Characterization

Limb loss is characterized by amputation etiology (e.g., traumatic, dysvascular), by the limb(s) affected (e.g., arm, leg) and by amputation level (e.g., below knee amputation (BKA), above knee amputation (AKA)). The context of amputation is often important. In traumatic amputations, the loss of the limb may be one of multiple injuries and may occur after attempts to salvage the injured limb are unsuccessful. In the context of diabetes and peripheral dysvascular disease, amputations may be required to manage non-healing wounds or infections. In such planned amputations, the underlying medical conditions that require the amputation often have a significant impact on other areas of health and functioning (e.g., renal and vision compromise). For planned major amputation surgeries necessitated by chronic disease, the anatomic level of amputation is determined on a case-by-case basis, considering demographic and health factors. Health care teams must balance the probability of survival and healing from the surgery (which is generally better if the amputation is at a higher anatomic level, often because an additional revision surgery to a higher level is less likely to be required) with the potential for good mobility/function (which is improved with a lower anatomic amputation level [1]).

Amputation

Prostheses and Orthoses

Prostheses are frequently used by persons with limb loss either alone or in combination with orthoses or aids (e.g., crutches, canes). Prosthesis use is an option for many individuals with amputations, including those with hemipelvectomy or hip disarticulation. Close collaboration with a certified Prosthetist/Orthotist is essential to identify, fabricate, and adjust equipment in an ongoing way. Many prosthesis choices are available; decisions about specific prostheses are related to function, comfort, appearance, cost, and insurance coverage. Individuals may require a range of prostheses for different activities (e.g., some prostheses are designed for certain sports or for use in water). Ongoing management is required to maintain a functional prosthesis and factors like weight gain or loss, postural changes, and comorbidities may necessitate ongoing prostheses adjustments.

Demographic Considerations

Because amputation is one of several surgical options for managing lower level ischemia, lower extremity wounds and infections, and other dysvascular conditions, there is some level of discretion and variation in clinical practice. Several large studies have identified disparities in the rate and type of amputations performed, with women, non-whites and individuals with lower income being more likely to receive amputation instead of a revascularization procedure [6–8], and more likely to have transfemoral amputations than amputations at a lower level [6]. There is also evidence that variations in regional practice and institution type influence amputation decisions; for example, there is elevated risk of amputation compared to revascularization based on non-teaching status of the institution [7]. For the rehabilitation psychologist, these socioeconomic status and hospital factors are important contextual contributions that influence functional outcomes, quality of life, and our understanding of the amputee’s experience.

Limb Salvage vs . Limb Amputation

Long-term functional outcomes after limb salvage are comparable to those with limb amputation, but tend to involve more hospitalizations and surgeries [9]. In a study of military veterans with serious lower extremity injuries, those with amputation within 90 days of injury had significantly fewer mental health problems and received more outpatient care compared to individuals who underwent salvage or amputations more than 90 days after injury. In the Military Extremity Trauma Amputation/Limb Salvage study [10] participants with amputation had better scores in all domains than those whose limbs had been salvaged, as well as lower likelihood of PTSD and higher likelihood of engagement in vigorous sports.

Assessment : Similar to other types of pain, pain intensity (sometimes referred to as severity) is typically measured via 0–10 numeric rating scales (0 meaning “no pain,” 10 as “the worst pain imaginable”). Pain interference with usual activities can similarly be measured with a 0–10 scale or via the interference scale of the Brief Pain Inventory (BPI) [17]. Assessment of potentially modifiable behaviors impacting pain such as activity level, fear avoidance of movement, pain catastrophizing (unhelpful thoughts about pain), and coping skills is also recommended for treatment planning [14].

Intervention : Ideally, nonpharmacological pain management strategies should be taught and encouraged in the postoperative and rehabilitation settings as a “first-line” intervention, given the high risk of developing some form of chronic pain. Such strategies may augment other medical and rehabilitation interventions for pain. Anticonvulsants such as gabapentin or pregabalin are commonly prescribed for neuropathic pain; nonsteroidal anti-inflammatory medications and antidepressants such as duloxetine may also be used for pain, including musculoskeletal pain. Interventions such as self-management training, cognitive behavioral therapy, hypnosis, and mindfulness are recommended to decrease pain and its negative effects on functioning, mood, and quality of life. An emerging, promising treatment for painful and nonpainful phantom sensations is mirror therapy, which involves the use of a mirror to create the illusion of movement of a removed limb [18].