations

Multidimensional Inventory Check List of Symptoms (SCL-90-r) is based on self-evaluation and it has been used for determination of level of: somatisation, obsessive-compulsive symptoms, interpersonal sensitivity, depression, anxiety, hostility, phobias, paranoia and psychosis at persons which are exposed to long term emotional and physical stress. Our goal was to determine relations of physical trauma and psychological changes at persons with lower extremities amputations and to determine factors which influence those changes. Thirty seven persons with lower extremities amputations were examined. The sample included 26 (70.2 %) veterans and 11 (29.7 %) civilians with diseases related amputations. They voluntarily filled Check List of Symptoms SCL-90-r. Symptoms Inventory includes 9 dimensions of primary symptoms: SCL1-somatisation, SCL2-obsessive-compulsive symptoms, SCL3-interpersonal sensitivity, SCL4-depression, SCL5-anxiety, SCL6-hostility, SCL7-phobias, SCL8-paranoia, SCL9-psychosis and SCL10-extra scale. Inventory includes 90 statements, each evaluated with five-level scale of disorder. Every answer is graded with 0-4 points. Thirty seven persons with lower extremities amputations and average chronological age 46.2 +/- 10.92 years were analyzed. Considering marital status 30 (81.1 %) of them were married, 4 (10.8 %) were not married and 3 (8.1 %) were widowers. Considering level of amputation 27 of them (73.0 %) had amputation below knee, 5 (13.5 %) of them amputation above knee and 5 of them (13.5 %) foot amputation. SCL-90-r in both groups determined high level of sensitivity, anxiety, hostility and paranoia. Veterans showed higher level of paranoia comparing to civilians (p<0.002), and younger veterans and married ones had higher level of paranoia comparing to other veterans (p<0.01). Persons with amputations below and above knee showed higher level of paranoia comparing those with foot amputation (p<0.001). Persons with lower extremities amputations have considerably more expressed sensitivity, anxiety, hostility and paranoia. These dimensions are related to age, marital status and level of amputation. These determinants are very helpful for planning and creation of psychological support and rehabilitation of persons with lower extremities amputations.

Chronic Low Back Pain in Individuals with Lower-limb Amputation

Low back pain (LBP) is a common condition in individuals which experienced psychology and physical trauma. LBP is usually found in persons with lower-limb amputation (LLA), as the most common sign of somatisation or inappropriately made prostheses. Our goal was to investigate cases of chronic pain syndrome in persons with LLA and to determine factors, which influence their functional inability due to LBP. Pain after LLA has been studied. 37 persons, including 26 war veterans (70.2 %) and 11 (29.8 %) civilians with LLA due to an illness, were examined. All participants gave their informed consent and filled Oswestry index of disability due to chronic LBP, divided into 10 sections with 6 questions each, with marks in the range 0-5. The average age of 37 analyzed participants with LLA was 46.2+-10.92 years. 30 participants (81.1 %) were married, 4 (10.8 %) were single and 3 (8.1 %) were widows. 27 (73.0 %) participants had below the knee amputation, 5 (13.5 %) had above the knee amputation and 5 (13.5 %) had foot amputation. 33 (89.6 %) participants experienced chronic LBP in the last 2-10 years and 4 (10.8 %) did not have pains. According to Oswestry index for chronic pain higher level of social functionality was found in civilian amputees than in war veterans (p<0.05). Married civilian amputees have higher level of disability during seating (p<0.01), sleeping (p<0.01) and traveling (p<0.05). Higher level of social disorder among civilian amputees is due to the fact that they belong to older group of participants which usually have social integration at the lower degree. More serious problems during seating, traveling and sleeping among this group are probably due to co morbidity. Chronic LBP was found among 89.6 % of the participants. Higher level of social disorder, problems during seating, traveling and sleeping were identified in the civilian amputees and the married participants.

Toe-to-hand transplantation surgery

This article discusses toe-to-hand transplantation. The purpose of this article is to familiarize nurses with this procedure. In many cases, the actions taken initially and postoperatively may have a direct effect on the success or failure of the surgery. Two different procedures are discussed. The first procedure is replantation or revascularization of amputated digits in which time is of the essence and is usually performed right after the initial injury. The second procedure is the toe-to-hand transfer, which is an elective procedure in which there is less emphasis on time. This procedure occurs a few months after the initial accident.

