Comprehensive Neuropsychological Assessment of Cognitive Functioning of Adults With Lower Limb Amputation in Rehabilitation.

OBJECTIVE: To establish a comprehensive profile of cognitive functioning in people engaged in lower limb amputation (LLA) rehabilitation. DESIGN: Cross-sectional study as part of a longitudinal prospective cohort. SETTING: A national tertiary rehabilitation hospital. PARTICIPANTS: Adult volunteer participants (N=87) referred for comprehensive rehabilitation for major LLA were sampled from 207 consecutive admissions. Participants with both vascular (n=69) and nonvascular (n=18) LLA etiologies were included. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and health information and a battery of standardized neuropsychological assessments. RESULTS: Compared to normative data, impairment was evident in overall cognitive functioning (P≤.003). Impairment was also evident in particular areas, including reasoning, psychomotor function, information processing, attention, memory, language/naming, visuospatial functions, and executive functions (all P≤.003 Holm-corrected). There were also higher frequencies of impaired functions across most aspects of functioning in this group compared with expected frequencies in normative data (P≤.003 Holm-corrected). There were no significant differences in cognitive functioning between participants of vascular and nonvascular LLA etiology. CONCLUSIONS: Findings support the need for cognitive screening at rehabilitation admission regardless of etiology. Administration of comprehensive neuropsychological assessment with a battery sensitive to vascular cognitive impairment is recommended in some cases to generate an accurate and precise understanding of relative strengths and weaknesses in cognitive functioning. Cognitive functioning is a potential intervention point for improvement of rehabilitation outcomes for those with LLA, and further research is warranted in this area.

Goal management tendencies predict trajectories of adjustment to lower limb amputation up to 15 months post rehabilitation discharge.

OBJECTIVES: To explore patterns of change in positive affect, general adjustment to lower-limb amputation, and self-reported disability from rehabilitation admission to 15 months postdischarge, and to examine whether goal pursuit and goal adjustment tendencies predict either initial status or rates of change in these outcomes, controlling for sociodemographic and clinical covariates. DESIGN: Prospective cohort study with 4 time points (t1: on admission; t2: 6wk postdischarge; t3: 6mo postdischarge; t4: 15mo postdischarge). SETTING: Inpatient rehabilitation. PARTICIPANTS: Consecutive sample (N=98) of persons aged ≥18 years with major lower-limb amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Positive affect subscale of the Positive and Negative Affect Schedule; general adjustment subscale of the Trinity Amputation and Prosthesis Experience Scales-Revised; and World Health Organization Disability Assessment Schedule 2.0. RESULTS: Positive affect decreased from t1 to t4 for the overall sample, whereas general adjustment increased. Self-reported disability scores remained stable over this period. Stronger goal pursuit tendencies were associated with greater positive affect at t1, and stronger goal adjustment tendencies were associated with more favorable initial scores on each outcome examined. With regard to rates of change, stronger goal pursuit tendencies buffered against decreases in positive affect and promoted decreases in self-reported disability over time, whereas stronger goal adjustment tendencies enhanced increases in general adjustment to lower-limb amputation. CONCLUSIONS: Greater use of goal pursuit and goal adjustment strategies appears to promote more favorable adjustment to lower-limb amputation over time across a range of important rehabilitation outcomes.

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

PURPOSE: To examine the impact of residual limb osteomyelitis (RLO) on the rehabilitation of lower limb amputees. METHOD: Retrospective review of the case notes of patients with RLO. Information sought included details of amputation, clinical features of investigations for and management of RLO and its effect on rehabilitation. RESULTS: There were seven transfemoral and three transtibial amputees. Indications for amputation were vascular disease in nine cases, trauma in one. In each case, delayed wound healing or residual limb pain prompted radiological, hematological and microbiological investigations. Average time between amputation and diagnosis was 187 days. One patient died before treatment commenced. Two transtibial amputees were treated with intravenous antibiotics while rehabilitating using pylons. The remaining seven transfemoral amputees required surgical intervention and intravenous antibiotics. Five achieved independent ambulation following modification to or replacement of the originally cast prosthesis, averaging 408 days between amputation and commencement of rehabilitation. Two patients have not engaged in rehabilitation. CONCLUSION: RLO delays rehabilitation and has significant financial implications, incurred by prolonged hospitalisation, radiological investigations and prosthetic modifications. RLO should be considered in any case of delayed wound healing or residual limb pain in amputees, as earlier diagnosis may reduce the time to commencement of rehabilitation and subsequent independent ambulation.

