Current Life Experiences in Veterans with Limb Loss: A Description of Survey Methods and Summary Results

Abstract

PURPOSE:

To present the methods and summary findings of a nationwide survey on the current life experiences of Operation Iraqi Freedom/Operation Enduring Freedom (OEF/OIF) Veterans with limb loss.

METHODS:

A questionnaire was sent to Veterans with items covering sample demographics, summaries of health status, prosthesis usage and fit, employment experience, and use and satisfactions with support services and providers.

RESULTS:

158 Veterans completed the survey. Approximately 40% perceived their overall status, function and problems related to the prosthesis as “Average”. 58% wore a prosthesis over 10 hours per day and 74% did not use additional walking aids. Approximately 75% had at least “Moderate” pain and residual limb health problems. 37% were employed though conditions often changed. Over 80% used healthcare, mental health counseling and education services. The Departments of Defense and VA were primary service providers.

CONCLUSIONS:

Respondents generally exhibited satisfactory life experiences. Results suggest a positive current status despite challenges that could impair health, functioning and quality of life. Support services were available as needed. Satisfaction with services and providers varied.

The Department of Veteran Affairs (VA) healthcare system provide services to over 80,000 Veterans with limb loss (Webster et al., 2014). Chronic health conditions (i.e., diabetes, peripheral vascular disease) are the leading cause for limb loss among these Veterans. Traumatic limb loss during military service accounts for a smaller number, including more than 5,000 amputations during the Vietnam War, and approximately 1,700 in Operation Enduring Freedom (OEF)/Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) (Fischer, 2015; Potter & Scoville, 2006). For these individuals, their young age at the time of injury necessitates evaluating the long-term experiences and needs as they age with limb loss (Geiling et al., 2012).

A series of articles previously examined survey outcomes related to physical health, prosthetic use, satisfaction, and quality of life (QOL) in service members and Veterans who experienced limb loss during OEF/OIF (Berke et al., 2010; Dougherty et al., 2010; Dougherty et al., 2012, 2014; Epstein et al., 2010; Gailey et al., 2010; Laferrier et al., 2010; McFarland et al., 2010; Reiber et al., 2010; Woodruff et al., 2017). Results revealed the respondents had significant phantom pain and/or other bodily pain, problems with sweating within the socket, and complications with the skin of the residual limb (Dougherty et al., 2010; Dougherty et al., 2014; Gailey et al., 2010; Reiber et al., 2010). Yet, most maintained a satisfactory overall prosthesis comfort and fit, and 90% used a prosthesis on a regular basis (Berke et al., 2010; Gailey et al., 2010; Reiber et al., 2010). Furthermore, 54% were engaged in low-to-high impact recreational activities or were employed (Gailey et al., 2010; Reiber et al., 2010). Overall, roughly 50% of the Veterans perceived their health status and/or QOL as “Excellent” or “Very Good” (Epstein et al., 2010; Gailey et al., 2010; McFarland et al., 2010; Reiber et al., 2010). However, respondents were on average 3 years since their limb loss. Evidence suggests the overall condition of individuals with traumatic limb loss deteriorates over time. Health related QOL for service members and Veterans with limb loss was lower 5 years post injury than a reference group of individuals with extremity trauma but no limb loss (Woodruff et al., 2017). Elsewhere, over half of young adults with traumatic limb loss rated themselves as severely disabled 7 years after the injury (MacKenzie et al., 2005). In most cases OEF/OIF/OND Veterans are 7 years or longer since the limb loss and more recent follow-up studies are lacking.

Comparisons with Vietnam Veterans with limb loss may offer insights into the future trajectory of OEF/OIF/OND Veterans with limb loss. Survey results showed similarities in post-limb loss outcomes for the two cohorts (Gailey et al., 2010; McFarland et al., 2010; Reiber et al., 2010). The prevalence of pain, sweating in the socket, and skin health issues were comparable between groups. Likewise, prosthesis comfort, fit, and use were mostly comparable. Vietnam Veterans were more likely to be employed than Veterans of OEF/OIF, but the percentages were similar if including those identified as students. The surveys identified some notable differences between groups. The Vietnam Veterans were more likely to report aging related co-morbidities like osteoarthritis, while Veterans of OEF/OIF had higher rates of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI). Furthermore, a higher functional ability and more active lifestyle was found for OEF/OIF Veterans compared to the Vietnam Veterans. The overall perceptions of health and QOL were generally lower among the Vietnam era Veterans compared to general population norms and OEF/OIF Veterans, though similar ratings were found among Veterans from both conflicts with multiple limb loss (Dougherty, 2003; Dougherty et al., 2012, 2014; Epstein et al., 2010; Foote et al., 2015; McFarland et al., 2010).

However, the post limb loss experience for OEF/OIF/OND Veterans may differ over the long-term from Vietnam Veterans. OEF/OIF Veterans received extensive rehabilitation in multidisciplinary military treatment programs designed specifically for those with limb loss (Gajewski & Granville, 2006). Furthermore, OEF/OIF Veterans have access at a much younger age to advanced prosthetic devices (ie, microprocessor knees, powered foot ankles, myoelectric/hybrid upper extremity devices) and specialized prosthetic devices (ie, running feet, waterproof/swim legs) (Gailey et al., 2010; McFarland et al., 2010). Broad public support for Veterans has also contributed to a variety of public and private services working to support psychological adjustment to limb loss and community reintegration. The combined effect may be that OEF/OIF/OND Veterans maintain a higher level of function and engagement in life activities. It is important to reassess the status of Veterans of OEF/OIF/OND with limb loss given the potential for difference in experiences between the Veteran groups.