Affective distress and amputation-related pain among older men with long-term, traumatic limb amputations

Psychological distress and postamputation pain were investigated in a sample of 582 males with long-term limb amputations (mean time since amputation 639.3 months, standard deviation 166.1; range 240-784 months). Prevalence of significant depressive symptoms (Hospital Anxiety and Depression Scale [HADS]-D score > or = 8) was 32.0%, and 34.0% of respondents met the screening criterion for clinical anxiety (HADS-A score > or = 8). Nearly one quarter (24.6%) of respondents reported significant post-traumatic psychological stress symptoms (Impact of Event Scale scores > or = 35). In total, 87.8% experienced either phantom or residual limb pain. Affective distress scores differed according to the respondents' type of pain experience. Respondents who experienced residual limb pain reported significantly higher affective distress scores than those with no phantom or residual limb pain. Many older individuals with long-term traumatic limb amputations could benefit from interventions to ameliorate affective distress and appropriate residual limb pain treatment.

Case management: heart and soul

Dear Colleagues: As a seasoned case manager, I have had the opportunity to serve our specialty practice in the development of the definition of case management, the creation of our standards of practice, the evolution of our professional code of conduct, and, of course, the process of certification. Yet it is the stories of our shared time with our clients that truly define what we do and who we are and clarify our contribution to health care. It is by the telling of the story that we understand our roles, our behavior, and the value of our activities.

Factor structure of the Trinity Amputation and Prosthesis Experience Scales (TAPES) with individuals with acquired upper limb amputations

OBJECTIVES

To investigate the factorial composition of the Trinity Amputation and Prosthesis Experience Scales (TAPES), a multidimensional assessment of adaptation to amputation and prosthesis, for use with individuals with acquired upper limb amputations.

DESIGN

Cross-sectional survey of members of the British Limbless Ex-Service Men's Association.

RESULTS

A total of 101 individuals (men, 100; mean age, 73.8 yrs, SD 11.94) with acquired upper limb amputations (98 traumatic cases) completed the TAPES. Principal components analyses with varimax rotation revealed four psychosocial subscales (general adjustment, social adjustment, optimal adjustment, and adjustment to limitation), four activity-restriction subscales (restriction of lifestyle, social restriction, occupational restriction, and restriction of mobility), and a single prosthesis-satisfaction subscale. Each of these subscales had high internal reliability.

CONCLUSIONS

The TAPES structure can be meaningfully represented in terms of nine internally consistent subscales. Additional research needs to be done on the TAPES for use with individuals with upper limb amputations. In particular studies of the scales, predictive validity is warranted.

Psychological factors after traumatic amputation in landmine survivors: the bridge between physical healing and full recovery

PURPOSE

Limb loss due to a landmine injury is sudden and devastating. The resulting disability makes life challenging in a world where physical ability is the 'norm'. In order to better understand the psychological adjustments individuals make in their recovery from a landmine injury, the Landmine Survivors Network conducted an exploratory qualitative study to determine factors that contribute to an individual's recovery. The study examined psychosocial aspects, coping strategies, and resilience characteristics of limb loss survivors across differing cultural, societal and economic backgrounds.

METHOD

Eighty-five participants (68 persons of limb loss, 10 family members, seven service providers) were interviewed using a semi-structured protocol in the USA and an open-ended format in six landmine affected countries. Data analysis was completed using grounded theory analytic strategies.

RESULTS

Data indicated that the survivors' acceptance of limb loss and their state of psychological recovery were greatly influenced by the individual's resilience characteristics, social support, medical care, economic situation and societal attitudes toward people with disabilities.

CONCLUSION

Recovery from traumatic amputation in landmine survivors needs to be comprehensive and coordinated, and requires addressing the individual's physical, psychological, economic and social needs within the context of family, community, and the socio-cultural environment in which they live.

Understanding and meeting the needs of farmers with amputations

BACKGROUND

Despite the hazardous nature of the occupation, farmers who sustain serious permanently disabling injuries return to the physical labor of production agriculture. It is estimated that amputations account for 11% of all major farm-related injuries.

PURPOSE

This report describes the process of reentry to farm work of farmers across the United States who experienced above-the-wrist traumatic amputations.

SAMPLE

Interviews with 16 farmers revealed the unique features of the work and world view of these workers who labor in the fields.

FINDINGS

The occupational recovery process included questioning, analyzing, and "getting along." Prostheses and formal rehabilitation programs were viewed as minimally helpful. Suggestions and resources that may be helpful for the orthopaedic nurse to assist this high-risk work group are included.

