A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

PURPOSE: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries. METHOD: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist. RESULTS: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status. CONCLUSIONS: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

Purpose: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries.

Method: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist.

Results: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status.

Conclusions: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

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.     

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.     

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.     

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.     

Mirror treatment of lower limb phantom pain: A case study

Purpose:?Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that ‘mirror treatment’ can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic ‘mirror treatment’ for lower-limb phantom pain.

Method:?We present the first case study of the use of ‘mirror treatment’ in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results:?During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion:?This case study, conducted in a conventional clinical setting, supports the potential of ‘mirror treatment’ for PLP in people with a lower limb amputation.     

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.     

A cross-sectional study of post-amputation pain in upper and lower limb amputees,experience of a tertiary referral amputee clinic

Purpose.?To determine the pain characteristics and health-related quality of life (HR-QOL) of upper and lower limb amputees.

Method.?Amputees attending the Prince of Wales Prosthetic Clinics in 2006 were administered a questionnaire survey of their pain experiences, Short form McGill pain questionnaire, Short Form 36 (SF 36) and Pain Self-Efficacy Questionnaire (PSEQ).

Results.?Of the 17 who were upper limb amputees (including the two multiple limb amputees), only 1 was pain free and of the 39 who were lower limb amputees 14 were pain free. Upper limb amputees experienced significantly greater proportion, frequency and severity of post-amputation pain than lower limb amputees. The presence of significant pre-operative pain did not correlate with the development of persistent post-amputation pain. In quality of life measures, the amputees experienced a better physical function, role physical and confidence in performance of activities than chronic pain patients attending the pain clinic. Lower limb amputees fared better than upper limb amputees in terms of bodily pain, social function and mental health. However, the amputee groups have a reduced health status in almost all domains compared to the aged matched Australian population norm.

Conclusions.?The study suggests that upper limb amputees are significantly more likely to suffer post-amputation pain which is more frequent, longer lasting and more severe in intensity when compared to lower limb amputees. This is accompanied by reduced HR-QOL especially that related to bodily pain, social function and mental health. The overall health status of amputees are also significantly lower compared to the Australian population norm.     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization. Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation. Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

Recovery-related anxiety and disability following upper limb injury: the importance of context

Abstract

Purpose: Anxiety following traumatic upper limb injury is common and may affect rehabilitation outcomes. Most previous research has focused on psychiatric anxiety disorders among those with severe injuries. The aims of this study were to determine the prevalence of anxiety among patients with mild to moderate traumatic upper limb injuries, to investigate the correlation between anxiety and disability, and to provide preliminary validation of the Recovery-Related Anxiety Questionnaire (RRAQ). Method: Eighty-four adults with a recent traumatic upper limb injury completed the State & Trait Anxiety Inventory (STAI), the Pain Anxiety Symptoms Scale (PASS-20), the RRAQ and the shortened Disability of the Arm, Shoulder and Hand Questionnaire (QuickDASH). Prevalence rates of anxiety were calculated and linear regression analysis was used to identify predictors of QuickDASH scores. Results: All participants reported some anxiety, with higher levels of recovery-related anxiety than general anxiety. In linear regression analysis, the four types of anxiety accounted for 29% of the variability in QuickDASH scores. The RRAQ accounted for 19% of the variability in QuickDASH scores. Conclusions: Recovery-related forms of anxiety appear to be more common and more strongly associated with disability than general anxiety symptoms for patients with mild to moderate traumatic upper limb injuries.

• Implications for Rehabilitation

• Following mild to moderate traumatic upper limb injury, anxiety about the injury and recovery is common.

• Recovery-related anxiety is more strongly associated with disability than general anxiety symptoms.

• Phrasing questions about anxiety directly associated with the recovery experience may give greater insight into the anxiety patients with mild to moderate upper limb injuries are experiencing.

• This insight may help clinicians to directly address recovery-related issues, potentially decreasing disability experienced by patients.

