Psychological adjustments among lower limb amputees in North Indian population: A cross-sectional study

ABSTRACT

Introduction:

Limb amputation is an extremely stressful event for an individual, following which the amputee develops inferior body image, anxiety, and changes in self-concept and identity. For holistic rehabilitation, understanding the psychosocial status of the amputee and its’ predictors is of utmost importance.

Objective:

The aim of the article is to assess the psychological adjustments in patients with lower limb amputation and determine its clinical and sociodemographic correlates.

Material and Methods:

A observational cross-sectional study was conducted from 2020 to 2022 among lower limb amputees of a tertiary care hospital in Lucknow which serves as the only rehabilitation and artificial limb center for the whole state of Uttar Pradesh. Baseline sociodemographic and clinical data were collected. The Hospital Anxiety and Depression Scale was used to determine underlying depression and anxiety, while the Trinity Amputation and Prosthesis Experience Scale was used for understanding the psychological adjustment.

Results:

The mean age of the amputee was 39.47 ± 16.99 years. The mean general, social adjustment, and adjustment to limitation score was 16.3 ± 3.34, 15.19 ± 3.59, and 12.76 ± 3.15, respectively. Male amputees, aged >40 years, and pensioners had significantly higher scores for general adjustment (P < 0.05). Those aged >40 years were pensioners and had no underlying depression and anxiety and had better social adjustment (P < 0.05). Those with transfemoral amputation had a significantly lesser adjustment to limitation (P = 0.003).

Conclusion:

Young age amputees had poor general and social adjustments and more activity restriction but high prosthesis satisfaction as compared to the elderly. Those with transfemoral amputation had a poor adjustment to limitation while those wearing above-knee prosthesis had more activity restriction.

Limb amputation has been documented to have been an extremely stressful consequence for an amputee.[1,2] Postamputation depression decreases the well-being and quality of life of the individual, as inferior body image, anxiety, and changes in self-concept and identity become common.[2,3] The incidence of amputees is approximately 0.62 in India per 1000 population which is around 1 million amputees in the country.[4]

Life faces numerous challenges postamputation, most evidently the procedure of prosthesis fitting, accepting, and learning the usage of a prosthetic limb, and adjusting to its regular use.[5] During the rehabilitation process, positive adjustments after amputation and the use of a prosthetic limb play vital roles.[6] Prosthesis use after an amputation influences an individual’s psychosocial status and quality of life.[7]

It is of the foremost importance to accept their body and motivate them to a new self-concept and rehabilitation by using the prosthesis. This study aims to understand the psychological adjustments required for active coping of the amputee from physical and mental health and provide and motivate appropriate rehabilitation by using the prosthesis.

Objectives: The aim of the article is to assess the psychological adjustments in patients with lower limb amputation and determine the effect of clinical and sociodemographic factors on psychological adjustments.

MATERIALS AND METHODS

Study design and participants

An observational cross-sectional study was conducted from 2020 to 2022 among lower limb amputees attending the outpatient department and inpatient department of a tertiary care hospital in Lucknow which serves as the only rehabilitation and artificial limb center for the whole state of Uttar Pradesh with an approximate population of 20 crores. Hence, it has the maximum footfall of amputees residing in Northern India.

Eligibility criteria

Lower limb amputees aged more than 18 years and who gave consent were included in the study. Patients with upper limb amputations or with any associated physical disabilities apart from amputation or any psychiatric issues and associated physical disabilities other than amputation were excluded.

Sample size

The sample size was calculated based on the following formula: n = (Z1 − a/2) 2* p * (100 − P)/d2, where n is the sample size; Z1 − a/2 is the value of the standard normal deviate at two-sided 95% confidence level = 1.96; p is the expected prevalence; q = 100 − p; d margin of error with its estimated prevalence. According to Sahu et al.[8], the prevalence of psychiatric disorders among the amputees was 42% (range: 32%–84%). Therefore, the minimum sample size was 84 patients.

Data collection tools and procedure

All lower limb amputee patients who fulfilled the inclusion criteria were enrolled and informed written consent was obtained. Clinicodemographic data of all enrolled patients were recorded, and they were subjected to a questionnaire-based assessment. HADS (Hospital Anxiety and Depression Scale) was used to detect anxiety and depressive states, while TAPES (Trinity Amputation and Prosthesis Experience Scale) was used to understand the psychological adjustment and prosthesis satisfaction.