Left and right hand recognition in upper limb amputees

Previous research suggests a close similarity in brain activity between mental simulation of a movement and its real counterpart. To explore this similarity, we aimed to assess whether imagery is affected by the loss of a limb or of its motor skills. We examined the performance of 16 adult, upper limb amputees (and age-matched controls) in a left/right hand judgement task that implicitly requires motor imagery. The experimental group included subjects who had suffered the amputation of the dominant or the non-dominant limb. Although responding well above chance, amputees as a group were slower and less accurate than controls. Nevertheless, their response pattern was similar to that of controls, namely slower response times and more errors for stimuli depicting hands in unnatural orientations, i.e. postures difficult to reach with a real movement. Interestingly, for all stimuli, amputees' performance was strongly affected by the side of limb loss: subjects who underwent amputation of their preferred limb made more errors and required greater latencies to respond as compared with amputees of the non-dominant limb. In a further analysis we observed that the habit of wearing an aesthetic prosthesis significantly interfered with the ability to judge the corresponding hand. Our data lead to three main conclusions: (i) loss of a single limb per se does not prevent motor imagery but it significantly enhances its difficulty; (ii) these subjects apparently perform the hand recognition task using a strategy in which they initially mentally simulate movements of their dominant limb; (iii) wearing a prosthesis, devoid of any motor function, seems to interfere with motor imagery, consistent with the view that only 'tools' can be incorporated in a dynamic body schema.

Trauma-related distress and mood disorders in the early stage of an acute traumatic hand injury

The aim of the study was to estimate the incidence of trauma-related distress and mood disorders in the early stages after acute traumatic hand injuries and identify characteristics associated with these reactions. Data were obtained from 112 patients by means of mailed questionnaires and medical records. Nearly half of the patients had increased levels of intrusive and avoidance symptoms, indicating trauma-related distress. One-third showed signs of a mood disorder. Mood disorders were associated with the need for help with activities of daily living, pain and avoidance symptoms. The study showed that emotional problems in the early stages after injury are related to the consequences of both the injury and the traumatic experience. Negative reactions to the sight of the hand were associated with both trauma-related distress and mood disorders, suggesting that observation of the reactions to the sight of the hand could help to identify patients in need of psychological support.

The psychosocial effects of landmines in Jaffna

The victims of landmines in Jaffna were studied from a psychosocial perspective in order to identity major problem areas and give priorities for rehabilitation. Sixty-seven victims of landmines from April 1996 to March 1998 in the Valikamam area of Jaffna were studied. There were three times as many males as females. About 48 per cent were aged 20-39 years. About one-fifth of the victims were children. Of the females, 60 per cent were unmarried. The majority belonged to the lower socioeconomic strata. Half lost their earning capacity after the injury. Post-traumatic stress disorder (72 per cent), acute stress reaction (73 per cent), anxiety disorder (80 per cent) and depression (73 per cent) were found to be very significantly higher in this group than in the general population. There were also remarkable changes in the areas of functional ability, religious practice, use of alcohol and social relationships. The 'phantom limb' phenomenon was a striking feature among amputees. The psychosocial impact of landmine injuries has to be considered seriously in rehabilitation work.

Functional results of the first human double-hand transplantation

OBJECTIVE

Objective of this study was to analyze fifteen months after surgery the sensorimotor recovery of the first human double hand transplantation.

SUMMARY BACKGROUND DATA

As for any organ transplantation the success of composite tissue allografts such as a double hand allograft depends on prevention of rejection and its functional recovery.

METHODS

The recipient was a 33-year-old man with bilateral amputation. Surgery included procurement of the upper extremities from a multiorgan cadaveric donor, preparation of the graft and recipient's stumps; then, bone fixation, arterial and venous anastomoses, nerve sutures, joining of tendons and muscles and skin closure. Rehabilitation program included physiotherapy, electrostimulation and occupational therapy. Immunosuppressive protocol included tacrolimus, prednisone and mycophenolate mofetil and, for induction, antithymocyte globulins and then CD25 monoclonal antibody were added. Sensorimotor recovery tests and functional magnetic resonance imaging (fMRI) were performed to assess functional return and cortical reorganization. All the results were classified according to Ipsen's classification.

RESULTS

No surgical complications occurred. Two episodes of skin acute rejection characterized by maculopapular lesions were completely reversed increasing steroid dose within 10 days. By fifteen months the sensorimotor recovery was encouraging and the life quality improved. fMRI showed that cortical hand representation progressively shifted from lateral to medial region in the motor cortex.

CONCLUSION

Even though at present this double hand allograft, treated using a conventional immunosuppression, allowed to obtain results at least as good as those achieved in replanted upper extremities, longer follow-up will be necessary to demonstrate the final functional restoration.

