Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group

Purpose.?To assess how upper limb amputation affects mental health and life satisfaction.

Method.?Cross-sectional study comparing the mental health and perceived satisfaction with life among adult acquired major upper limb amputees in Norway with a control group drawn from the Norwegian general population. The scales used were the Satisfaction With Life Scale (SWLS) and the Hopkins Symptom Check List 25-item (SCL-25). The groups were compared using multiple linear regression analyses.

Results.?The amputees scored significantly lower on life satisfaction than the control group. A tendency to poorer mental health in the amputee group was observed, but there was no clear evidence of such a difference. The amputation effect on life satisfaction seemed to be mediated mainly by changes in occupational status and by the occurrence of short- or long-term complications related to the amputation.

Conclusions.?Our findings imply that rehabilitation of upper limb amputees should emphasise facilitating return to work as well as the prevention of short- and long-term complications, and that this will be of importance not only for the amputees' physical function, but for the maintenance of acceptable life satisfaction. Further studies on the effect of upper limb amputation on mental health are recommended.     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

Phantom pain in bilateral upper limb amputation

Purpose.?To alert health professionals on presence and extent of phantom pain and sensation following bilateral upper limb amputation.

Methods.?Of a total of 140 war-related bilateral upper limb amputees in Iran, 103 subjects were thoroughly examined in this cross-sectional study by a physical medicine specialist. The patients were questioned for the presence of phantom pain and sensations, and frequency and intensity of the feeling were recorded.

Results.?At 17.1 ± 6.1 years after injury, 82.0% of the 103 amputees suffered from phantom sensation, including varying degrees of phantom limb pain in 53.9% of stumps. Phantom phenomena had a higher frequency in the right extremities, but this was not statistically significant (p > 0.01). Of those amputees who had phantom pain or sensation, 51.2% reported that they ‘always’ had phantom limb sensation; and approximately one-fourth of the subjects (24.6%) ‘always’ had phantom pain. Among the stumps who reported phantom pain (N = 112), the pain was excruciating (38.5%), distressing (34.9%) or discomforting (25.6%). A significant statistical relation between phantom limb sensation and level of amputation was observed (p < 0.01).

Conclusion.?At this time there is no healing for phantom pain; medical and surgical modalities only bring temporary relief, and less than 1% of the respondents achieve permanent relief through different treatment methods.     

Individual differences in response to phantom limb movement therapy

Purpose.?Phantom limb pain (PLP) is a distressing condition experienced by many amputees. The purpose of this study was to investigate whether motor imagery could be used to treat PLP.

Method.?Four single case studies were conducted. The participants kept a pain diary in which they recorded the intensity of their PLP during a baseline period, general motor imagery training, phantom limb movement therapy and a follow-up period. Qualitative and quantitative (i.e. interrupted time series) analyses were employed to determine whether phantom limb movement therapy had a significant effect on PLP intensity.

Results.?Phantom limb movement therapy significantly reduced intensity of PLP in one participant. One participant gained occasional relief by doing phantom limb movement therapy exercises but did not experience an overall reduction in PLP intensity. The third participant did not experience any relief and the fourth participant reported experiencing the re-emergence of an old pain.

Conclusion.?The results display individual differences in response to phantom limb movement therapy. Individual differences are discussed in the context of motor imagery ability and the phantom limb phenomenon as a multi-dimensional disorder.     

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.     

Six-day course of repetitive transcranial magnetic stimulation plus occupational therapy for post-stroke patients with upper limb hemiparesis: A case series study

Purpose.?To clarify the safety and feasibility of a 6-day protocol of low-frequency repetitive transcranial magnetic stimulation (rTMS) combined with intensive occupational therapy (OT) for upper limb hemiparesis.

Methods.?In-hospital combination treatment was provided for 5 post-stroke patients with upper limb hemiparesis after more than 12 months of the onset of stroke. Over 6 consecutive days, each patient received 10 sessions of combination treatment with 1?Hz rTMS and intensive OT (one-on-one training and self-training). Motor function in the affected upper limb was evaluated by Fugl-Meyer Assessment (FMA), Wolf Motor Function Test (WMFT), Ten-Second Test at admission, discharge, and 4 weeks after treatment.

Results.?All patients completed the 6-day treatment protocol and none showed any adverse effects throughout the treatment. At the end of treatment, improvements in the scores of FMA, WMFT, and Ten-Second Test were found in all patients. No deterioration of improved upper limb function was observed at 4 weeks after the treatment.

