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Introduction
mputation surgery is the excision of whole
Aextremity or limb or its part i.e. a leg, arm,
finger, toe, hand and foot. Trauma is prime reason of
leg amputation in developed countries and it’s second
main prevalent reason of amputation in growing
countries, leading to peripheral artery disease. There
are countless causes of amputation which could be
vascular such as peripheral artery disease, diabetes,
vasculitis or non-vascular conditions i.e. neoplasm,
trauma or other pathologies associated with
1,2
infections. Peripheral neuropathy related diabetic
ulceration in foot is chief reason of amputation in
Quality of Life and Depression among Lower Limb Amputees
1 2 3 4 5
Anna Zaheer , F aiza Sharif , Z eeshan Khan , S ana Batool , H ussain Iqbal
Abstract
Background: Amputation is the surgical excision of all or part of extremity. After amputation patient may
suffer various physical and psychological consequences. These symptoms may be due to adaptive responses
to the emotional experiences of this serious impairment. Amputation certainly results in massive change in
life situations of a person; therefore, it is important to assess psychological status as well as quality of their life
(QOL) of amputation surgery survivors.
Objective: To measure quality of life and level of depression among lower limb amputees having transtibial
or transfemoral amputation. Moreover, to find the correlation between QOL and depression scores of
amputees.
Methods: In this study 70 both female and male lower limb amputees participated. To assess QOL of
amputees WHOQOL-BREF questionnaire and for assessing status of depression PHQ-9 questionnaire was
used.
Results: Mean scores of all domains of QOL questionnaire were: physical (53.44), psychological (56.41),
social (60.29) and environmental (54.10). Among all amputees, 55 participants reported to have mild - severe
depression. Moreover, strong negative correlation was analyzed between QOL score and depression score of
responders (-0.615, p=0.000). Social domain of QOL was strongly correlated with overall QOL score of
amputees (0.808, p=0.000).
Conclusions: Amputees participated in this study encountered significant life changes after amputation
which adversely effected their quality of life. Many of participants suffered moderate depression. Depression
and QOL scores of amputees were negatively correlated (p<0.05).
Corresponding Author | Anna Zaheer: Lecturer, University Institute of Physical Therapy, University of Lahore.
E-mail: annazaheer@yahoo.com
Keywords | Depression, quality of life and amputation.
1 2
Lecturer, University Institute of Physical Therapy, University of Lahore; Assistant Professor, University Institute of
3
Physical Therapy, University of Lahore; Medical Officer, Chaudhry Pervaiz Elahi Institute of Cardiaology(CPEIC)
4 5
Multan; Assistant Professor, University Institute of Physical Therapy, University of Lahore; Demonstrator, University
Institute of Physical Therapy, University of Lahore
April – June 2020 | Volume 26 | Issue 02 | Page 1
Pakistan while below and above knee amputations
3
are most frequently used. Assessing QOL of survi-
vors of amputation surgery is very important indi-
cator as amputation definitely results in a remarkable
transformation of the life situations for the person
involved. The World Health Organization defines
QOL as “Individual’s perception of his/her position in
routine life in the context of system of principles and
culture as well as in relation with common standards
4
and personal goals”. According to a systematic
review conducted by Fiona Davie-Smith et. al, QOL
is an important outcome in amputees and there are
many factors that influences it, some of which are
patient’s ability to walk with prosthesis, living situa-
tion, psychological status, co-morbid diseases, living
5
situation and social life. While measuring QOL,
person may undervalue physical aspect and discom-
fort, instead more importance may be given to
psychological induced problems, these necessities
6
psychological assessment. Worldwide, depression is
the second most important reason of life days spent
with disability, and the third leading reason of
disability-adjusted life- years caused by adaptive
responses of emotional experiences due to impair-
7,8
ment. Depression refers to a broad variety of
psychological troubles characterized by the defi-
ciency of optimistic approach (a loss of satisfaction
and pleasure in everyday experiences), continuous
low mood and a variety of related physical, cognitive,
9
psychological symptoms. A study was conducted on
effects of traumatic limb amputation on the mental
health of amputees in which researchers concluded
that amputees have various psychosocial issues that
need to be consider to deliver a better QOL and
holistic care. In order to achieve the holistic care, best
knowledge about amputees mental and physical
10
condition should be available.
According to researcher’s best knowledge, most
previous studies were cross-sectional and mainly
focused only on QOL or psychological assessment
and limited evidence is present about association of
psychological status of amputees with their overall
well-being. Therefore, this study not only assess QOL
and depression score but also correlated different
aspects of QOL of amputees with their depression
status, as distinct attention on mental evaluation and
psychological or emotional counselling of amputees
is required for improving their self-esteem and moti-
vating them towards better QOL. Due to the high
frequency of amputation in Pakistan, there is need to
sensitize the community and patient’s family about
psychological concerns and other domains of QOL of
amputees in order to improve rehabilitation of this
challenging condition.
Methods
It was a cross-sectional research in which convenient
sampling procedure was used to gather responders.
