Sexuality in persons with lower extremity amputations

Purpose : There is a paucity of information regarding sexual functioning in persons with lower extremity amputations. The purpose of this study was to describe sexual and psychological functioning and health status in persons with lower extremity amputation. Methods : Self-report surveys assessed sexual functioning (Derogatis Inventory), depression (Beck Depression Inventory, anxiety (State-Trait Anxiety Inventory), and health status (Health Status Questionnaire) in a convenience sample of 30 men with lower extremity amputations. Mean age of the participants was 57 years (range 32-79). Mean duration since amputation was 23 months (range 3-634 months). Twenty one subjects (70%) had trans-tibial and seven subjects (23%) had trans-femoral amputations. Results : A majority of subjects were experiencing problems in several domains of sexual functioning. Fifty three percent ( n = 16) of the subjects were engaged in sexual intercourse or oral sex at least once a month. Twenty seven percent ( n = 8) were masturbating at least once a month. Nineteen subjects (63%) reported orgasmic problems and 67% were experiencing erectile difficulties. Despite these problems, interest in sex was high in over 90% of the subjects. There was no evidence of increased prevalence of depression or anxiety in these subjects when compared to other outpatient adult populations. Conclusions : Sexual problems were common in the subjects studied. Despite these problems, interest in sex remained high. Few investigations have been directed toward identifying the psychological and social factors that may contribute to these problems and more research with a larger population is needed in this area.     

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

OBJECTIVE: To examine the long-term outcomes of persons undergoing trauma-related amputations, and to explore factors affecting their physical, social, and mental health and the role of inpatient rehabilitation in improving such outcomes. DESIGN: Abstracted medical records and interview data sought for a retrospective cohort of persons who had undergone a lower-limb trauma-related amputation. PARTICIPANTS: Patients identified with a principal or secondary diagnosis of a trauma-related amputation to the lower extremity at the University of Maryland Shock Trauma Center between 1984 and 1994. Patients with spinal cord injury or traumatic brain injury were excluded. RESULTS: Of 146 patients who had trauma-related amputations to the lower limb at the University of Maryland Shock Trauma Center during the study period, nearly 9% died during the acute admission and 3.5% died after discharge. About 87% of all trauma-related amputations involved males, and roughly three quarters involved white persons. About 80% of all amputations occurred before age 40. The health profile of traumatic amputee subjects interviewed in the study (n = 78, 68% response rate) was systematically lower than that of the general US population for all SF-36 scores. The differences in profiles were largest among SF-36 scales sensitive to differences in physical health status, particularly physical functioning, role limitations due to physical health, and bodily pain. About one fourth of persons with a trauma-related amputation reported ongoing severe problems with the residual limb, including phantom pain, wounds, and sores. The number of inpatient rehabilitation nights significantly improved the ability of patients with amputation to function in their physical roles, increased vitality, and reduced bodily pain. Inpatient rehabilitation was also significantly correlated with improved vocational outcomes. CONCLUSIONS: These findings suggest a substantial effect of inpatient rehabilitation in improving long-term outcomes of persons with trauma-related amputations.     

Sex after amputation: the relationships between sexual functioning,body image,mood and anxiety in persons with a lower limb amputation

Aim: The study examined the relationships between psychological variables and sexual functioning in persons with lower limb amputations.

Method: Sixty-five participants (n?=?49 males, n?=?16 females) with lower limb amputations completed a battery of self-report questionnaires regarding their current psychological well-being and their current sexual activity. Measures included the anxiety items on the Hospital Anxiety and Depression Scale, the Beck Depression Inventory – Second Edition, Body Image Quality of Life Inventory, Body Exposure Self-Consciousness during Intimate Situations and the Golombok-Rust Inventory of Sexual Satisfaction.

Results: Half of all participants with lower limb amputations were not currently sexually active. Approximately 60% of those who were sexually active scored within the clinical range for overall sexual dysfunction. Overall levels of sexual dysfunction were associated with significantly higher levels of anxiety (r?=?0.40, p?r?=?0.41, p?r?=?0.56, p?Conclusions: Psychological challenges following limb loss are strongly associated with levels of sexual dysfunction. The study highlights the need for psychological and psychosexual assessment and intervention following limb loss to enhance sexual functioning and overall quality of life.

