|Year : 2022 | Volume
| Issue : 1 | Page : 49-55
Factors influencing quality of life after lower extremity amputation
Dantis John Thomas, CV Rajendran
Department of General Surgery, Government Medical College, Thiruvananthapuram, Kerala, India
|Date of Submission||09-May-2022|
|Date of Decision||15-May-2022|
|Date of Acceptance||17-May-2022|
|Date of Web Publication||14-Jul-2022|
Dr. Dantis John Thomas
Department of General Surgery, Government Medical College, Thiruvananthapuram - 695 011, Kerala
Source of Support: None, Conflict of Interest: None
Background: Despite the fact that patients with critical limb ischaemia, diabetic foot, advanced malignancies and major trauma to extremities undergo lower limb amputation, the personal satisfaction or quality of life (QoL) of such patients remains inadequately portrayed. This study tried to portray which spaces' amputees consider significant in deciding their well-being related QoL. Objective: To study the factors influencing QoL of patients who have undergone lower extremity amputation attending the department of general surgery of a tertiary hospital and to compare the QoL of amputee population with that of general population. Methodology: It was a cross-sectional study. The study population included patients who underwent lower extremity amputation in the department. 110 subjects, aged above 18 years, who have undergone lower extremity amputation and who consented to take part in the study were included. Results: The QoL as calculated from the Physical Component Summary and Mental Component Summary scores, using short-form-36 questionnaire showed that the physical health and the mental health (MH) both were significantly low in the amputee population. It was seen that gender with female sex having a better physical health quality compared to the male sex. Gender, use of prosthetic devise, stump infections and employment status contributed to MH quality. The QoL of an individual was severely altered following amputation. Both physical and MH domains were significantly reduced in an amputee compared to the general population. Gender influenced both the mental and physical QoL, with females performing better. Use of prosthesis was seen to be significant in MH. This underscores the need for proper rehabilitation programmes. Conclusion: The factors recognised should be seriously addressed in order to improve the QoL of lower limb amputees.
Keywords: Lower limb amputation, quality of life, rehabilitation
|How to cite this article:|
Thomas DJ, Rajendran C V. Factors influencing quality of life after lower extremity amputation. Kerala Surg J 2022;28:49-55
| Introduction|| |
Lower extremity amputations (LEA) are performed for various reasons such as tumour, trauma congenital anomalies and vascular diseases including Peripheral Occlusive Vascular Disease (POAD) and diabetic foot. Amputation leads to permanent disability and brings a dramatic change in the life and function of the individuals; this change is more marked in lower extremity amputees compared to upper extremity amputees. When performed, they are lifesaving and pain relieving, but come at the cost of functional and socioeconomic disability to the patient. The incidence of LEA is also higher than upper limb amputations. Vascular complications and comorbidities including diabetes are the major health issues in and diabetic ulcer being the precursor to amputation in developing countries., The participation of the individual in the society is affected due to the limitations in structure and function following amputation. In addition to the mentioned factors, personal and environmental factors also play an important role in determining the outcome and long-term survival and functioning following amputation. Mobility is considered an important rehabilitation goal. Quality of life (QoL) was affected by the individual's ability to walk independently on prosthesis. Additional factors also affect the functioning and well-being of amputees.
QoL is an important outcome of rehabilitation programmes. Limitation in body structure and function due to amputation affects the activity level and thereby the participation of the individual in society. In addition, personal and environmental factors play important roles in determining outcomes after amputation and long-term functioning of amputees.
LEAs also have wider implications, as they are associated with increased level of anxiety and depression, altered body image and social discomfort, all of which add psychological burden to the patient. They represent a significant financial burden on health service. In addition, there is a significant long-term economic impact as rehabilitation and social care are required.
Most commonly, LEAs are performed globally due to peripheral occlusive arterial disease. Diabetes is a major contributor to peripheral occlusive disease, apart from causing diabetic foot disease, where accidental trauma of the lower limb leads to ulceration or ischaemia due to compromised vasculature.
