ArticlePDF Available

Abstract and Figures

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).
Content may be subject to copyright.
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
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
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
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
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.
Keywords | Depression, quality of life and amputation.
1 2
Lecturer, University Institute of Physical Therapy, University of Lahore; Assistant Professor, University Institute of
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
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
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
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
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-
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,
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
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.
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
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
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.
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.
Number of
Range Min Max Mean SD
70 68 13 81 53.44 18.358
l domain
70 75 25 100 56.41 17.260
Social Domain 70 100 0 100 60.29 28.264
al domain
70 75 19 94 54.10 18.090
Total quality
of life score
70 224 132 356 224.24 59.748
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
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
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
Sahu E at al. Ghous, Misbah et al., performed a
cross-sectional descriptive study in different
hospitals of Rawalpindi and Islamabad. They also
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-
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
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
(PHQ -9)
Total quality
of life
Physical domain of
-0.566 *
(p 0.000)
(p 0.000)
Psychological domain
(p 0.000)
(p 0.000)
Social domain of
(p 0.000)
(p 0.000)
Environmental domain
(p 0.000)
(p 0.000)
*Correlation is significant at the 0.01 (2-tailed)
According to researchers 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
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.
1. Padovani MT, Martins MRI, Venâncio A, Forni JEN.
Anxiety, depression and quality of life in individuals
with phantom limb pain. Acta ortop. Bras. 2015;
2. Ramanaiah J, Pavani M, Reddy NDK, Subrah-
manyam S. Limb Salvage In Diabetic Foot Infection.
JEBMH 2017;4(12):686-689.
3. Assaad-Khalil S, Zaki A, Rehim AA, Megallaa M,
Gaber N, Gamal H, et al. Prevalence of diabetic foot
disorders and related risk factors among Egyptian
subjects with diabetes. Prim. Care Diabetes. 2015;
9(4): 297-303.
4. Hye RJ, Mackey A, Hill MD, Voeks JH, Cohen DJ,
Wang K, et al. Incidence, outcomes, and effect on
quality of life of cranial nerve injury in the Carotid
Revascularization Endarterectomy versus Stenting
Trial. JVS. 2015;61(5):1208-1215.
5. Davie-Smith F, Coulter E, Kennon B, Wyke S, Paul
L. Factors influencing quality of life following lower
limb amputation for peripheral arterial occlusive
disease: a systematic review of the literature. Prosthet
orthot int. 2017;41(6):537-547.
6. Lam T-wJ, Tang L-cL, Chau W-w, Law S-w, Chan K-
m. The Effect of Age, Gender and Socioeconomic
Status on Self-esteem, Body Image and Quality of
Life of Amputees: An Evaluation Seven Years after
the 2008 Sichuan Earthquake. DCID. 2018;29(3):32-
7. Pedras S, Vilhena E, Carvalho R, Pereira MG.
Psychosocial adjustment to a lower limb amputation
ten months after surgery. Rehabil. Psychol. 2018;
63(3): 418.
8. Kassebaum NJ, Arora M, Barber RM, Bhutta ZA,
Brown J, Carter A, et al. Global, regional, and
national disability-adjusted life-years (DALYs) for
315 diseases and injuries and healthy life expectancy
(HALE), 1990–2015: a systematic analysis for the
Global Burden of Disease Study 2015. The Lancet.
9. Derry HM, Padin AC, Kuo JL, Hughes S, Kiecolt-
Glaser JK. Sex differences in depression: does
inflammation play a role? Current psychiatry reports.
10. Bhutani S, Bhutani J, Chhabra A, Uppal R. Living
with amputation: anxiety and depression correlates.
JCDR. 2016;10(9):RC09.