• Implications for Rehabilitation

• Only half of the participants with a lower limb amputation were sexually active. Over 60% of those who were sexually active reported clinical levels of sexual dysfunction. One third of the entire sample scored within the clinical range for depression and for anxiety.

• Depression, anxiety and body image issues were significantly associated with sexual dysfunction in the current sample of individuals with lower limb amputation.

• There is a need for psychosexual assessment following limb loss to ensure that appropriate and timely interventions are made available. Interventions that target the psychological factors related to sexual dysfunction are likely to improve overall quality of life for these individuals

     

Sexuality and sexual adjustment of patients with chronic pain

Purpose: To describe sexual functioning and its relationship with psychological measures in chronic pain patients.

Method: It is a self report survey with a convenience sample. Seventy consenting chronic pain patients responded to a questionnaire. Mean age was 49-9 years (range 29–74); mean pain duration was 146–7 months (range 6–624). Participants endorsed a wide variety of pain conditions.

Instruments used: (1) Derogatis Inventory of Sexual Functioning; (2) Multidimensional Pain Inventory; (3) Center for Epidemiological Studies Depression Scale; (4) Multidimensional Health Locus of Control; (5) Hopkins Symptom Check List; (6) Vanderbilt Pain Management Inventory; (7) Coping Strategies Questionnaire.

Results: Sixty-six per cent of patients were interested in sex, 50% were satisfied with current sexual partner and 20% considered current sexual life to be adequate. Over 70% fantasized at least once a month. Only 44% experienced normal arousal during intercourse; 33% practiced masturbation and 47 % were involved in sexual intercourse or oral sex at least once a month. The majority were dissatisfied with orgasmic activities. No relationship was found between pain severity, duration, frequency and sexual functioning. A relationship was found between disability status, age and several psychological variables and various domains of sexual functioning.

Conclusions: Sexual problems are common in chronic pain patients. Patients who reported symptoms of depression and distress had more sexual problems.     

A two-year longitudinal study of social support following amputation

Purpose: (1) To describe one aspect of social support, social integration, longitudinally for 2 years following lower limb amputation and (2) to explore the impact of social support on depression, pain interference, life satisfaction, mobility, and occupational functioning.

Method: Eighty-nine adults recruited from consecutive admissions to an orthopaedic surgery service completed telephone interviews 1, 6, 12 and 24 months following amputation surgery. Dependent variables included the Social Integration (SI) sub-scale of the Craig Handicap Assessment and Reporting Technique (CHART) and the Multidimensional Scale of Perceived Social Support (MSPSS).

Results: There was a high level of SI among most persons following lower limb amputations that was relatively unchanged in the 2 years following surgery. However, mean levels of SI were lower in this group compared to a sample without disabilities. MSPSS scores were highly variable, ranging from almost no support to the maximum amount of support. MSPSS was an important concurrent predictor of pain interference, life satisfaction, and mobility, controlling for demographic and amputation-related factors. Baseline MSPSS predicted mobility and occupational functioning 6 months post-amputation, controlling for demographic and amputation-related factors.

Conclusions: Findings suggest that interventions aimed at improving the quality of social relationships after amputation may facilitate participation in activities.     

Evaluation of prosthetic usage in upper limb amputees

Purpose: Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method: The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results: Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion: No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Performance of persons with juvenile-onset amputation in driving motor vehicles

OBJECTIVE: To study the driving of motor vehicles by persons with juvenile-onset amputation and to compare the percentage of drivers among them with that found in the general population. DESIGN: A follow-up study of subjects who were younger than 18 years of age at amputation and who underwent one-sided amputation, covering the period 1976 to 1996. SETTING: The Prosthesis Service of the Asturias Central Hospital, Spain. SUBJECTS: A total of 236 juvenile amputee patients. RESULTS: The percentage of women with amputations who drive is lower than that of their male counterparts (p<.05). The percentage of drivers with upper limb amputations is greater than that of drivers with amputation of the lower limb (p<.05). Motor vehicle adaptations were used more frequently by people with upper limb amputations (p<.05). The ability to drive was not affected by the etiology or the side of amputation, or by the use of a prosthesis. The level of amputation affected driving ability in cases of amputation of the lower limb, but not in those of amputation of the upper limb. CONCLUSION: The percentage of persons with juvenile-onset amputation who drive (47.4%) is similar to that found in the general population (40.8%), and the use of a prosthesis does not have any influence on the capacity to drive a car--89.2% of drivers and 93.5% of nondrivers used a prosthesis.     