Fifty to sixty per cent of those who have LEAs with or without diabetes have a life expectancy of 2 years post-amputation. Mortality rate ranges from 52% to 82%, when 5-year survival was studied. Advanced age and above-the-knee amputations were seen to be associated with increased mortality. It was also seen that in the presence of other comorbidities such as diabetes mellitus and hypertension, risk of mortality increases.
Life of a patient is completely changed after lower extremity amputation. Only a small proportion will go on to rehabilitate with a prosthetic limb. A proportion will be wheel chair dependent, and the rest bed ridden, especially old age and neglected patients. This eventually affects an individual's ability to perform his daily routine activities and subsequently affect an individual's QoL. This thesis aims to provide new knowledge as to how LEA affects the QOL of an individual and the factors which mainly affect the QoL.
The objectives of the paper was to study the factors influencing QoL of patients who have undergone LEA attending the department of general surgery of a tertiary care hospital and to compare the QoL of amputee population to that of general population. There have been many studies examining the morbidity and mortality associated with a major LEA. Not many studies are there which determine the QoL after such a major life-changing surgery. This study was undertaken to address the gaps in the literature.
| Methodology|| |
It was a hospital-based cross-sectional study for 1 year after getting clearance from the institutional human ethical committee. Inclusion criteria were LEA patients above 18 years of age at the time of study. Patients with severe cognitive impairment who could not answer the questions of questionnaire were excluded from the study. Sample size was calculated as 110.
p = 44% (prevalence of persons using assistive devices from the study conducted by Sinha et al.18)
d = 20% of P
Convenience sampling was utilised. The QoL study in the general adult population was conducted in Trivandrum, following purposive sampling. These data were used to compare QoL profiles of general and amputee populations. Subjects were provided with information on the study and signed consent was requested. Face-to-face interviews among amputees and among the general population were performed. In total, 110 amputees from the general population were selected. Questionnaires were distributed to collect the patient's background and amputation characteristics and to assess QoL. Background variables included age, sex, comorbidities, years since amputation, education status and employment status. Amputation characteristics included why was the amputation performed, amputation level, infection at stump site, stump pain and phantom-limb sensation, as these were the factors seen influencing health outcome in lower limb amputation population.,, QoL was measured using the Medical Outcomes Study short-form health survey (SF-36). The SF-36 is a multipurpose SF health survey consisting of 36 questions and has been used as an outcome measurement instrument to assess QoL in amputees., The SF-36 measures health status in eight dimensions: The SF-36 measures health status in eight dimensions: 1. physical functioning 2. role limitations due to physical health problems, 3. bodily pain (BP), 4. general health perceptions, 5. vitality, energy and fatigue, 6. Social functioning, 7. role limitations due to emotional problems, and 8. general mental health covering psychological distress and well-being.
The first four dimensions of the SF-36 contribute to the Physical Component Summary (PCS) scores and the last four dimensions to the Mental Component Summary (MCS) scores; a higher score implies a better QoL. The PCS and MCS scores are statistically easier to interpret due to smaller confidence intervals, lower floor and ceiling effects and fewer statistical tests required, thus lowering Type I error. PCS and MCS scores provide a comprehensive approach to the application of results in clinical decision-making.
Statistical analyses were performed using the Statistical Package for the Social Sciences (IBM-SPSS, India, 2020). Descriptive statistics were performed for both background and amputation characteristics. The prevalence of different amputation-related factors and comorbidities per amputation level was calculated. The PCS and MCS scores were obtained from SF-36 scales using a correlated (oblique) physical and mental health factor model. Forward stepwise multivariate linear regression analyses were performed for PCS and MCS scores using background and amputation-related factors. Four background variables and nine amputation-related variables were entered into the initial regression analysis. Binary coding was done for each level of the categorical variables to enable forward regression. The regression procedure resulted in a parsimonious model based only on the factors which achieved statistical significance (P < 0.05). QoL scores of amputees were compared to those of the general population to assess the impact of amputation on QoL. The PCS and MCS scores were compared between amputees and the general population.
