Quality of life in persons with lower limb amputations

INTRODUCTION

India is home to many individuals with disabilities living in the community.¹ In India, traumatic accidents are one of the commonest causes of lower-limb amputations.² Traumatic amputations can lead to lifelong functional limitations and injury in young as well as adolescents.³ They lead to irreversible disability and can change one's life and functions immensely, which is experienced more by individuals with lower-limb amputations.⁴ Additionally, challenges like learning to care, walking with an amputated leg, and adapting and coping with the loss of a limb are experienced by people with lower-limb amputations.⁵ An amputation leads to several limitations in performing professional and much other leisure and social activities.⁶ Due to decreased mobility, discomfort and physical integrity compromises the human body's integrity and decreases the quality of life (QOL). Patients are affected not only psychologically but also socially.⁴ Individuals with lower limb amputations have experienced a variety of psychological problems. Depression is estimated to affect 28% of amputees and 3.6-10.6% of the general population. Higher levels of pain and anxiety are common in amputees.⁷ In recent times, Quality of life (QOL), has been recognized as an important outcome of rehabilitation programes.⁴ The Short-Form health survey (SF-36), assesses health through 8 components which are categorized as Physical Component Summary (PCS) and Mental Component Summary (MCS) scores in which higher score implies a better QOL⁴ The QOL is likely to get affected adversely in individuals with lower-limb amputations and has been reported to be lower in individuals with lower-limb amputations compared to able-bodied individuals.⁷

Objectives

The objective of the present study was to assess the QOL in individuals with lower limb amputations via telephone.

METHODS

This was an observational study. The study was carried out at REHABS clinic, Vadodara, Gujarat, which is an orthotic and prosthetic clinic. Individuals above 18 years of age, both genders, individuals with transfemoral and transtibial amputation were included in the study. Individuals with complete loss of vision, hearing, cognition, and upper limb amputations were excluded from the study. The study was carried out from July 2020 to June 2021. Convenient sampling method was used. All the individuals with lower limb amputations who came to REHABS clinic and fulfilled the inclusion criteria were approached on the telephone and given a detailed explanation of the study. Informed consent was taken over the telephone from those who were willing to participate. In addition to demographic data; employment status, type and duration of amputation, associated comorbidities, use of prosthesis and its duration, and use of any assistive device were also asked. The outcome measure SF 36 was taken over the telephone.

Statistical analysis

All the statistical analysis was performed using SPSS version 22.0 software. Descriptive statistics including mean, standard deviations, and standard error were computed for all variables. Normal distribution was assessed by the Kolmogorov Smirnov test. An independent t-test was used for comparing the bilateral and unilateral types of amputations among males and females with lower limb amputations. One-way ANOVA was used to see the difference between various levels of amputations. The level of significance was set at p<0.05.

RESULTS

The demographic details of amputation-related variables are presented in (Table 1). There were total of 140 individuals with lower limb amputations, 119 males and 21 females. Participants mean age was 46.77±14.9 years. A statistically significant difference in QOL between individuals with unilateral and bilateral amputations for Energy/Fatigue component of QOL (p=0.017) (Table 2).

A statistically significant difference in QOL between the genders in the physical functioning and general health component of QOL (p=0.001) and (p=0.038) respectively is depicted in (Table 3). There was no statistically significant difference found in individuals with unilateral bilateral amputations depending on levels of amputations as shown in (Table 4-5).

QOL-Quality of Life, SF-36-Short Form 36

DISCUSSION

Amputation is a major life event that is known to affect QOL many years after the event.³ Various factors which affect the QOL are employment status, use of assistive device or prosthesis and problems associated with it, comorbidities, phantom limb pain, depression, age and societal support and social activity participation.^4,5 The number of males with lower-limb amputations in the present study was 119, which comprises more than three-fourths of the population.

Several other studies ^3,4,5,8 have also observed a higher prevalence of amputations among males. Nearly two-thirds of all individuals in the present study underwent amputation due to trauma, which is in line with various studies ^9-12 that report trauma to be the main cause of amputation in developing countries.

It is reported that individuals with bilateral amputations walk with increasing difficulty and their gait is less efficient compared to individuals with unilateral amputations.¹³ However, our study found a significant difference in the Energy/Fatigue component of QOL between individuals with bilateral and unilateral amputations, in favor of the bilateral group. The probable reason for this could be that the mean duration of amputation was 16 years in the bilateral group which shows a long duration since amputation. Individuals with lower-limb amputations must have adjusted/adapted to their condition during this long duration and hence had a better QOL. Prosthesis usage has been shown to influence QOL positively.¹⁴ In our study 34% of individuals wore the prostheses for >8 hours a day and 19% wore for 4 to 8 hours and 23% removed the prosthesis only while sleeping which shows good compliance with prosthesis use. A study also reported that QOL and the use of prosthesis increase parallelly, as individuals get accustomed to prosthesis use and limb loss and ultimately improve the QOL.¹⁴

Secondly, 15 out of 17 individuals with bilateral amputations were employed in the present study. Employment status is also a predictor of a QOL and is known to influence QOL positively.⁴ Also, only 5 in the bilateral group had comorbidities like diabetes mellitus and hypertension, which are known to affect QOL negatively. There was a statistically significant difference found between males and females in the component of Physical Functioning in QOL. This suggests that males were much more active physically and had better mobility.

Traditionally, males are the family’s primary breadwinners and are involved in performing moderate to vigorous activities, climbing several flights of stairs; walking several blocks, etc. One of the reasons for better physical function in males could be that out of 119, 80 (67%) were employed. So, for work purposes, they would have to go out every day, and in the process, walk some distance, climb stairs and be physically active. On the other hand, most of the females (19) were housewives who were involved in household chores and were limited to the house except for running a few errands and socializing.⁴

Our study did not find a significant difference in QOL in individuals with different amputation levels. The number of individuals with trans-tibial amputation was 92 (65.7%) and 39 (27.8%) had transfemoral amputation which included even bilateral amputation. 54 (45.3%) of them were young adults who fell in the 20 to 40 years age group and 52 (37.1%) fell in the 41-60 age group. The present study administered the SF-36 to individuals with lower-limb amputations via telephone due to the COVID-19 pandemic.

It took approximately 20-30 minutes to administer this questionnaire and some individuals were not very forthcoming and willing to answer questions. As reported by a study,¹⁵ there was no significant difference between QOL when self-administered or administered via telephone. Telephonic administration had the advantages of better understanding, better response rates, took less time and fewer missing items over self-administration.¹⁵

Limitations

All the individuals with amputations were recruited from only one orthotic and prosthetic clinic. The individuals self-reported the details regarding amputation and were not derived from the medical records. Complications due to amputation, which can affect QOL, were not assessed.

CONCLUSION

Physical functioning and the general health components of QOL were better in males as compared to females. Individuals with bilateral amputations had more energy compared to individuals with unilateral amputations and hence had a better QOL.

ACKNOWLEDGEMENTS

Authors would like to thank Dr. Veerendra Shandilya, Director of the REHABS clinic Vadodara for allowing us to recruit patients from his clinic.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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