Before starting research, permission was taken from
higher authorities /ethical committee of institutions
and basic knowledge and instructions was given to
study population. Patient Health Questionnaire-9
(PHQ-9) and World Health Organization Quality of
Life Questionnaires (WHOQOL- BREF) were used
to gather data on depression and quality of life.
Ethical considerations were taken in account. Partici-
pants were given comfortable environment and
proper consent form was given to each responder
containing detail information about study and resear-
cher’s contact detail. Confidentiality of information
was maintained and participants were included on the
basis of informed consent. Sample size of 86 lower
11
limb amputees was calculated by formula. Confi-
dence level was set at 95% and margin of error at 5%.
Sample size could not be completed because of
limited sources. Total 76 participants fulfilling the
study criteria, due to uncomplete data 6 participant’s
questionnaires were not included, so total lower limb
amputation (LLA) participants included was 70.
Study was conducted in 6 months after the acceptance
of Research proposal. Participants were recruited
from orthopedic and surgical units of three govern-
ment hospitals and two private rehabilitations
hospitals of Lahore. Inclusion criteria of study inclu-
ded both genders with more than 18 years of age with
either trans-femoral or trans-tibial lower extremity
removal surgery. Exclusion criteria of study was
infectious stump, pregnancy, lower motor disease,
upper motor disease, malignancy and participants
having other disabilities. At start questions related
demographic information of participants and physio-
therapy rehabilitation were included. WHOQOL-
BREF was used to measure QOL of the participants.
WHOQOL-BREF is multidimensional tool which is
12
very useful to measure quality of life. This tool
includes 4 areas of life i.e. psychological, physical
health, environmental and social domain and comp-
rised of 26 questions relevant to their perception of all
April – June 2020 | Volume 26 | Issue 02 | Page 2
domains of QOL. It is self-administrated tool but
interviewer gave assistance to participants who were
not able to read questionnaire. Frequency and level of
depression was measured by PHQ-9, which contains
9 questions. It is a valid tool in detecting presence and
severity of depression. Each responder can score
from 0-27. Depression level (PHQ-9) scoring was
categorized as: 0-4 scores = no depressing symptoms,
5-9 scores=mild depressing symptoms, 10-14scores
= moderate depressing symptoms, 15-19scores=
moderately Severe and 20-27 scores =severe depre-
ssing symptoms. Cut-off greater or equal to 10 gives
most precision in identifying depression. In total,
questionnaire used in this study had 44 questions.
Descriptive statistics of demographic data of partici-
pants, domains of WHOQOL-BREF questionnaire,
level of depression and correlation statistics was
calculated using version 22.0 of SPSS. For quality of
life assessment first raw scores were calculated for
each individual included in the study, then it was
transformed according to QOL-BREF questionnaire
transforming score into 100 rules. Means and stan-
dard deviations were calculated of all four quality of
life domains separately as well as collective overall
QOL score. Overall depression score of each partici-
pant was calculated. Both values of variable are
quantitative, so Pearson correlation was used with p
value of 0.05 and CI was 95% to measure correlation
between results of different domains of QOL ques-
tionnaire and depression statistics.
Results
In this study 70 amputees were requited, having either
trans-femoral or trans-tibial lower limb amputation.
Among all participants 17(24.3%) were females and
53(75.7%) were male. Mean and standard deviation
of ages of male and female participants are 37.92,
19.103 and 38.88, 16.603 respectively. From 70
participants 55 participants had depression, among
those 2(2.9%) responders had severe depression,
12(17.1%) moderately severe, 20 (28.6%) moderate
and 21 (30%) participants reported to have mild
depression. Frequency of depression level among
male and female participants is given in figure 1.
Mean of psychological, physical, environmental and
social relationships domains of WHOQOL-BREF are
56.41, 53.44, 54.1 and 60.29 respectively. Mean of
overall total quality of life score by adding together
scores of all 4 domains is 224.24 and standard
deviation is 59.748. (Table I). Study showed strong
negative correlation between depression and the QOL
scores. Coefficient of correlation between depression
statistics of participants with psychology, physical,
environmental and social domains of QOL ques-
tionnaire are as follows: -0.454(p 0.000), -0.566
(p0.000), -0.389(p=0.001) and -0.406 (p=0.000)
respectively. Negative significant correlation was
also seen in depression and scores of physical aspects
of QOL that is - 0.566(p 0.00). Results of all areas of
QOL and overall QOL scores were correlated with
depression score and negative correlation between
these measures was observed. Social domain of QOL
was seen significantly correlated with Total quality of
life score that is 0.808 ( p=0.000).
Figure 1: Frequency of Depression Level Among
Male and Female Participants
1= male 2 = female
April – June 2020 | Volume 26 | Issue 02 | Page 3
Table 1: Statistics of all domains of QOL.