Initial development and validation of a multidimensional pain readiness to change questionnaire

Psychometric instruments that assess patient readiness to adopt pain management skills taught in multidisciplinary pain management programs have the potential to clarify interindividual responses to treatment. To date, however, such questionnaires have examined overall readiness to self-manage pain in general rather than readiness to adopt the various specific skills that are taught in multidisciplinary pain treatment. The present study describes the initial construction and evaluation of a Multidimensional Pain Readiness to Change Questionnaire (MPRCQ) that measures readiness to adopt adaptive and avoid maladaptive pain coping strategies. The MPRCQ was initially administered to patients with fibromyalgia syndrome (n = 93) and then to a replication sample of persons with acquired amputations and spinal cord injuries who have chronic pain (n = 88). The results provide preliminary support for the reliability and validity of this instrument. Further research is needed to clarify the construct validity of the MPRCQ and its clinical utility.

Depression in men with traumatic lower part amputation: a comparison to men with surgical lower part amputation

This study aimed at comparing the prevalence of depression among traumatic and surgical amputees and examining the relationship between depression and sociodemographic/clinical characteristics of amputees. Participants were 49 patients with traumatic lower part amputation and 35 patients with surgical lower part amputation. The diagnosis of depression in each participating patient was confirmed by means of the Structured Clinical Interview for DSM-IV, Turkish version. The level of depression was assessed by using the Hamilton Depression Rating Scale. The prevalence of depression was 34.7% in the traumatic amputee group and 51.4% in the surgical amputee group (p > 0.05). In the traumatic group, depression was associated with time since amputation but not with other variables. However, in the surgical group, depression was associated with age, education level, marital status, economic status, time since amputation, and whether the patient was treated with prosthesis. Our data indicated that depression is a common clinical condition among amputees. Clinicians may be advised to schedule periodic contacts with amputees over long periods to identify those in need of psychiatric intervention.

Psychological aspects of mutilating hand injuries

The immediate and long-term outcome of a mutilating hand injury can be positively influenced by health care professionals adopting a biopsychosocial perspective toward treatment and management. Such an injury produces a psychological and social impact that should be openly and candidly addressed with the injured individual and with the family. The earlier and the more skillfully these issues are addressed, the more likely it is that psychological factors will not impede functional outcome.

Concerns about human hand transplantation in the 21st century

The decision to perform a human hand transplant was justified perhaps on less than an ideal scientific basis-only approximately 60 rat limb transplants and 2 primate limb transplants have survived for longer than 200 days and only 8 of 19 pig limb osteomyocutaneous transplants showed no signs of rejection at 90 days. It seems unlikely that the survival of a human hand transplant will be any better than the survival of a kidney transplant, which has a half-life of approximately 7.5 to 9.5 years. Fourteen hand transplants, however, have now been performed in 11 humans with the skin component of 1 remaining viable up to 3 years after surgery. Intermittent episodes of acute rejection seem to have been relatively simple to reverse by temporarily increasing the dose of immunosuppressive agents and steroids. Chronic rejection has occurred in 1 patient, necessitating re-amputation of the transplanted hand. Active range of motion of the digits has been surprisingly better than would have been expected based on previous results of replantation, but return of sensibility has been less than optimal. The immunosuppression has been well tolerated without any major medical problems or life-threatening episodes, but some patients have developed chronic viral and fungal infections and several have developed posttransplant diabetes. Extrapolating from the previous experience of solid-organ transplants, chronic immunosuppression may predispose a hand transplant patient to an 80% chance of developing an infection, a 20% potential risk of developing posttransplant diabetes, and a 4% to 18% potential risk of developing a malignancy. Even though there is universal agreement that composite tissue allograft transplantation will become the ultimate reconstructive option, no one can predict the eventual role of hand transplantation in the future, but perhaps an international database of these hand transplant patients should be established so that independent reviewers can more objectively evaluate their functional outcome, the incidence of chronic rejection, and the risks of long-term immunosuppression.