| Results|| |
Of 110 subjects, the mean age was 61.61. Majority were in the age group of 61–70 [Table 1]. Eighty-seven (79.1%) were male and 23 (20.9%) were female. Among them, only 20 (18.2%) had no schooling; majority had high schooling (79; 71.8%) and 11 (10%) had college education. Almost half of them 54 (49.1%) remained unemployed. Diabetes mellitus was the most common comorbidity (60.9%) among amputee population followed by hypertension (20%). 23.6% of the population also suffered from other major vascular diseases such as cerebrovascular accident/Coronary artery disease. Other comorbidities included chronic obstructive pulmonary disease, dyslipidaemia and neurological diseases (11.8%).
25.5% of amputee population survived with amputation >5 years. Majority of the subjects were recently (<3 years) amputated (47.3%). It was seen that vascular complications are the most common case leading to amputation. Microangiopathy of diabetes and POVD accounted for 81.8% of the amputations. It was followed by necrotising fasciitis of lower limb, putting the patient in severe sepsis, and amputation was performed as a lifesaving procedure in them. Other causes including malignancy and severe extremity trauma caused only 4.5% of the amputations. Level of amputation in the study population included AK – 62 (56.4%), BK – 38 (34.5%), bilateral – 3 (2.7%) and others – 7 (6.4%).
Thirty-five percentage of the amputee population had comorbidities [Table 2]. Use of a prosthetic device was reported by 63.6% and 42.7% reported to be using an assistive device such as canes or crutches. Walking limitation was reported maximally by AK amputation population (61.1%), followed by BK amputation and bilateral amputees (33.3%). Stump infections were a major issue in 57.9% of the AK amputation population; 36.8% of BK amputation population also reported stump infections. Phantom limb was also a major concern, with 65.5% of the total amputee population reporting the same. It was maximally seen in bilateral amputee population (66.7%).
|Table 2: Prevalence of amputation related factors and comorbidities as per the level of amputation|
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Descriptive of the eight SF-36 scales is provided in [Table 3] and [Figure 1]. From these data, higher order PCS and MCS scores were generated. The PCS and MCS scores of the study population were compared to the general population. On comparison, it was seen that, except for the domain of BP, all other domains were significant in commenting the QoL. Comparing with general population, the physical health (PCS) and mental health (MCS) were significantly reduced in the amputee population.
|Figure 1: SF-36 Scale Descriptive. SF-36: Short-form-36, PF: Physical functioning, BP: Bodily pain, GH: General health, VT: Vitality, SF: Social functioning, RE: Role-emotional, MH: Mental health|
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For participants of the general population, the age ranged from more than 18 years to over 80 years. The higher order PCS and MCS scores were generated from the data and both the population were compared [Figure 2] and [Table 4]. On comparison, both the physical health and mental health were significantly reduced in the amputee population. Bilateral amputee population had a poor PCS, and while those with prosthetic use had better PCS (P < 0.1). Individuals using prosthesis were found to have a slightly better physical health compared to those who are not using it.
|Table 4: Short-form-36 physical component summary scores of the variables|
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|Figure 2: Comparison of physical and mental health of amputee and general population|
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Gender (P < 0.05), level of amputation (P < 0.05), prosthetic use (P < 0.05), employment status (P < 0.05) and stump infections (P < 0.05) were seen to be significant. It was observed that gender predicted PCS score and gender and prosthetic use predicted the MCS scores [Table 5].
From the data, it can be inferred that gender and use of prosthesis are independent predictors of the MCS scores [Table 6] and [Table 7].
|Table 6: Multivariate regression model for estimation of physical component|
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|Table 7: Multivariate regression model for estimation of mental component|
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| Discussion|| |
This study was conducted to assess the factors influencing the QoL after LEA and weather the QoL is decreased comparing to the general population. People with LEA were seen to have a lower QoL compared to the general population. The same finding can be found in many other studies as well., In both physical and mental health domains, the general population outperformed the amputee population. The physical health component was more severely affected than the mental health component, showing the effect of amputation on the physical health of an individual. This implies that amputation is a major life-changing procedure that significantly affects the QoL of an individual.
