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.     

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

     

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.     

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.     

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.     

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.     

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.     

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.     

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].     

Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study

OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.     

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   

Rehabilitation in dual disability of hemiplegia and upper extremity amputation: two case reports

Dual disability involving amputation and hemiplegia is relatively rare. The vast majority of these cases involve lower extremity amputations. In this report two patients sustained a right-sided hemiplegia complicating an old left upper extremity amputation. Through the comprehensive rehabilitation program these two patients were able to make gains, especially in some activities of daily living and in lower extremity functions. Since some of the upper extremity activities, such as dressing or bathing, could not be accomplished, it appears that patients with upper extremity amputation who have a contralateral hemiplegia have a poorer prognosis for achieving functional independence than patients with lower extremity amputation and similar neurologic loss.     

Postacute care services use for dysvascular amputees: a population-based study of Massachusetts

OBJECTIVE: Rehabilitation and other postacute care services utilization for persons with a lower limb amputations due to dysvascular disease is important information for physiatrists, therapists, patients, and health-policy planners. The purpose of this study was to examine rates of inpatient rehabilitation services use in a statewide population. DESIGN: Massachusetts Hospital Case Mix and Charge Data for 1997 were used to select persons with dysvascular limb amputations. Disposition locations after amputation were analyzed. RESULTS: There were 2487 persons who incurred a lower limb amputation, with the majority being white (94%), male (58%), and elderly (69 yrs). Most had diabetes (62%) or peripheral vascular disease (51%). The most common disposition was home (33%), with 16% receiving inpatient rehabilitation after amputation. Persons with transtibial and transfemoral amputations were the most likely to receive inpatient rehabilitation, 28% and 19% respectively. CONCLUSIONS: Sixteen percent of dysvascular amputees received inpatient rehabilitation services. This was higher than the 1997 rate for Maryland (12%) and suggests geographic differences in services utilization. Prospective studies are necessary to examine outcomes for persons receiving rehabilitation services in different care settings to define the optimal rehabilitation venue for functional restoration. Development of more specific International Classification of Diseases, Ninth Revision-Clinical Modification codes for dysvascular amputations would further research and public policy efforts.     

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.     

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.     

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.

Implications for Rehabilitation

• Cognitive impairment appears to be more prevalent among persons with lower limb amputations than in the general population.

• Cognitive impairment is negatively associated with mobility, prosthesis use, and maintenance of independence following amputation.

• Cognitive screening prior to rehabilitation could assist in determining patients’ suitability for prosthetic or wheelchair use, ascertaining appropriate goals, and tailoring rehabilitation to patients’ strengths so as to optimise their mobility and independence.

     

Identifying diabetic patients at high risk for amputation.

Lower-extremity amputation is a much feared complication of diabetes mellitus; however, 40% to 50% of these amputations are preventable. Peripheral neuropathy has been implicated as a cause in some 82% of diabetic amputations. Patient education on foot care is often not enough to prevent foot ulceration and potential amputation. Health care providers can lower the incidence of lower extremity amputation by using a Semmes-Weinstein monofilament to identify protective sensation loss and quickly taking measures to prevent ulceration. Diabetes patients who have a history of foot deformity, ulceration, or amputation of any part of the foot should be referred for special shoes or orthotics. This article reviews the methods for identifying those patients with diabetes that are at high risk for amputation and preventive interventions.     

Use of administrative data to risk adjust amputation rates in a national cohort of medicare-enrolled veterans with diabetes

BACKGROUND: A reduction in diabetes-related lower extremity amputations is a national health care priority. OBJECTIVE: To develop a risk adjustment model for total amputation rates, using claims data. RESEARCH DESIGN: A retrospective longitudinal cohort analysis of veteran clinical users of the Veterans Health Administration (VHA)--Veterans with diabetes who were Medicare nonhealth maintenance organization enrolled in 1997 or 1998. Baseline risks ascertained in 1997 to 1998 were used to adjust Veterans Integrated Service Networks (VISN) amputation rates in 1999. MEASURES: Individual-level amputation outcome in VHA and private hospitals in 1999; VISN-level amputation rates adjusted for age, gender, race, foot risk factors, and macro- and microvascular complications; and rankings of 22 VISNs on amputation rates. RESULTS: A total of 218,528 patients incurred 3077 (14.1 per 1000) amputations in 1999, with 10.6 to 18.0 amputations per 1000 across 22 VISNs. Age, gender, race, prior amputation, infections, ulcers, peripheral vascular disease, and vascular complications were significant independent predictors of amputation (R = 0.20); demographic variables accounted for < 1% of the variance. The C statistic of the final model was 0.83. VISN rankings using age-, gender-, and race-adjusted rates were not substantially altered compared with rankings using the full risk-adjusted model (Spearman rank correlation, 0.85). CONCLUSION: Addition of foot risk and comorbidity variables increased the discrimination of a predictive model for total amputations in an elderly, largely male population of veterans with diabetes compared with use of demographic data alone. The authors suggest that this model be validated in other settings with availability of individual-level claims data.     

Prevalence of risk factors predisposing to foot problems in patients on hemodialysis.

A disturbingly high prevalence of single or bilateral lower extremity amputations in our program prompted us to conduct a study to identify the prevalence of risk factors that predispose patients on hemodialysis (HD) to foot problems. The study consisted of a one-time assessment of subjects' risk for and actual prevalence of amputation. The sample consisted of 232 subjects--56% male, 44% female. Ages ranged from 21-91 years, mean age 65.1 and median age 69 years. The most common comorbidities were hypertension (75%), coronary artery disease (50%), diabetes (42.2%), hyperlipidemia (34.9%), and peripheral vascular disease (27.2%), which are all established risk factors for peripheral arterial occlusive disease. Twenty-one percent of subjects were current smokers; 28% were former smokers. Nearly 13.4% of subjects had undergone amputations ranging from single toes to bilateral above knee amputations. Only 31% of subjects had both bilateral palpable pedal pulses present. Neuropathy, as evidenced by the inability to feel the application of monofilaments to 10 sites on each foot or the presence of symptoms, was present in 74.6% of subjects. Only 2.6% of subjects demonstrated comprehensive self-care behaviors (SCBs). With respect to subjects' ability for self-care, 75% of subjects had adequate vision, 60% adequate dexterity, and 55% adequate flexibility to perform self-care. Study findings confirmed impressions that patients are at considerable risk for foot complications. Implications for nursing practice include regular foot assessment, education for self-care, and referral to specialists when required.