11. Hisam A, Ashraf F, Rana MN, Waqar Y, Karim S,
Irfan F. Health related quality of life in patients with
single lower limb amputation. JCPSP. 2016; 26(10):
12. Uddin MN, Islam FMA. Psychometric evaluation of
an interview-administered version of the WHOQOL-
BREF questionnaire for use in a cross-sectional study
of a rural district in Bangladesh: an application of
Rasch analysis. BMC Health Serv. Res. 2019; 19(1):
13. Amtmann D, Morgan SJ, Kim J, Hafner BJ. Health-
related profiles of people with lower limb loss. Arch.
Phys. Med. Rehabil. 2015;96(8):1474-1483.
14. Raichle KA, Osborne TL, Jensen MP, Ehde DM,
Smith DG, Robinson LR. Preoperative state anxiety,
acute postoperative pain, and analgesic use in persons
undergoing lower limb amputation. Clin J Pain.
2015; 31(8):699.
15. Sahu A, Sagar R, Sarkar S, Sagar S. Psychological
effects of amputation: A review of studies from India.
. Ind. Psychiatry J. 2016;25(1):4.
16. Ghous M, Gul S, Siddiqi FA, Pervaiz S, Bano S.
Depression; Prevalence among amputees. TPMJ.
17. Iqbal M, Mohamed S, Mohamad M. Depression and
Its Associated Factors among Lower Limb Amputees
at Hospital Kuala Lumpur and Hospital Sultanah
Bahiyah: A Cross Sectional Study. J Depress Anxiety.
18. Juszczak M, Beattie A, Smith M, Nelson L, Maikos J,
Bushnik T. The Influence of Social Support on
Functional Outcomes and Quality of Life in Lower
Limb Amputees. Arch. Phys. Med. Rehabil. 2016;
April – June 2020 | Volume 26 | Issue 02 | Page 5
Full-text available
Background: This study assessed the effectiveness of the NEVERMIND e-health system, consisting of a smart shirt and a mobile application with lifestyle behavioural advice, mindfulness-based therapy, and cognitive behavioural therapy, in reducing depressive symptoms among patients diagnosed with severe somatic conditions. Our hypothesis was that the system would significantly decrease the level of depressive symptoms in the intervention group compared to the control group. Methods: This pragmatic, randomised controlled trial included 425 patients diagnosed with myocardial infarction, breast cancer, prostate cancer, kidney failure, or lower limb amputation. Participants were recruited from hospitals in Turin and Pisa (Italy), and Lisbon (Portugal), and were randomly assigned to either the NEVERMIND intervention or to the control group. Clinical interviews and structured questionnaires were administered at baseline, 12 weeks, and 24 weeks. The primary outcome was depressive symptoms at 12 weeks measured by the Beck Depression Inventory II (BDI-II). Intention-to-treat analyses included 425 participants, while the per-protocol analyses included 333 participants. This trial is registered in the German Clinical Trials Register, DRKS00013391. Findings: Patients were recruited between Dec 4, 2017, and Dec 31, 2019, with 213 assigned to the intervention and 212 to the control group. The sample had a mean age of 59·41 years (SD=10·70), with 44·24% women. Those who used the NEVERMIND system had statistically significant lower depressive symptoms at the 12-week follow-up (mean difference=-3·03, p<0·001; 95% CI -4·45 to -1·62) compared with controls, with a clinically relevant effect size (Cohen's d=0·39). Interpretation: The results of this study show that the NEVERMIND system is superior to standard care in reducing and preventing depressive symptoms among patients with the studied somatic conditions. Funding: The NEVERMIND project received funding from the European Union's Horizon 2020 Research and Innovation Programme under grant agreement No. 689691.