     

Management of the multiple limb amputee

Issue : Multiple limb amputations involving at least one upper extremity are very uncommon. The amputation of both an upper and lower limb is even more uncommon. Due to the rarity of these amputations therapists are uncertain regarding the most appropriate treatment methods. While the majority of the protocols used for single limb amputations are appropriate for these multiple limb amputees, there are differences. Loss of multiple limbs creates a problem of overheating for the individual. Loss of an arm and leg results in difficulty donning the prostheses and difficulty using crutches and parallel bars during mobilization.

Method : A review is given of 16 multiple limb amputees seen in our rehabilitation centre in the last 15 years. Return to work was seen in one third and was not related to the number of the amputations. A higher proportion of these multiple limb amputations occur through alcoholism or attempted suicide behaviour than occurs with either single upper limb amputations or lower limb amputations. This existing behaviour can create a management problem for the rehabilitation team during rehabilitation.

Conclusion : Guidelines as to appropriate prosthetic and preprosthetic care are provided to assist the practitioner who has the acute and long term care of these patients. All multiple limb amputees should be referred to a specialized rehabilitation centre to discuss prosthetic options and long term rehabilitation requirements. This paper does not discuss bilateral lower limb amputations when not combined with an upper limb amputation.     

A prospective study examining balance confidence among individuals with lower limb amputation

Purpose:?In this study we assessed whether balance confidence scores changed over a 2-year follow up period, and identified predictors of balance confidence and predictors of change in balance confidence among lower limb amputees.

Method:?A prospective follow-up survey of 245 community living adults with unilateral below and above knee lower limb amputation who used their prosthetic limb daily was conducted. Balance confidence, assessed using the 16-item Activity-specific Balance Confidence (ABC) Scale, socio-demographic, health and amputation related variables were collected at baseline and 2 years later.

Results:?ABC scores were similar at baseline (mean?= 67.6; SD?=?25.7) and follow up (mean?=?68.0; SD?=?25.8). Lower balance confidence scores at follow up were predicted by older age, being female, use of a mobility device, poor perceived health, increased symptoms of depression, having to concentrate while walking, and fear of falling (all p?<?0.05). Predictors of change in balance confidence included gender and perceived health (all p?<?0.05).

Conclusion:?Balance confidence appears to be a persistent problem in the amputee population. Health professionals are encouraged to consider balance confidence as a potentially important variable that may influence function in this clinically unique group of individuals. The identified predictor variables may be useful to clinicians in targeting individuals who require attention to improve balance confidence.     

Relationship between self-reported upper limb disability and quantitative tests in hand-arm vibration syndrome

Purpose. To establish the relationship between quantitative tests of hand function and upper limb disability, as measured by the Disability of the Arm, Shoulder and Hand (DASH) questionnaire, in hand-arm vibration syndrome (HAVS).

Method. A total of 228 individuals with HAVS were included in this study. Each had undergone a full HAVS assessment by an experienced physician, including quantitative tests of vibrotactile and thermal perception thresholds, maximal hand-grip strength (HG) and the Purdue pegboard (PP) test. Individuals were also asked to complete a DASH questionnaire.

Results. PP and HG of the quantitative tests gave the best and statistically significant individual correlations with the DASH disability score (r² = 0.168 and 0.096). Stepwise linear regression analysis revealed that only PP and HG measurements were statistically significant predictors of upper limb disability (r² = 0.178). Overall a combination of the PP and HG measurements, rather than each alone, gave slightly better discrimination, although not statistically significant, between normal and abnormal DASH scores with a sensitivity of 73.1% and specificity of 64.3%.

Conclusions. Measurements of manual dexterity and hand-grip strength using PP and HG may be useful in helping to confirm lack of upper limb function and ‘perceived’ disability in HAVS.     