HADS is a self-reported questionnaire with multiple choices for every question. The questions concerned with anxiety were marked “A” and concerning depression marked “D.” It has 14 items, 7 for anxiety and 7 for depression. Scoring was from 0 to 3 and scores ranged from 0 to 21 for both anxiety and depression. A score up to 7 is considered normal, and more than 11 indicates the probable presence of a mood disorder. The internal consistency and test–retest reliability of the Hindi version HADS has been known to be satisfactory (Cronbach’s alpha value of 0.652).[9]

TAPES is a multidimensional self-report instrument that focuses on understanding the experience of, and adjustment to, both the amputation of the lower limb and the usage of a prosthesis. The current study majorly addressed psychosocial adjustment which has three 5-item subscales (general adjustment, social adjustment, and adjustment to limitation). Scores for the subscales vary from 5 to 25 with an indication of better adjustment with a higher score. The items of the scale were translated into Hindi, and back translation was also done to ensure reliability. The content validity of the Hindi version of the scale was done and was found satisfactory (S-CVI = 0.482). The internal consistency was good with a Cronbach’s alpha value of 0.783.[10]

Ethical considerations

The study was approved by the Institutional Review Board and IEC No. is 95^th ECM II A/P3. The ethical standards of procedures followed in the study were following the Declaration of Helsinki for studies involving human beings.

Data analysis

The data was analyzed using SPSS version 24.0. Descriptive statistics using frequencies, percentages, mean, and standard deviation were used to present the study results. Probability (P) was calculated to test statistical significance at the 5% level of significance. The mean score of various domains of TAPES was calculated and a comparison of mean scores for identifying the associated sociodemographic and clinical factors affecting psychological adjustment was made using a one-way ANOVA test.

RESULTS

The mean age of the amputee was 39.47 ± 16.99 years. More than three-fourths (75.3%) of the amputees were males. More than half (59.6%) were from a rural background and were working (51.7%). The majority (30.3%) were graduates and above. The most evident cause of lower limb amputation was accidents (66.3%), the level of amputation was transtibial (64.1%), and the type of prosthesis was below knee prosthesis (51.7%). The mean duration of amputation and prosthesis was 8.56 ± 10.57 years and 6.84 ± 9.33 years, respectively [Table 1].

Table 1.

Demographic and clinical profile of the study participants (n=88)

Parameters	Class intervals	n	%
Age (mean±SD)	39.47±16.99	–	–
Gender	Male	67	75.3
	Female	22	24.7
Residence	Rural	53	59.6
	Urban	36	40.4
Status of education	Illiterate	18	20.2
	Primary	3	3.4
	Middle	12	13.5
	High School	29	32.6
	Graduation and above	27	30.3
Occupation	Working	46	51.7
	Student	13	14.6
	Pensioner	6	6.7
	Dependent	24	27.0
Level of amputation	Transtibial	57	64.1
	Transfemoral	30	33.7
	Others	2	2.2
Cause of amputation	PVD	4	4.5
	Diabetes	5	5.6
	Cancer	8	9.0
	Accidents	59	66.3
	Others	13	14.6
Type of prosthesis	Below knee	46	51.7
	Through knee	2	2.2
	Above knee	19	21.3
	Others	22	24.7
Duration of amputation (mean±SD)	8.56±10.57 years	–	–
Duration of prosthesis use (mean±SD)	6.84±9.33 years	–	–

The mean HAD score for depression and anxiety was 7.54 ± 4.52 and 6.25 ± 3.57, respectively. The mean general adjustment score was 16.3 ± 3.34 followed by the mean social adjustment score which was 15.19 ± 3.59. The mean score for adjustment to limitation, activity restriction scale, and prosthesis satisfaction were 12.76 ± 3.15, 11.24 ± 4.21, and 7.56 ± 1.67, respectively [Table 2].

Table 2.