Full-text available
Background This study aimed to validate the psychometric properties of the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF) questionnaire for use in a rural district of Bangladesh. Methods This cross-sectional study recruited a multi-stage cluster random sample of 2425 participants from the rural district Narail of Bangladesh in May–July 2017. Rasch analysis was carried out using the sampled participants, as well as multiple validation random sub-samples of 300 participants, to validate four domains of the WHOQOL-BREF questionnaire: physical, psychological, social and environmental. Results The original WHOQOL-BREF appeared to be a poor fit for both sampled and sub-sampled group of participants in Narail district in all underlying domains: physical, psychological, social and environmental. Two items (sleep and work capacity) from the physical domain, two items (personal belief and negative feelings) from the psychological domain and three items (home environment, health care and transport) from the environment domain were excluded for goodness of fit of the Rasch model. The social domain exhibited reasonably reliable fitness while fulfilling all the assumptions of the Rasch model. A modified version of the WHOQOL-BREF questionnaire using five-items for the physical (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\upchi}_{(20)}^2 $$\end{document}χ202 = 36.47, p = 0.013, Person Separation Index (PSI) = 0.773), four-items for the psychological (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\upchi}_{(16)}^2 $$\end{document}χ162 = 28.30, p = 0.029, PSI = 0.708) and five-items for the environmental (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ {\upchi}_{(20)}^2 $$\end{document}χ202 = 36.97, p = 0.011, PSI = 0.804) domain was applied, which showed adequate internal consistency, reliability, unidimensionality, and similar functioning for different age-sex distributions. Conclusions The modified WHOQOL-BREF questionnaire translated into Bengali language appeared to be a valid tool for measuring quality of life in a typical rural district in Bangladesh. Despite some limitations of the modified WHOQOL-BREF questionnaire, further application of Rasch analysis using this version or an improved one in other representative rural areas of Bangladesh is recommended to assess the external validity of the outcomes of this study and to determine the efficacy of this tool to measure the quality of life at the national rural level. Electronic supplementary material The online version of this article (10.1186/s12913-019-4026-0) contains supplementary material, which is available to authorized users.
Full-text available
Purpose: Psychological well-being is a growing concern in society. It is starting to play a pivotal role in the treatment and care of clients. This study aimed to evaluate the effect of age, sex and socioeconomic status on the self-esteem, body image and quality of life of the 2008 Sichuan earthquake amputees. Many of them are at a significant stage in their lives, especially those who are making the transition from childhood and adolescence into adulthood.Methods: This cross-sectional study was conducted in October 2015. Forty-five participants were recruited from clinic sessions in Sichuan. The main outcome measures were Rosenberg Self-Esteem Scale (RSE), Chinese Amputee Body Image Scale (CABIS), and WHO Quality of Life-Bref Instrument (WHO-QOL-Bref). Results were analysed using Student’s T-test and Chi-square test where appropriate, and ANOVA for multi-group comparisons.Results: Participants under 18 years of age scored higher in RSE (p=0.05), and lower in CABIS (p<0.005). They also scored higher in various QOL domains (D3: p<0.08, D4: p=0.06) and WHOQOL-Bref question 2 (p=0.06). Participants of different SES did not show any significant differences in the outcome measures. Female subjects scored higher in WHOQOL-Bref Question 1 (p=0.03).Conclusion and Implication: Younger amputees have less body image distortion, higher quality of life and self-esteem compared to older amputees. Female amputees also appear to have a higher quality of life compared to male amputees. Socioeconomic status does not affect rehabilitation outcome and psychological well-being of amputees. However, the main factors affecting psychological well-being appear to be predominantly age and, possibly, gender.
Full-text available
Background: The majority of lower limb amputations are undertaken in people with peripheral arterial occlusive disease, and approximately 50% have diabetes. Quality of life is an important outcome in lower limb amputations; little is known about what influences it, and therefore how to improve it. Objectives: The aim of this systematic review was to identify the factors that influence quality of life after lower limb amputation for peripheral arterial occlusive disease. Methods: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science and Cochrane databases were searched to identify articles that quantitatively measured quality of life in those with a lower limb amputation for peripheral arterial occlusive disease. Articles were quality assessed by two assessors, evidence tables summarised each article and a narrative synthesis was performed. Study design: Systematic review. Results: Twelve articles were included. Study designs and outcome measures used varied. Quality assessment scores ranged from 36% to 92%. The ability to walk successfully with a prosthesis had the greatest positive impact on quality of life. A trans-femoral amputation was negatively associated with quality of life due to increased difficulty in walking with a prosthesis. Other factors such as older age, being male, longer time since amputation, level of social support and presence of diabetes also negatively affected quality of life. Conclusion: Being able to walk with a prosthesis is of primary importance to improve quality of life for people with lower limb amputation due to peripheral arterial occlusive disease. To further understand and improve the quality of life of this population, there is a need for more prospective longitudinal studies, with a standardised outcome measure. Clinical relevance This is of clinical relevance to those who are involved in the rehabilitation of persons with lower limb amputations. Improved quality of life is associated with successful prosthetic use and focus should be directed toward achieving this.