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 < 0.005), depression (r = 0.41, p < 0.015) and body exposure self-consciousness during sexual activities (r = 0.56, p < 0.005). Body image self-consciousness during sexual activities was the strongest predictor of sexual dysfunction. 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.

Establishing the Turkish version of the SIGAM mobility scale, and determining its validity and reliability in lower extremity amputees.

PURPOSE: The aim of this study is to adapt the Special Interest Group in Amputee Medicine (SIGAM) mobility scale to Turkish, and to test its validity and reliability in lower extremity amputees. MATERIAL AND METHODS: Adaptation of the scale into Turkish was performed by following the steps in American Association of Orthopedic Surgeons (AAOS) guideline. Turkish version of the scale was tested twice on 109 patients who had lower extremity amputations, at hours 0 and 72. The reliability of the Turkish version was tested for internal consistency and test-retest reliability. Structural validity was tested using the "scale validity" method. For this purpose, the scores of the Short Form-36 (SF-36), Functional Ambulation Scale (FAS), Get Up and Go Test, and Satisfaction with the Prosthesis Questionnaire (SATPRO) were calculated, and analyzed using Spearman's correlation test. RESULTS: Cronbach's alpha coefficient was 0.67 for the Turkish version of the SIGAM mobility scale. Cohen's kappa coefficients were between 0.224 and 0.999. Repeatability according to the results of the SIGAM mobility scale (grades A-F) was 0.822. We found significant and strong positive correlations of the SIGAM mobility scale results with the FAS, Get Up and Go Test, SATPRO, and all of the SF-36 subscales. CONCLUSION: In our study, the Turkish version of the SIGAM mobility scale was found as a reliable, valid, and easy to use scale in everyday practice for measuring mobility in lower extremity amputees. Implications for Rehabilitation Amputation is the surgical removal of a severely injured and nonfunctional extremity, at a level of one or more bones proximal to the body. Loss of a lower extremity is one of the most important conditions that cause functional disability. The Special Interest Group in Amputee Medicine (SIGAM) mobility scale contains 21 questions that evaluate the mobility of lower extremity amputees. Lack of a specific Turkish scale that evaluates rehabilitation results and mobility of lower extremity amputees, and determines their needs, directed us to perform a study on this topic when we took the number of amputations performed in our country into consideration. SIGAM mobility scale is directed at rehabilitation specialists who are working in amputee medicine. Turkish version of this scale was found both reliable and valid in our study and hence it can be used in clinical practice and studies.

Beyond function: Using assistive technologies following lower limb loss.

OBJECTIVE: To explore how individuals experience and perceive the use of assistive technologies following lower limb loss. DESIGN: Cross-sectional qualitative interview design. PATIENTS: Thirty individuals with lower limb amputation were recruited from a multi-disciplinary rehabilitation programme (26 males and 4 females); comprising individuals with above-knee (n=16), below-knee (n=12) and bilateral (n=2) amputations. Patients were at least 15 months post-rehabilitation, at least 18 years old and spoke English. METHODS: Semi-structured interviews were conducted via telephone or in person. Interview data were inductively thematically analysed by a researcher who had no previous contact with participants. RESULTS: Three key themes were identified: "It didn't feel part of me" - Heightened awareness and experiences of distance from prostheses following lower limb loss; "Depending on others is really tough" - Independence through assistive technologies; and "I feel confident with this leg" - The value of prosthesis use following amputation. CONCLUSION: The findings demonstrate that individuals with lower limb loss perceive and experience assistive technologies to have uses in ways beyond their potential for functional restoration. They may also attribute meanings and values relating to such technologies that may influence their use. Ascertaining and being aware of individuals' experiences and perceptions of assistive technologies is important for lower limb loss rehabilitation.

Transcultural validation of the SIGAM mobility grades in French: The SIGAM-Fr.