WHOQOL-
BREF
Domains
Number of
partici-
pants
Range Min Max Mean SD
Physical
domain
70 68 13 81 53.44 18.358
Psychologica
l domain
70 75 25 100 56.41 17.260
Social Domain 70 100 0 100 60.29 28.264
Environment
al domain
70 75 19 94 54.10 18.090
Total quality
of life score
70 224 132 356 224.24 59.748
Discussion
In current study QOL and frequency of depression
was estimate in 70 amputees having either above or
below knee amputation. This study concluded that
QOL of the participants was weakened specifically in
terms of physical participation in activities mainly
due to numerous physical limitations they deal.
Fortington et al., studied the change in health related
QOL in first 18 months after lower limb amputation.
They conducted a prospective longitudinal study
comparing the quality of life of amputees with Dutch
population normal standards of life, they concluded
that QOL improved in 5 out of 7 domains under
consideration with time within 6 months but the
physical fitness remain low than the population
13
normal norms.
Recent study suggested there is link of psychosocial
and physical domains of quality of life. Anxiety is
positively correlated with postoperative pain and
physical discomfort and residual or phantom limb
pain. Katherine A. Raichle et al., also suggested that
acutely greater postoperative pain was seen in people
having higher level of anxiety prior to operation.
Thus preventing phantom limb pain soon after
14
operation can prevent chronic phantom limp pain.
In this study most people were suffering from mild
depression and were not severely depress, this may be
due to the fact that as the time passes people start
excepting their bodies, they start adapting their life
with the fact that they had lost a limb and depressing
thoughts decreases. As a result, as the time passes
anxiety and stress related diseases may decrease. It
was also investigated in a study performed in India by
15
Sahu E at al. Ghous, Misbah et al., performed a
cross-sectional descriptive study in different
hospitals of Rawalpindi and Islamabad. They also
16
found that amputees have mild level of depression.
Moreover, those it was seen that people who had good
approach to health-related facilities, had fewer
negative concepts about their situation with lesser
hopeless thoughts.
A cross sectional study was conducted by Mohamad
Iqbal M et al. on 196 LLA, this study showed a corre-
lation between QOL and depression measures that
multiple factors of QOL such as a good social
support, lesser part of limb removed, optimistic
personality and lower level of stump pain effects
positively on person’s positive psychological adjust-
17
ment of amputation. In current study there was
similar significant negative correlation, and there was
a report between depression and quality of life score
as those who are more stronger physically, having
minimal functional limitation, good focusing capa-
city, more indulged in for recreational activities,
having enough information regarding their condition,
having plenty of money suffers less from depression.
There was strong positive correlation between social
area score and entire QOL score of amputees. This is
due to the reason that people having good social life
and satisfied with the relationships with their and
spouse, family and friends had mental harmony,
because they enjoy assistance from family and
society in form of emotional support, financial and
social support, this reduces depressive thoughts, this
depression is negatively correlated with physical
aspect of QOL, therefore upgrading overall QOL
scores. This is also shown in study conducted by
Juszczak M et al., they reported people having social
assistance had better QOL, they also had dignity and
18
better activity status. So, in order to achieve holistic
care of amputees, knowledge about both mental and
physical condition is required.
However, this study included all aspects of QOL and
results of all four items of QOL were correlated with
total QOL as well as with depression scores. How-
ever, small sample size and no follow-up can produce
inappropriate results. Moreover, difference among
trans-tibial and trans-femoral amputation as well as
comparison between people with prosthesis and non-
prosthesis users in terms of quality of life and depre-
ssion was not assessed.
April – June 2020 | Volume 26 | Issue 02 | Page 4
Table 2: Correlation of Scores of Domains of Quality of
Life and Depression Score
Depression
score
(PHQ -9)
Total quality
of life
Score
Physical domain of
WHOQOL - BREF
-0.566 *
(p 0.000)
0.670*
(p 0.000)
Psychological domain
of WHOQOL - BREF
-0.454*
(p 0.000)
0.716*
(p 0.000)
Social domain of
WHOQOL - BREF
-0.406*
(p 0.000)
0.808*
(p 0.000)
Environmental domain
of WHOQOL - BREF
-0.389*
(p 0.000)
0.676*
(p 0.000)
*Correlation is significant at the 0.01 (2-tailed)
According to researcher’s knowledge, most of the
studies were cross-sectional and no good prospective
data correlating quality of life, anxiety and depression
is present, thus this is needed to be address in future
studies. Strong negative association between depre-
ssion and QOL score of amputees represents that
specific concentration on psychological evaluation
and mental counselling of lower limb amputees is
required. This will uplift their self-esteem which may
improve their QOL. Moreover, social abolition or
absence of social assistance can aggravate this nega-
tive situation, therefore rehabilitation team’s know-
ledge about the importance of the amputee’s involve-
ment into social life is crucial and should never be
ignored.
Conclusion
Amputees participated in this study encountered
significant life changes which adversely effected all
areas of their quality of life. Participants suffered
from mild to moderate depression. QOL and depre-
ssion scores of amputees were negatively correlated
(p<0.05) i.e., those who had high score in depression
had low quality of life score and vice versa.
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