Conclusions.?Our proposed protocol of combination treatment seems to be safe and feasible for post-stroke patients with upper limb hemiparesis, although the efficacy of the protocol needs to be confirmed in a large number of patients.     

USA paralympic team archer with McCune Albright Syndrome: A retrospective case report

Purpose.?This retrospective case report describes a 22-year-old woman with McCune Albright Syndrome who was an archery Bronze Medalist at the 2008 USA Paralympic Games.

Methods.?The subject completed the Medical Outcome Survey Short Form-36 (SF-36) and the Hip Dysfunction and Osteoarthritis Score (HOOS).

Results.?SF-36 scores met or exceeded those for National Collegiate Athletic Association (NCAA) female athletes, and age and gender matched USA norms for vitality, mental health and role emotional subscales. General health was lower than NCAA female athletes. Physical functioning, role: physical, bodily pain and social functioning subscale scores were lower than both comparison groups. HOOS symptom subscale scores revealed disabilities with walking (performed with crutches), hip abduction and stair climbing.

Conclusions.?Target archery does not require the lower extremity strength and motion required by many other sports. Identifying the ideal time to undergo total hip arthroplasty is difficult. As total hip arthroplasty becomes less invasive, more durable, with greater modular options, and with lower revision rates, more young patients will likely benefit. Serial SF-36 and HOOS surveys may help patients and surgeons better delineate symptom, functional limitation and disability changes across the early lifespan assisting surgical timing decisions while balancing existing function, quality of life values and near future technological advances.     

Health promotion needs of physically disabled individuals with lower limb amputation in Rwanda

Purpose.?The objectives of the study were to identify the health-related behaviors among physically disabled individuals with lower limb amputation resident in Rwanda, the factors that influenced these behaviors, and the major issues that should be targeted in health promotion programs for physically disabled individuals with lower limb amputation.

Method.?A cross-sectional survey, utilizing a self-administered questionnaire, was carried out among 334 lower limb amputees who volunteered to take part in the study. In addition, a sub-sample of 15 participants was purposively selected for in-depth face-to-face interviews.

Results.?Many participants did not engage in physical exercises (64.7%). Others abused alcohol on daily basis (14.4%), smoked 11?–?20 cigarettes daily (13.2%), and used recreational drugs such as marijuana, opium and cocaine (9.6%). There were significant associations between the age group of the participants and participation in exercises (P?=?0.001), and consuming alcohol, tobacco and recreational drugs (P?=?0.001). In-depth interviews revealed factors influencing the behavior of participants.

Conclusions.?Participants were found to be at risk of secondary complications because of poor lifestyle choices. There is a need to develop and promote wellness-enhancing behaviors in order to enhance the health status of physically disabled individuals in Rwanda who have lower limb amputations.     

Achilles and patellar tendinopathy: Current understanding of pathophysiology and management

Purpose.?Achilles and patellar tendinopathy cause significant morbidity in professional and recreational athletes. Both the Achilles and patellar tendons are weight-bearing tendons that lack a true tendon sheath but are surrounded by paratenon.

Method.?A review of the literature to outline the characteristics of tendinopathy in these two tendons, and to discuss current concepts of pathophysiology, use of imaging in the diagnosis and aid to clinical management strategies in tendinopathy.

Results.?Achilles and patellar tendinopathy share common histopathology such as intratendinous failed healing response and neoangiogenesis.

Conclusion.?Achilles and patellar tendinopathy cause much morbidity in the athletic and non athletic population attending sports medicine and rheumatology clinics. Tendinopathy is essentially an ‘overuse’, degenerative condition. Neovascularisation evident on Doppler ultrasound correlates well with pain and poor function. Peritendinous injections and eccentric training decrease neovascularity, relieve pain and improve outcome. Although surgery is the last resort in those patients failing conservative management, it is still unclear how the removal of adhesions and excision of affected tendinopathic areas affects healing and vascularity, or resolves pain.     

Upper limb recovery after stroke: The stroke survivors' perspective

Purpose.?This study investigated stroke survivors' perspective of upper limb recovery after stroke. The aim was to determine factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize upper limb recovery.

Method.?A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke survivors (n = 19) and spouses (n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using principles of grounded theory.

Results.?Stroke survivors maximize upper limb recovery by ‘keeping the door open’ a process of continuing to hope for and work towards improvement amidst adjusting to life with stroke. They achieve this by ‘hanging in there’, ‘drawing on support from others’, ‘getting going and keeping going with exercise’, and ‘finding out how to keep moving ahead’.