Rehabilitation process and functional results of patients with amputated fingers

Digit amputation is a physical and psychological trauma that can influence the daily living of a person. The rehabilitation of patients with digit amputation is a complex process and should take into consideration all influencing factors, such as the functional, emotional, social, and professional profile of the patient. This study was conducted to evaluate the functional level of patients with amputated fingers and to understand the factors that influence their rehabilitation. Fifty patients (42 male and 8 female with an age ranging from 7 to 84 years) who had digit amputation(s) between January of 1990 and December of 1998 at the level of the metacarpus or distal to it and who had at least 6 months of follow-up were examined. The patients were divided into three different study groups: patients with distal amputation were compared with patients who had proximal amputation, patients with one finger amputation were compared with patients who had multiple finger amputations, and patients who suffered finger amputations caused by work-related accidents were compared with those who suffered amputations caused by other incidents. In addition, the time lapse from the amputation was checked as an influencing factor for different functional levels. The results showed that patients with distal amputation reached a higher motor and sensory functional level than patients with proximal amputation. Patients with one-finger amputation reached higher motor, sensory, and activities of daily living functional levels than patients with multiple amputations, and the level of motor and sensory function of patients with finger amputations caused by work-related accidents was lower than that of patients who suffered amputations in other incidents. Time was proven to be an important factor in the process of motor and emotional recovery.

Amputee fetishism and genital mutilation: case report and literature review

A case is presented of a 49-year-old man who amputated his penis following instructions that he had obtained from the Internet. The patient had a long-standing amputee fetish, which evolved into eroticized genital mutilation. The transformation of the preferred fetish occurred in a setting of depression due to environmental stressors. The literature about amputee fetishism, also called "apotemnophilia," is reviewed, and possible connections with the genital mutilation are discussed.

Rehabilitation and the long-term outcomes of persons with trauma-related amputations

OBJECTIVE

To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes.

DESIGN

Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation.

PARTICIPANTS

Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded.

RESULTS

Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes.

CONCLUSIONS

These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.

[The methodological approaches to organizing the rehabilitation of servicemen with amputation defects of the extremities]

10-year experience in prosthetics of extremity stumps in conditions of the Central Military Clinical Hospital N 6 was analyzed. In the hospital during the period from 1989 to 1999 prosthetic appliance was made in 203 patients with amputating defects of extremities, 37 of them with pair stumps and 1 with lack of segments of all extremities. Most patients (80.5%) had stumps at the level of femur and crus. Basing on the analysis of modern scientific literature and experience gained in hospital the authors have formulated organizational and methodical states. Thanks to observance of the stated principles it was possible to optimize considerably the process of medico-psychological and social rehabilitation, to achieve good functional results in all patients treated in the hospital. Adequate use of experience in other military medical and prophylactic institutions will contribute to significant decrease in periods of return of servicemen to social useful labour and increase in efficiency of rehabilitation measures.

Factors associated with penile amputation in Thailand

This report describes factors associated with the act of penile amputation by three female partners in southern Thailand. While gender-specific roles and paternalistic behaviors are normative in Thai society, specific precipitating factors for the three amputations included: (1) an immediate financial crisis that adversely affected one of the children in the family; (2) ingestion of drugs or alcohol by the husband immediately before the event; (3) public humiliation of the wife in the presence of a mia noi (secondary wife) or concubine within the week that preceded the incident. Understanding women's cultural preservation in Thailand may promote culturally sensitive and meaningful nursing care.

The psychosocial effects of landmines in Cambodia

The widespread use of landmines in conflict situations around the world and their continuing legacy for the civilian population in injuries, amputations, disabilities and economic costs has been recognized as a major problem. However, the psychosocial consequences for landmine victims are still to be realized. Although there are some facilities for the medical, orthopaedic and long-term rehabilitative care of landmine victims, hardly any exist for their psychosocial needs. This study considers the mental costs in terms of post-traumatic stress disorder, depression and anxiety. Individual difficulty in relationships and daily functioning is considerable, and the landmine victim faces social stigmatization, rejection and unemployment. Suggestions are made for brief training in relatively simple mental health care for staff working in already functioning programmes.

Case consultation: ablatio penis

In male infants, traumatic ablation of the penis, with or without loss of the testicles may occur as a sequel to mutilatory violence, accidental injury, or circumcision error. Post-traumatically, one program of case management is surgical sex reassignment to live as a girl, with female hormonal therapy at the age of puberty. The other program is genital reconstructive surgery to live as a boy, with male hormonal therapy at puberty if the testicles are missing. In both programs, the long term outcome is less than perfect and is contingent on intervening variables that include societal ideology; surgical technology; juvenile and adolescent timing and frequency of hospital admissions construed by the child as nosocomial abuse; development of body image; health and sex education; fertility versus sterility; coitus and orgasm; possible lesbian orientation if living as a girl; and long-term cost accounting, including the psychic cost of being a pawn in possible malpractice litigation on whose disability a very large fortune in compensation may devolve. There is, as yet, no unanimously endorsed set of guidelines for the treatment of genital trauma and mutilation in infancy, and no provision for a statistical depository for outcome data.