Full-text available
Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India. A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.
Full-text available
Objective: To determine the effects of age, cause of amputation, and anatomic level of amputation on the health related quality of life (HRQOL) in individuals with unilateral lower limb amputation. Study design: Across-sectional survey. Place and duration of study: The Armed Forces Institute of Rehabilitation Medicine, from August 2014 to February 2015. Methodology: Short Form-36 (SF-36) health related quality of life (HRQOL). Survey questionnaire was used to collect data. The responses were scored by using the quality metric health outcomes™ scoring software 4.5. The scores were entered and analysed in SPSS version 21. Results: Atotal of 52 patients were inducted with mean age of 30.71 ±7.50 years. Mean physical component summary (PCS) was lower than mental component summary (MCS) (38.7 vs. 44.8). RP and RE scores were found to be significantly associated with gender (p=0.024 and p=0.003, respectively). Age group was also significantly associated with RP(p=0.037) and SF (p=0.041). When SF-36 domains were compared with level of amputation (i.e. trans-tibial and transfemoral), none of the domains showed any statistically significant results. Conclusion: Age and indication affect different aspects of quality of life but level of amputation did not. If these are known and anticipated before any type of rehabilitation, this could help in anticipation of health consequences and prevention accordingly.
Full-text available
Background: Healthy life expectancy (HALE) and disability-adjusted life-years (DALYs) provide summary measures of health across geographies and time that can inform assessments of epidemiological patterns and health system performance, help to prioritise investments in research and development, and monitor progress toward the Sustainable Development Goals (SDGs). We aimed to provide updated HALE and DALYs for geographies worldwide and evaluate how disease burden changes with development. Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for all-cause mortality, cause-specific mortality, and non-fatal disease burden to derive HALE and DALYs by sex for 195 countries and territories from 1990 to 2015. We calculated DALYs by summing years of life lost (YLLs) and years of life lived with disability (YLDs) for each geography, age group, sex, and year. We estimated HALE using the Sullivan method, which draws from age-specific death rates and YLDs per capita. We then assessed how observed levels of DALYs and HALE differed from expected trends calculated with the Socio-demographic Index (SDI), a composite indicator constructed from measures of income per capita, average years of schooling, and total fertility rate. Findings: Total global DALYs remained largely unchanged from 1990 to 2015, with decreases in communicable, neonatal, maternal, and nutritional (Group 1) disease DALYs offset by increased DALYs due to non-communicable diseases (NCDs). Much of this epidemiological transition was caused by changes in population growth and ageing, but it was accelerated by widespread improvements in SDI that also correlated strongly with the increasing importance of NCDs. Both total DALYs and age-standardised DALY rates due to most Group 1 causes significantly decreased by 2015, and although total burden climbed for the majority of NCDs, age-standardised DALY rates due to NCDs declined. Nonetheless, age-standardised DALY rates due to several high-burden NCDs (including osteoarthritis, drug use disorders, depression, diabetes, congenital birth defects, and skin, oral, and sense organ diseases) either increased or remained unchanged, leading to increases in their relative ranking in many geographies. From 2005 to 2015, HALE at birth increased by an average of 2·9 years (95% uncertainty interval 2·9–3·0) for men and 3·5 years (3·4–3·7) for women, while HALE at age 65 years improved by 0·85 years (0·78–0·92) and 1·2 years (1·1–1·3), respectively. Rising SDI was associated with consistently higher HALE and a somewhat smaller proportion of life spent with functional health loss; however, rising SDI was related to increases in total disability. Many countries and territories in central America and eastern sub-Saharan Africa had increasingly lower rates of disease burden than expected given their SDI. At the same time, a subset of geographies recorded a growing gap between observed and expected levels of DALYs, a trend driven mainly by rising burden due to war, interpersonal violence, and various NCDs. Interpretation: Health is improving globally, but this means more populations are spending more time with functional health loss, an absolute expansion of morbidity. The proportion of life spent in ill health decreases somewhat with increasing SDI, a relative compression of morbidity, which supports continued efforts to elevate personal income, improve education, and limit fertility. Our analysis of DALYs and HALE and their relationship to SDI represents a robust framework on which to benchmark geography-specific health performance and SDG progress. Country-specific drivers of disease burden, particularly for causes with higher-than-expected DALYs, should inform financial and research investments, prevention efforts, health policies, and health system improvement initiatives for all countries along the development continuum.