Descriptive statistics of the outcome measures

Measures	Subscale	Median	Range	Mean	SD
HADS	Depression	7.00	0–19	7.54	4.52
	Anxiety	6.00	0–21	6.25	3.57
TAPES	General Adjustment	16.00	5–20	16.3	3.34
	Social Adjustments	15.00	5–20	15.19	3.59
	Adjustment to limitation	13.00	5–20	12.76	3.15
	Activity Restriction Scale	12.00	2–19	11.24	4.21
	Prosthesis Satisfaction	8.00	4–10	7.56	1.67

There was a significant difference in the mean score for general adjustment (P = 0.002), social adjustment (P = 0.014), activity restriction scale (P = 0.026), and prosthesis satisfaction (P = 0.038) for study participants of age <40 years and more than 40 years with a higher score in those of age >40 years indicating greater adjustment. Females had a higher mean score for general adjustment and prosthesis satisfaction as compared to the males, and this was statistically significant (P = 0.001, 0.025). Those who were illiterate had the higher mean score for the activity restriction scale, while those who studied up to senior secondary had higher mean scores for prosthesis satisfaction (P = 0.001, 0.001). The study participants who were working had greater general adjustment as compared to others, while the pensioners had a higher social adjustment and both these findings were statistically significant (P = 0.0001, 0.0001) [Table 3].

Table 3.

Demographic predictors of psychological adjustment

Parameter	Class interval	General adjustment	Social adjustment	Adjustment to limitation	Activity restriction scale	Prosthesis satisfaction
Sex	Male	15.64±3.41	15.02±3.64	12.7±3.39	11.64±4.20	7.35±1.72
	Female	18.22±2.26	15.7±3.49	12.9±2.36	10.09±4.09	8.17±1.37
	P	0.001*	0.431	0.689	0.128	0.025*
Background	Rural	16.15±3.01	15.09±3.32	12.92±3.03	11.72±3.75	7.42±1.54
	Urban	16.53±3.81	15.33±4.01	12.53±3.35	10.53±4.77	7.78±1.85
	P	0.62	0.769	0.571	0.192	0.336
Education	Illiterate	16.37±3.08	14.68±3.30	12.37±2.14	13.63±2.49	6.68±1.57
	Up to senior secondary	16.49±3.44	15.40±3.61	13.23±3.55	9.74±4.51	8.17±1.49
	Graduation and above	15.87±3.43	15.17±3.90	12.13±3.55	12.30±3.48	7.04±1.66
	P	0.767	0.766	0.323	0.001*	0.001*
Occupation	Working	17.28±2.5	16.39±2.49	12.80±2.62	11.43±4.06	7.50±1.74
	Students	12.00±4.36	9.31±2.89	12.00±4.76	11.62±4.77	7.08±1.98
	Pensioner	16.50±4.04	18.33±258	13.50±3.94	10.00±4.47	8.17±1.72
	Dependent	16.71±2.09	15.29±2.55	12.92±2.96	10.96±4.29	7.79±1.35
	P	0.0001*	0.0001*	0.769	0.847	0.501

*Indicate significant P- Value

Those with another level of amputation had higher mean scores for adjustment to limitation as compared to those with transtibial and transfemoral levels of amputation, and this was statistically significant (P = 0.003). The lowest mean score was observed for those wearing above-knee prosthesis, but at the same time they had prosthesis satisfaction, and both these findings were significant (P = 0.001, 0.025). Those study participants who had no anxiety had greater and significant mean scores for both general and social adjustment (P = 0.003, 0.01). Those with borderline and abnormal depression scores had significantly lower mean scores for general adjustment as compared to those who had no depression (P = 0.031) [Table 4].

Table 4.

Clinical parameters affecting psychological adjustment

Predictors	General adjustment	Social adjustment	Adjustment to limitation	Activity restriction scale	Prosthesis satisfaction
Level of amputation
Transtibial	16.14±3.77	14.65±3.79	13.54±3.29	11.11±4.46	7.54±1.80
Transfemoral	16.60±2.46	16.23±3.14	11.20±2.31	11.53±3.70	7.57±1.46
Others	16.50±2.12	15.00±0.000	14.00±1.41	10.50±6.36	8.00±1.41
P	0.830	0.148	0.003	0.878	0.932
Type of prosthesis
Below knee	16.07±3.11	14.98±3.37	13.15±2.89	12.20±4.04	7.30±1.63
Through knee	15.50±0.707	14.00±1.41	13.50±2.12	12.00±4.24	7.50±0.707
Above knee	16.15±4.45	15.40±4.81	11.75±3.96	7.95±3.79	8.55±1.50
Others	17.05±2.77	15.57±2.91	12.81±2.87	12.19±3.54	7.19±1.61
P	0.704	0.881	0.415	0.001	0.025
Anxiety (HAD-A)
Normal	17.12±2.49	16.00±2.02	12.69±3.04	11.08±4.17	7.71±1.59
Borderline	15.12±3.79	13.41±3.04	13.12±2.59	11.35±4.27	7.24±1.82
Abnormal	14.15±4.74	13.85±5.87	12.62±4.33	11.77±4.59	7.31±1.84
P	0.003*	0.010*	0.875	0.864	0.496
Depression (HAD-D)
Normal	17.15±3.20	15.77±3.47	12.47±3.06	10.89±4.47	7.68±1.71
Borderline	15.80±1.42	15.40±1.99	13.33±3.27	10.80±4.21	7.93±1.49
Abnormal	15.11±3.95	14.07±4.29	12.96±3.29	12.07±3.70	7.15±1.68
P	0.031*	0.146	0.608	0.467	0.271