Factors that influence the level of activities in persons with lower extremity amputation

This study explored the problems of prosthesis use in four dimensions of activity in 122 males and 9 females, aged 24 to 90 years, with lower extremity amputations. Comparisons were made between persons with above-the-knee amputation and those with below-the-knee amputation. A four-dimensional prosthetic problem inventory scale developed by the investigators was used. Results of this study provide a framework for identifying and addressing problematic areas in the use of prostheses.     

Predictors of return to work following traumatic work-related lower extremity amputation

Purpose. To determine factors predictive of return to work (RTW) and days of total disability (TD) in a population of persons working at the time of lower extremity amputation.

Method. Retrospective chart and database review.

Results. Of 88 valid cases, 48% involved toe amputation, 23% transtibial, 14% partial foot, 14% transfemoral, and 2% high level. Fifty-eight percent of all subjects RTW, 19% were deemed 'fit for work', and 23% did not RTW. Days TD ranged from 0 to 1664, with a mean of 366 days. Toe amputation level showed a mean of 127 days of TD. Bivariate analysis showed amputation level, total costs to Workers Compensation Board (WCB), and days TD significantly related to RTW, and rehabilitation costs, vocational rehabilitation, work assessment, age, number of surgical procedures, number of days in acute care, and amputation level significantly related to days TD. In the multivariate model, only amputation level and higher gross annual income showed predictive value for RTW. However older age, more surgical procedures, less days in hospital, and higher amputation levels were all predictive of increased days TD.

Conclusion. Toe amputation level had a surprisingly high number of days TD, which may have significant potential economic and disability impact on the workplace. Other factors beyond simply amputation level (such as previous income level) are important considerations for RTW.     

Death and venous thromboembolism after lower extremity amputation

Summary. Background: Lower extremity amputation is often performed in patients with end‐stage vascular disease and is considered a high‐risk procedure. Uncertainty exists about the rate of venous thromboembolism (VTE) in these patients. Objectives: To establish the incidence of death and venous thromboembolism after lower extremity amputation. Methods: A prospective cohort study was performed to establish the incidences of death and VTE after lower extremity amputation, as detected by bilateral complete compression ultrasonography and ventilation‐perfusion scintigraphy performed preoperatively and around day 14 postoperatively. Standard low‐molecular‐weight heparin thromboprophylaxis was given during the study period. A secondary outcome was the incidences of mortality and symptomatic venous thromboembolic complications during 8 weeks of postoperative follow‐up. Results: Forty‐nine patients (53 amputations) were ultimately included in the intention‐to‐treat analysis. Five patients died within the 2‐week period and an additional seven patients died during the 8 weeks clinical follow‐up period. The total mortality rate therefore was 12 of 53 amputations [22.6%; 95% confidence interval (CI), 12.3–36.2%]. Six patients developed pulmonary embolisms (of which two were fatal) and one patient developed an asymptomatic contralateral distal deep venous thrombosis, resulting in a total VTE rate of 7 out of 53 amputations (13.2%; 95% CI, 5.47–25.3%). Conclusion: Lower extremity amputation is accompanied by a high mortality rate from sepsis, and respiratory and vascular causes. This study shows that VTE substantially contributes to the morbidity and mortality after lower extremity amputation despite adequate pharmacological thromboprophylaxis in this vulnerable population of patients.     