Conclusions.?This study provides valuable insight into the personal experience of upper limb recovery after stroke. It highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper limb training programmes.     

Systematic review of the effectiveness of mirror therapy in upper extremity function

Purpose.?This review gives an overview of the current state of research regarding the effectiveness of mirror therapy in upper extremity function.

Method.?A systematic literature search was performed to identify studies concerning mirror therapy in upper extremity. The included journal articles were reviewed according to a structured diagram and the methodological quality was assessed.

Results.?Fifteen studies were identified and reviewed. Five different patient categories were studied: two studies focussed on mirror therapy after an amputation of the upper limb, five studies focussed on mirror therapy after stroke, five studies focussed on mirror therapy with complex regional pain syndrome type 1 (CRPS1) patients, one study on mirror therapy with complex regional pain syndrome type 2 (CRPS2) and two studies focussed on mirror therapy after hand surgery other than amputation.

Conclusions.?Most of the evidence for mirror therapy is from studies with weak methodological quality. The present review showed a trend that mirror therapy is effective in upper limb treatment of stroke patients and patients with CRPS, whereas the effectiveness in other patient groups has yet to be determined.     

Effects of paediatric limb loss on healthcare utilisation,schooling and parental labour supply

Purpose.?To explore the impact of childhood limb loss on families in terms of healthcare utilisation, schooling and parental labour supply.

Methods.?Data were obtained from a cross-sectional, retrospective pilot survey of 123 parents or caregivers of children with limb loss selected randomly after stratification by aetiology (i.e. trauma, malignancy and congenital limb deficiency) from among eligible families identified by the Amputee Coalition of America. Healthcare utilisation, school (child) and labour market (parents) participation were examined.

Results.?Children with limb loss use health services frequently and miss school for limb loss-related concerns. Over half of all parents adjusted their work participation in response to their child's limb loss. The use of prostheses may increase direct and indirect costs of limb loss. Children with acquired limb loss (amputation following trauma or cancer) were more likely than those with a congenital limb deficiency to use a prosthesis.

Conclusions.?Our data suggest that the impact of limb loss on families of affected children may include substantial costs, particularly when school and work effects are taken into account. Further research is needed to identify the full household- and societal-level costs of childhood limb loss and suggest interventions to reduce the burden experienced by families.     

Residual limb osteomyelitis: A case series from a national prosthetic centre

Purpose. To examine the impact of residual limb osteomyelitis (RLO) on the rehabilitation of lower limb amputees.

Method. Retrospective review of the casenotes of patients with RLO. Information sought included details of amputation, clinical features of investigations for and management of RLO and its effect on rehabilitation.

Results. There were seven transfemoral and three transtibial amputees. Indications for amputation were vascular disease in nine cases, trauma in one. In each case, delayed wound healing or residual limb pain prompted radiological, hematological and microbiological investigations. Average time between amputation and diagnosis was 187 days. One patient died before treatment commenced. Two transtibial amputees were treated with intravenous antibiotics while rehabilitating using pylons. The remaining seven transfemoral amputees required surgical intervention and intravenous antibiotics. Five achieved independent ambulation following modification to or replacement of the originally cast prosthesis, averaging 408 days between amputation and commencement of rehabilitation. Two patients have not engaged in rehabilitation.

Conclusion. RLO delays rehabilitation and has significant financial implications, incurred by prolonged hospitalisation, radiological investigations and prosthetic modifications. RLO should be considered in any case of delayed wound healing or residual limb pain in amputees, as earlier diagnosis may reduce the time to commencement of rehabilitation and subsequent independent ambulation.     

Guillain-Barre Syndrome – rehabilitation outcome,residual deficits and requirement of lower limb orthosis for locomotion at 1 year follow-up

Objective.?To analyse long-term functional recovery, deficits and requirement of lower limb orthosis (LLO) for locomotion in patients with Guillain-Barre Syndrome (GBS).

Design.?Prospective longitudinal follow-up study.

Setting.?Neurological Rehabilitation unit of university hospital.

Patients and Method.?Sixty-nine patients of GBS admitted for inpatient rehabilitation. Thirty-five patients (M:F, 19:16) reporting after1 year follow-up (50.72%) were included in study (between September 2005 and July 2009). Their residual deficits and requirement of LLO were recorded and analysed.