*Indicate significant P-Value

DISCUSSION

Lower limb amputation causes a huge toll on the life of the patient with a potential impact on their psychosocial health. With the advent of prosthesis, the physical constraints faced by this vulnerable population has been lessened but still coping with the lost limb and adjusting to the prosthesis becomes challenging for them. Very few studies have explored the psychosocial status of lower limb amputees, but there are still gaps in our understanding of this crucial event due to which the following study was conducted so that better rehabilitative services can be planned for them.

The mean age of the study participants was 39.47 ± 16.99 years with a female: male ratio of 1:4. Male preponderance for lower limb amputations has also been observed by other researchers also in their study.[11-13] This is because the majority of the males are the working-class population and highly susceptible to occupational injuries and accidents culminating in amputation when severe. The most common amputation was transtibial in our study, and this finding was in concordance with a study by Pooja et al.[14] who also reported that 90% of lower limb amputations were below the knee. Another reason cited by a few researchers is that a limb’s distal portion is usually more likely to be injured, and surgeons focus on amputating as distally as possible to retain the functional activity. However, in amputations due to malignancy, transfemoral amputation is the most common.[15,16]

Gender has been noted to play a pivotal role in adjustment to amputation and prosthesis uptake. In our study, females had significantly higher scores for general adjustments and prosthesis satisfaction as compared to other domains of TAPES where not much gender disparity was observed. Our findings are contrary to studies by Sinha et al.[4] who have portrayed that female amputees had poor social adjustments as compared to their male counterparts because they face a lot of social stigmas in society.[4] This difference can be attributed to the fact that the educational status of the study participants was high in our study and most of them were working, whether male or female. Studies have reported that economic independency due to employment status makes the amputees more psychosocially adjusted and they tend to be more physically active.[4,15,16] However, our results are supported by Horgan et al.[1] who stated that gender was not conclusive of adaptation to amputation but since women are more prone to body image concerns than men so emotional and social components get affected but still were not statistically significant.

In our study, it was observed that those with transfemoral amputation had a significantly poor adjustment to limitation as compared to transtibial or others and those who were wearing above-knee prosthesis had the lowest score for activity restriction due to prosthesis. Both these findings were also reported by Sinha et al.[4] in their study who gave the reason that a higher level of amputation also meant less satisfaction with the weight of the prosthesis, which consequently reduces independence and increases restriction in activities.

Lastly, anxiety and depression due to amputation are crucial in psychological adjustment and prosthesis acceptance. Those amputees with abnormal anxiety and depression had lesser general adjustment, while underlying anxiety was also affecting the social adjustment domain. Various studies on the mental health status of amputees have shown those symptoms of depression in people suffering from amputation increase with increased social isolation and decreased social support.[3,16,17]

The study has one limitation; the results of our study are completely quantitative but to get a deeper understanding of this crucial event in the life of an amputee, a qualitative study design like in-depth interviews or focused group discussions would be more beneficial.

CONCLUSIONS AND RECOMMENDATIONS

Young age amputees had poor general and social adjustments and more activity restriction but high prosthesis satisfaction as compared to the elderly. Gender disparity was not associated with psychological adjustment. Those with transfemoral amputation had a poor adjustment to limitation, whereas those wearing above-knee prosthesis had more activity restriction. Underlying anxiety and depression were responsible for poor general and social adjustment. There should be a holistic approach to amputee rehabilitation which should include physical, psychological, and social interventions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.