Balance confidence among people with lower-limb amputations

BACKGROUND AND PURPOSE: Confidence in a person's balance has been shown to be an important predictor of social activity among people with lower-limb amputations. The purposes of this study were to describe confidence in balance among people with transtibial or transfemoral lower-limb amputations and to compare people whose amputations were due to vascular and nonvascular causes. SUBJECTS AND METHODS: A survey of a sample of 435 community-dwelling individuals from 2 regional clinics was conducted. The sample consisted of people with unilateral transfemoral (26.7%) and transtibial (73.3%) amputations who lost their limb for vascular (53%) and nonvascular (47%) reasons. The mean age of the primarily male (71%) sample was 62.0 years (SD=15.7). RESULTS: Mean scores, using the Activities-specific Balance Confidence (ABC) Scale, were 63.8 for the total sample, 54.1 for the subjects with amputations due to vascular reasons, and 74.7 for the subjects with amputations due to nonvascular reasons. Given a maximum possible ABC Scale score of 100, the results suggest that confidence was low. A difference between the subjects with amputations due to vascular reasons and those with amputations due to nonvascular reasons was observed over each item of the ABC Scale. Variables that were statistically related to balance confidence included age, sex, etiology, mobility device use, the need to concentrate while walking, limitations in activities of daily living, depression, and fear of falling. DISCUSSION AND CONCLUSION: Balance confidence scores among the study sample were low when compared with values previously reported by other researchers. Confidence was particularly low among individuals who had their amputation for vascular reasons. Balance confidence might be an important area of clinical concern.     

Back pain as a secondary disability in persons with lower limb amputations

OBJECTIVE: To evaluate the frequency, duration, intensity, and interference of back pain in a sample of persons with lower limb amputations. DESIGN: Retrospective, cross-sectional survey. SETTING: Community-based survey from clinical databases. PARTICIPANTS: Participants who were 6 or more months post lower limb amputation (n = 255). INTERVENTION: An amputation pain survey that included several standardized pain measures. MAIN OUTCOME MEASURES: Frequency, duration, intensity, and interference of back pain. RESULTS: Of the participants who completed the survey (return rate, 56%), 52% reported experiencing persistent, bothersome back pain. Of these, 43% reported average back pain intensity in the mild range (1-4 on 0-10 rating scale) and 25% reported pain of moderate intensity (5-6 on 0-10 scale). Most respondents with back pain rated the interference of their pain on function as none to minimal. However, nearly 25% of those with back pain described it as frequent, of severe intensity (>or=7 on 0-10 scale), and as severely interfering with daily activities including social, recreational, family, and work activities. CONCLUSIONS: Back pain may be surprisingly common in persons with lower limb amputations, and, for some who experience it, may greatly interfere with function.     

Gait evaluation of a transfemoral prosthetic simulator

OBJECTIVE: To test a prosthetic simulator developed to allow persons without amputation to walk like a person with a transfemoral (TF) amputation. PATIENTS: Five able-bodied subjects; comparison with data from the literature on persons with TF amputations. SETTING: Motion analysis laboratory. DESIGN: Two 45- to 60-minute gait training sessions before subjects walked along a 10-meter walkway. There were 6 trials: 3 walking with a cane, 3 without a cane. MAIN OBJECTIVE MEASURES: Sagittal plane kinematic and kinetic analysis of ankle, knee, and hip: angular velocity, joint moment, and power. RESULTS: Kinematic and kinetic analyses showed that joint mechanics during walking were similar between the test subjects and comparative results from persons with TF amputations (reported in the literature). Test subjects walked slower and moved their hip and knee joints faster (higher angular velocity values during the terminal swing) than the TF amputee subjects, although these results were not statistically significant (p < .05). These findings were consistent with new prosthetic users who are more tentative during gait training. However, a perfect simulation would show no difference in kinematic results. CONCLUSION: These results support the use of a TF prosthetic simulator to help health care professionals experience the process of fitting the prosthesis from the client's perspective.     

Physiological responses to multiple speed treadmill walking for Syme vs. transtibial amputation--a case report

Purpose: To date, there have been no longitudinal studies comparing walking at different levels of amputation. The objective of this study was to compare the self-selected walking velocity (SSWV) and selected physiologic variables during walking between a Syme and a later transtibial level of amputation for a single subject. Additional comparison was made between the SACH foot prosthesis and a dynamic response foot prosthesis.

Method: A 35-year-old male with a traumatic Syme amputation later underwent elective transtibial amputation. SSWV and multiple speed treadmill walking tests (53.64, 67.05, 80.46, 93.87 and 107.28 m/min) were evaluated under three conditions (Syme prosthesis with SACH foot, transtibial prosthesis with SACH foot, and transtibial prosthesis with Flex-Foot).