How ‘preventable’ are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors

Purpose: Clinicians commonly believe that lower extremity amputations are potentially preventable with coordinated care and motivated patient self-management. We used in-depth interviews with recent amputees to assess how patients viewed their initial amputation risk and causes. Method: We interviewed 22 patients at a rehabilitation hospital 2–6 weeks after an incident amputation. We focused on patients’ representations of amputation cause and methods of coping with prior foot and leg symptoms. Results: Patients reported unexpected onset and rapid progression of ulceration, infection, progressive vascular disease, foot trauma and complications of comorbid illness as precipitating events. Fateful delays of care were common. Many had long histories of painful prior treatments. A fatalistic approach to self-management, difficulties with access and communication with providers and poor understanding of medical conditions were common themes. Few patients seemed aware of the role of smoking as an amputation risk factor. Conclusions: Most patients felt out of control and had a poor understanding of the events leading to their initial amputations. Prevention of subsequent amputations will require rehabilitation programs to address low health literacy and psychosocial obstacles to self-management.

Implications for Rehabilitation

• Among amputees, pre-amputation perceptions of decisional and informational control are known to affect rehabilitation and disability adjustment prospects.

• Our findings on patient perceptions of their experiences with an initial lower extremity amputation are salient to rehabilitation specialists working with amputees to avoid a proximal or contralateral amputation.

     

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.     

Impact of pain in vertebral column on activities of daily living in the Iranian amputees with bilateral lower limb amputation

Purpose: To determine the impact of pain in the vertebral column on the activities of daily living (ADL) level of war victims with bilateral lower limb amputation. Method: All the war-related bilateral lower limb amputees were invited. More than half of them (n?=?335) participated and underwent a thorough assessment after giving informed consent. Results: The majority of the participants were male (97.6%). Their mean age was 42 years and 97.6% of them were married. The most common causes of injury leading to amputation were shells of artillery and mortar (56.7%). The most common level of amputation was bilateral transtibial (37.6%) and 64% were wearing the prosthesis of both sides. The most ADL dependency were transfer activities (27.8%) and bathing (23.3%) and the most independent functioning was eating (97.6%). Upper cervical vertebral pain was associated with dependency in the bowel and bladder management and dressing (p < 0.03 and p < 0.04, respectively). Pain in the lower cervical vertebrae was associated with dependency in toileting and dressing (p < 0.01 and p < 0.01, respectively). There were significant relationships between pain in the thoracic vertebrae and dependency in bathing, transfer activities and toileting (p < 0.02, p < 0.003 and p < 0.03, respectively). Pain in the lumbosacral region had a relationship with the level of amputation, transfer activities and toileting (p < 0.006, p < 0.03 and p < 0.05, respectively). Conclusions: Vertebral pain in bilateral lower limb amputees, especially lumbosacral pain, was accompanied with higher dependency in ADL. Therefore, a multidisciplinary approach to the management of pain is required to minimize disability and maximize functioning.

Implications for Rehabilitation

• As common as back pain in the general population, some studies have found that people with lower limb amputation are at even greater risk of back pain and interference with their lifestyle.

• The results of this study suggest that after bilateral lower extremity amputations, some patients experience various kinds of pain in the spinal column, which may affect their activities of daily living.

• A multidisciplinary approach to the management of pain is necessary to minimize disability and maximize functioning in these patients.

     

An investigation to determine the association between neck pain and upper limb disability for patients with non-specific neck pain: a secondary analysis

This study investigated the relationship between neck pain and upper limb disability in patients with non-specific neck pain (n = 151) recruited from physiotherapy departments in the United Kingdom. Baseline neck pain/disability was measured using the Northwick Park Neck Pain Questionnaire (NPQ). Baseline upper limb disability was measured using the Disabilities of Arm, Shoulder, Hand questionnaire (DASH). A range of baseline psychosocial variables were measured as potential confounding variables. Pairwise analysis revealed a positive correlation between NPQ score and DASH score (Pearsons’ r = 0.799, p < 0.001). After adjusting for potential confounding variables, stepwise linear regression indicated that increasing upper limb disability was predicted by two baseline variables: higher NPQ scores (B = 0.743) and lower pain self efficacy (PSE) scores (B = −0.489) {R² = 0.713; n = 100, p < 0.001}. This study provides preliminary evidence that patients with severe neck pain/disability also report severe upper limb disability. The relationship between neck pain/disability and upper limb disability was mediated by PSE. Clinically, the presence of severe neck pain or low PSE should direct clinicians towards an assessment of upper limb function. In these cases upper limb disability may need to be addressed as part of the neck management process.