BACKGROUND: The main French language scales evaluating functioning after lower-limb amputation have not undergone exhaustive psychometric validation. OBJECTIVE: A transcultural validation of the Special Interest Group in Amputee Medicine (SIGAM) mobility grades questionnaire, with 21 closed questions, as an administered questionnaire. METHODS: The questionnaire translation, back-translation and original-author validation was followed by a pretest with 5 patients to check comprehension. The psychometric properties of the scale were validated with 49 patients at the definitive prosthesis stage by an investigator via telephone. Criterion validity was evaluated by comparison with the Houghton Scale score and construct validity by correlation between the questionnaire scores and convergent dimensions (performing everyday activities and performing transfers on a numerical rating scale [NRS], 2-min walk test) and divergent dimensions (managing medication and stump skin care on an NRS). Internal consistency was assessed by the Kuder-Richardson Formula 20 (KR-20) coefficient and test-retest reproducibility by the Cohen kappa coefficient. RESULTS: The resulting questionnaire was validated by the original author after the back-translation. It showed good psychometric properties when administered by an investigator as a self-reporting questionnaire, excellent criterion validity (r=0.89, P<0.01), excellent reproducibility (kappa coefficient 0.87) and satisfactory construct validity. The KR-20 coefficient was 0.67. CONCLUSION: The French version of the SIGAM mobility grades questionnaire (SIGAM-Fr) has satisfactory psychometric properties and can be administered in clinical practice.

Goal pursuit, goal adjustment, and affective well-being following lower limb amputation.

OBJECTIVES: This study examined the relationships between tenacious goal pursuit (TGP), flexible goal adjustment (FGA), and affective well-being in a sample of individuals with lower limb amputations. DESIGN: Cross-sectional, quantitative. METHODS: Ninety-eight patients recently admitted to a primary prosthetic rehabilitation programme completed measures of TGP, FGA, positive affect, and negative affect. RESULTS: Hierarchical regression analyses revealed that TGP and FGA accounted for a significant proportion of the variance in both positive and negative affect, controlling for sociodemographic and clinical characteristics. TGP was significantly positively associated with positive affect, while FGA was significantly negatively associated with negative affect. Moderated regression analyses indicated that the beneficial effect of FGA on negative affect was strongest at high levels of amputation-related pain intensity and low levels of TGP. DISCUSSION: TGP and FGA appear to influence subjective well-being in different ways, with TGP promoting the experience of positive affect and FGA buffering against negative affect. TGP and FGA may prove useful in identifying individuals at risk of poor affective outcomes following lower limb amputation and represent important targets for intervention in this patient group. STATEMENT OF CONTRIBUTION: What is already known on this subject? The loss of a limb has a significant impact on several important life domains. Although some individuals experience emotional distress following amputation, the majority adjust well to their limb loss, with some achieving positive change or growth as a result of their experiences. Theories of self-regulation propose that disruptions in goal attainment have negative affective consequences. The physical, social, and psychological upheaval caused by limb loss is likely to threaten the attainment of valued goals, which may leave individuals vulnerable to negative psychosocial outcomes if they do not regulate their goals in response to these challenges. According to the dual-process model of adaptive self-regulation, individuals manage discrepancies between perceived and desired goal attainment by either modifying their life situation or behaviour to fit their goals (tenacious goal pursuit [TGP]) or adjusting their goals to situational constraints (flexible goal adjustment [FGA]). Examining psychosocial adjustment to amputation from this perspective may offer some insight into the diversity of affective outcomes observed. What does this study add? Contributes to our understanding of the mechanisms underlying adjustment to acquired disability. Offers a theory-based explanation for the diversity of psychosocial outcomes observed post-amputation. Identifies important targets for interventions to enhance adjustment in this population.

Understanding the benefits of prosthetic prescription: exploring the experiences of practitioners and lower limb prosthetic users.

PURPOSE: While lower limb prosthetic prescription is reliant on many physical indicators, it is clear that psychosocial factors need to be emphasised to a greater extent within this field if the needs of users are to be appropriately addressed. The aim of this study is to explore and identify the outcomes of prosthetic prescription through qualitative inquiry. METHOD: Six focus groups with prosthetic service users and 10 semi-structured interviews with service providers were conducted and then analysed with inductive thematic analysis. RESULTS: The outcomes identified were: independence, not being in a wheelchair, balance and safety, improved quality of life and reaching potential. CONCLUSIONS: These emergent themes challenge the predominating focus on physical functioning that many practitioners have. These findings are important for developing a user-based model of service provision and outcome evaluation.