Results: Walking with transtibial prosthesis showed minimal differences in oxygen consumption (0 - 5% reduction), heart rate response (0 - 1% reduction), or gait efficiency (0 - 5% improvement) across all speeds when compared with Syme prosthesis (both with SACH foot). However, the SSWV was 6 - 8% faster for the transtibial SACH foot. Walking with transtibial Flex-Foot required less cardiovascular demand than with transtibial SACH foot at higher speeds.

Conclusions: In this case report, it seemed that transtibial amputation did not have adverse effects on selected physiological responses at a variety of walking speeds when compared to Syme amputation, and that the use of a dynamic response foot enhanced his gait performance. Further experimental studies involving more subjects with traumatic Syme and transtibial amputations are required to better understand the effect of these two levels of amputation on energy cost of walking.     

The 2-minute walk test as a measure of functional improvement in persons with lower limb amputation

OBJECTIVE: To determine the construct validity and responsiveness of the 2-minute walk test as a measure of function in individuals with lower extremity amputation. DESIGN: The distances walked in 2 minutes were compared with the results on the physical functioning subscale of the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36) and the Houghton Scale. SETTING: Regional amputee rehabilitation program. PATIENTS: Retrospective data from 290 patients (mean age, 66yr) with unilateral transtibial, unilateral transfemoral, or bilateral amputations. INTERVENTION: Repeated testing. MAIN OUTCOME MEASURES: Distance walked in 2 minutes, SF-36 (aggregated into physical and mental composite scores), and the Houghton score. We also examined the change in the distance before and after a rehabilitation program. RESULTS: The distance walked in 2 minutes showed a weak correlation with the physical functioning subscale of the SF-36 (r = .22, p = .008) and a moderate correlation with the total Houghton score at discharge from rehabilitation (r = .493, p 相似文献   

Cognitive functioning in persons with lower limb amputations: a review

Purpose: To review the literature on cognitive functioning in persons with lower limb amputations. Method: A search of the MEDLINE, PsycINFO and Web of Science databases was carried out. Results: Thirty papers were found that met the inclusion criteria. The studies were characterised by heterogeneity of design, methodological quality, sample characteristics, assessment of cognitive functioning, and outcomes examined. The research published to date suggests that cognitive impairment is more prevalent among persons with lower limb amputations than in the general population, and is linked with a number of important outcomes in this patient group, including mobility, prosthesis use, and maintenance of independence following amputation. Conclusions: These findings highlight the importance of assessing the cognitive abilities of persons with lower limb amputations. An understanding of the cognitive profile of these patients could assist rehabilitation teams in determining their suitability for prosthetic or wheelchair rehabilitation, ascertaining appropriate and realistic goals for rehabilitation, and tailoring rehabilitation programmes to patients' strengths so that maximal mobility and independence is achieved. [Box: see text].     

Psychosocial adaptation to amputation: the role of sociodemographic variables, disability-related factors and coping strategies

This study examined the roles of sociodemographic variables, disability-related factors, and coping strategies as predictors of the psychosocial adaptation of 61 persons with amputations. Psychosocial adaptation was conceptualized as a multifaceted outcome criterion and was measured by seven scales from the Reactions to Impairment and Disability Inventory (RIDI) and the Acceptance of Disability (AD) scale. A series of multiple regression analyses indicated that both a set of sociodemographic variables and disability-related factors (age, duration of amputation, type of amputation) and a set of coping strategies (action problem-solving, emotion-focusing, behavioral/problem disengagement, cognitive disengagement) accounted, albeit differentially, for significant portions of the variance in the outcome measures of psychosocial adaptation to amputation. Of the various coping strategies, active problem-solving was negatively associated with the psychosocial reactions of depression and internalized anger (RIDI) but it was positively associated to adjustment (RIDI) and acceptance of disability (AD). Emotion-focusing and cognitive disengagement were positively associated with anxiety, depression, and externalized hostility (RIDI) and negatively associated with acceptance of disability (AD). Measurement and theoretical implications are briefly outlined.