Results.?Age ranged from 4 to 65 year (29.74?±?15.75). Twenty-seven patients had typical GBS and eight patients had acute motor axonal neuropathy variant. Twenty-eight patients (80%) had neuropathic pain needing medication with 11 required more than one drug. Twenty-one patients (60%) had foot drop and advised ankle-foot orthosis-AFO (20 bilateral AFO). Thirty patients (85.71%) needed assistive devices also for locomotion at discharge. After 1 year, foot drop was still present in 12 patients (34.28%) using orthosis. Modified Barthel Index scores, Modified Rankin Scale and Hughes Disability Scale were used to assess functional disabilities. Significant recovery was observed at the time of discharge and after 1 year (p?<?0.001 each).

Conclusions.?Patients with GBS continue to show significant functional recovery for long period. They have residual deficits even after 1 year with requirement of orthosis in large number of patients.     

Multiple joint pain and lower extremity disability in middle and old age

Purpose.?To determine whether the extent of multiple-site lower extremity joint pain contributes to disability in middle and old age and describe patterns of severity in site-specific measures amongst those with multiple-site pain.

Method.?Population-based, cross-sectional postal survey. Adults aged 50 years and over registered with three general practices and reporting pain lasting one month or longer in the previous year in at least one hip, knee, or foot were included. Respondents completed a generic measure of physical function and site-specific measures of severity for each relevant joint pain.

Results.?Of 2429 eligible participants, 1801 reported multiple-site lower limb joint pain. Lower limb joint pain count was independently associated with reduced physical function after adjusting for a range of covariates. The severity of pain and disability attributed to each site increased as the number of painful sites increased.

Conclusion.?Many older people with joint pain in the lower limb have more than one joint affected. Generic and site-specific measures of disability both show the same pattern of reduced physical function. Treatment targeted at a single joint may have only a marginal effect on reducing disability in individuals with multiple joint involvement unless treatment is also conferring benefit at other sites.     

Developing stroke-specific vocational rehabilitation: a soft systems analysis of current service provision

Purpose.?To establish interrater and test–retest reliability of a clinical assessment of motor and sensory upper limb impairments in children with hemiplegic cerebral palsy aged 5–15 years.

Method.?The assessments included passive range of motion (PROM), Modified Ashworth Scale (MAS), manual muscle testing (MMT), grip strength, the House thumb and Zancolli classification and sensory function. Interrater reliability was investigated in 30 children, test–retest reliability in 23 children.

Results.?For PROM, interrater reliability varied from moderate to moderately high (correlation coefficients 0.48–0.73) and test–retest reliability was very high (>0.81). For the MAS and MMT, total score and subscores for shoulder, elbow, and wrist showed a moderately high to very high interrater reliability (0.60–0.91) and coefficients of >0.78 for test–retest reliability. The reliability for the individual muscles varied from moderate to high. The Jamar dynamometer was found to be highly reliable. The House thumb classification showed a substantial reliability and the Zancolli classification an almost perfect reliability. All sensory modalities had a good agreement.

Conclusions.?For all motor and sensory assessments, interrater and test–retest reliability was moderate to very high. Test–retest reliability was clearly higher than interrater reliability. To improve interrater reliability, it was recommended to strictly standardize the test procedure, refine the scoring criteria and provide intensive rater trainings.     

A Rasch-based validation of a short version of ABILHAND as a measure of manual ability in adults with unilateral upper limb amputation

Purpose.?To evaluate the measurement properties of ABILHAND (a generic measure developed to assess functioning in people with upper limb impairments) when used in adults with unilateral upper limb amputation (ULA).

Methods.?A convenience sample of 72 adults who had unilateral ULA and completed rehabilitation at the Institute for Rehabilitation in Ljubljana at least 1 year prior to the study. They filled in the ABILHAND questionnaire. Rating scale analysis (Rasch model) was used to evaluate functioning of the rating scale categories, the validity of the measure by examining fit of the items to the latent trait and the hierarchy of item difficulties compared with expectations of the construct.

Results.?Rasch analysis allowed us to improve ABILHAND by rescoring to reduce the response categories from 5 to 4, and identifying 22 of 46 items that are useful to measure upper limb function in people with ULA. The results indicate that high confidence can be placed in the consistency of both person-ability and item-difficulty estimates.

Conclusions.?This revised ABILHAND for people with unilateral ULA (ABILHAND-ULA 1.0) is a promising instrument for measuring their degree of manual functioning.