In this study, it was seen that gender was a major factor contributing to physical health component of QoL. The mental health component was significantly influenced by gender and use of prosthetic device. This was different with some of the findings in the study conducted by Sinha et al., where they concluded that use of prosthesis and comorbidities affected the physical component and employment status and comorbidities determined the mental health component.
Majority of the amputee population was identified above 60 years of age. Rehabilitation of this population in a developing country like India remains unaddressed. In the present study, almost half (49.1%) of the study group remained unemployed. Amputation has a direct effect on employability of a subject. Here comes the importance of vocational rehabilitation and other skill development training, which at many times goes unaddressed.
71.8% of the study subjects had high schooling and only 10% had college education. Post-amputation these subjects can be rehabilitated by less physically demanding jobs. However, the lack of educational qualification in many of them acts as a hindrance for the same.
Most of the amputee population consisted of male gender (79.1%). It was consistent with many other studies. In Indian society, male gender acts as the bread winner, and following amputation, they may land up in unemployment as previously described, which may add up to the additional financial burden to the family. Even though majority was male population, it was the female gender who had a better physical health compared to the male. However, when the mental health was studied, male gender had a better MCS score. Asano et al. reported that employment was an important factor influencing the QoL. However, in the present study, it was not seen as a factor contributing to QoL.
Prosthesis usage was seen affecting both physical health and mental health in previous studies. In the present study, it was seen to be a factor influencing the mental health only. 63.6% of the amputee population was using prosthetic devices, which has greatly added to the mobility of the patient, as only 32.7% of patients reported a walking limitation. This throws light on the importance of adequate gait training and promoting prosthesis usage among the amputee population. This help in developing confidence among the population for performing social and community activities.
The presence of phantom limb was seen to affect the QoL in many studies. However, here, phantom limb pain was not seen a factor contributing to the QoL. This result should be dealt with caution, as previous studies have shown that phantom limb contribute to the QoL. In my study, among the various amputation-related factors studied, majority complained about phantom limb (65.5%).
The most common cause of amputation was found to be due to diabetes mellitus and POVD (vascular causes). It accounted for 81.8% of the total cases studied. This stresses on the importance of early identification, patient education and management of microangiopathy associated with diabetes mellitus as the prevalence of diabetes in Indian population is very high. POVD also is an important factor causing amputation. This has to be read in line with the finding that diabetes was the most common comorbidity associated with the amputee population (60.9%).
It was seen that most of the subjects underwent above-the-knee amputation (56.4%). Stump-related issues, including stump infections, phantom limb pain and walking limitation, were also high among the AK amputee population.
Duration since amputation was not seen as a factor affecting QoL. However it may contribute to mortality. Majority of the population were < 3 years since amputation (47.3%). This could imply that as time advances, either mortality increases or an attrition in follow up as duration increases. Since this was a hospital-based cross-sectional study, we could collect data from only those subjects who were coming for follow-up in the outpatient department.
Many of the findings in this study are seen contradictory to the many previous studies. However, this result should be dealt with caution, as the study population was less. Moreover, selection bias could not be completely ruled out.
| Conclusion|| |
Lower limb amputations are a life-changing surgery affecting both the physical and mental health of an individual. Gender was seen as a factor affecting both the physical and mental health status. Use of prosthetic device significantly affected the mental health status of the individual. Walking limitation was seen following amputation surgeries. Even though prosthesis usage is prevalent, the number of patient opting for the same remains less. Diabetes has turned out to be the factor leading to amputation as well as the most common comorbidity seen among the amputee population. Amputee population mainly consisted of male gender, and amputation is more common among the older age group above 60 years. Stump-related issues were more common among the AK amputation population. Phantom limb sensation is the most common amputation-related issue complained by the subjects.
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Conflicts of interest
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]