Depression has been estimated to have an increased prevalence amongst allpopulation and particularly among diseased population. Objectives: To determine prevalenceof depression among amputees after major traumas by using Beck Depression Inventory(BDI), in different hospitals of Rawalpindi and Islamabad. Methodology: A descriptive Crosssectional survey was done with a sample of 110 amputees of age between 15-60 years, indifferent hospitals of Rawalpindi and Islamabad. The study duration was completed from 1stJune 2013 to 1st January 2014. Details of data were collected through structured questionnaire.Questionnaire contained causes responsible for this depression and Beck’s Inventory Score tomeasure level of depression. Results: According to the data analyzed results shows that outof 110 amputees 28(25.5%) were having no depression, 35(31.8%) were mildly depressed,16(14.5%) were borderline depressed, 14(12.7%) were moderately depressed, 8(7.3%) wereseverely depressed and 9 (8.2%) were extremely depressed according to BDI. Conclusions:The current study suggests that amputees in sample have mostly mild mood disturbance BDI,as they were following rehabilitation and using assistive devices which reduces the impact ofdisability and dependency and helps coping with depression. Sample selection was from thosehospitals of Rawalpindi and Islamabad where a proper Rehabilitation setup was working and alot of emphasis was laid on the Rehabilitation regime after Amputation. So on the whole mostlypatients were mildly depressed according to BDI.
Objective: This longitudinal multisite study examined the influence of demographic characteristics, psychological reactions, functionality, coping strategies, and social support on psychosocial adjustment to lower limb amputation 10 months after surgery. Method: Of an initial referral of 206 Portuguese patients, a sample of 86 patients who underwent a lower limb amputation due to Diabetes Mellitus Type II were evaluated during the hospitalization that preceded surgery (t0) and at inpatient follow-up consultations, 1 (t1), 6 (t2), and 10 months (t3) after surgery. Results: Higher levels of anxiety symptoms and functionality at presurgery were associated with lower social adjustment to amputation and with higher adjustment to the limitations (t3) respectively. Traumatic stress symptoms (t1) were negatively associated with general and social adjustment, and with the adjustment to the limitations (t3). Perceived social support (t2) mediated the relationship between traumatic stress symptoms (t1) and adjustment to the limitations (t3). Male gender was associated with a higher anxiety and depression symptoms (t0) and with a higher level of functionality (t1). Male gender was associated with functionality at presurgery and postsurgery, and with anxiety and depression symptoms of presurgery. Implications: Results support the need to improve psychological screening and early treatment of anxiety symptoms before the surgery, as well as depression and traumatic stress symptoms after a lower limb amputation, and the promotion of social support over time, in order to promote psychosocial adjustment to amputation. This set of psychosocial variables should be included when planning postamputation rehabilitation and psychosocial intervention programs for this target population. (PsycINFO Database Record