The purpose of this study was to assess the current life experiences of OEF/OIF/OND Veterans with limb loss. Employment experiences were of particular interest in the questionnaire since almost a quarter responded they were students at the time of the prior study (Reiber et al., 2010). Employment has an important role in health related QOL, and attention on employment experience in this group would be novel and warranted (Christensen et al., 2016; Sinha et al., 2011). Of note, the present article is part of a larger effort to assess the status of OEF/OIF/OND Veterans with limb loss. Additional research expands upon the summary results to identify barriers and facilitators to employment and resilience (Armstrong et al., 2018; Hawley et al., 2022).

Methods

Participants

The population of interest was working aged Veterans with combat related lower limb loss during OEF/OIF. A list of Veterans to contact about the questionnaire was generated using the VA Corporate Data Warehouse (CDW). Names were identified using diagnostic codes for major limb loss levels of the upper or lower limbs (partial foot or partial hand amputation(s) only were excluded), OEF/OIF service, and our defined age range (18–55 years of age). The Veterans were notified about the questionnaire using 2 separate mailings of an informational flyer. The individuals had the option to take either an electronic or pen-and-paper version of the questionnaire. The study was approved by institutional review boards at Virginia Commonwealth University and the Central Virginia Veterans Health Care System.

Questionnaire

The questionnaire was designed using conventional survey methodology to assess 1) demographic variables, 2) summary of health status, prosthesis usage and fit, 3) employment experiences, and impact of prosthesis problems on employment and QOL, and 4) use and satisfaction with support services and service providers available to Veterans with limb loss (Dillman, 2009).

The section on demographic variables included questions about the Veteran’s age, gender, race, time since and level(s) of limb loss, health co-morbidities, education level, marital status, and if the Veteran had children. Descriptive questions on military service covered the Veteran’s service branch, length of service, and final rank. The section on health status, prosthesis usage and fit included items asking respondents to summarize their overall situation, functional ability, and severity of problems experienced with prosthesis use. The items were selected for use from the Questionnaire for Persons with Transfemoral Amputation (Q-TFA) (Hagberg et al., 2004). Respondents were also asked to report on fit of the prosthesis, hours per day of prosthesis use, and identify any additional assistive devices used for walking (i.e., cane, walker). A third component of this section involved assessing the perceived resilience using the 10-item Connor-Davidson resilience scale (CD-RISC) (Campbell-Sills & Stein, 2007). The section on employment experiences included items on current employment status, characteristics, and perceptions of the employment. Employment characteristics included items such as physical demands of their job prior to limb loss and since, involvement in supervision roles, and hours worked per week. The perceptions of their employment included questions on productivity and interest level in staying in current job. In addition, items modified from the Q-TFA asked respondents to perceive the impact of common complications associated with limb loss on the ability to work and QOL (Hagberg et al., 2004). Support services and service providers were assessed in a fourth section. Participants were asked to identify services and providers used, and their satisfaction with each. Respondents were also asked if a support service was needed but not available.

Analysis

Descriptive Frequencies and percentages were calculated using Statistical Analysis Software (SAS) v9.4. An answer was not selected by all participants for some questions. This missing data resulted in the aggregate number of responses for the question not equaling the total number of survey participants.

Results

A total of 870 mailing addresses were identified through the CDW search. 154 letters were returned as undeliverable. Of the remaining, 158 individuals meeting our inclusion criteria completed the survey for an overall response rate of 22%. Among the respondents, 73.7% (n=116) completed a pen-and-paper copy, and 26.7% (n=42) completed the online version.

Demogaphic Characteristics

Demographic data (Table 1) indicated 76% of the respondents were between 26 and 40 years of age. The sample was predominately Caucasian and virtually all male. The majority were married with children. Nearly half reported earning a college degree. Over 80% reported the loss of 1 or both lower limbs, with unilateral transtibial limb loss most common. 31% percent had more than one limb amputated, with nearly 90% of those involving both lower limbs. The limb loss occurred 8 or more years prior in 54% of the respondents, and 5–7 years ago in another 36%. Respondents self-reported a range of co-morbid conditions with results indicating all but 12 met the VA definition for polytrauma of “two or more injuries, one of which may be life threatening, sustained in the same incident that affect multiple body parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disabilities” (Department of Veterans Affairs, 2019). TBI, PTSD and hearing loss were selected most often, with the frequencies between 51%–60%. Musculoskeletal injury (other than limb loss), anxiety, and depression were also common. Over half served in the Army, approximately a third were Marines, and 11% served in one of the remaining branches of the military. Virtually all completed service at an enlisted rank.

Table 1.

Sample demographic and service information. Note: frequencies may not sum to N=158 due to missing values.

Characteristic	Level	N (%)
Age (years)	18–25	6 (4%)
	26–30	31 (20%)
	31–35	56 (36%)
	36–40	32 (20%)
	41–45	15 (10%)
	46–50	8 (5%)
	51–55	7 (5%)
Gender	Male	151 (97%)
	Female	4 (2%)
Race	White/Caucasian	122 (81%)
	Non-White	29 (19%)
Limb loss Level
Unilateral Lower Limb		85 (54%)
	Transtibial	53 (62%)
	Transfemoral	31 (36%)
	Hip disarticulation	1 (1%)
Unilateral Upper Limb		22 (14%)
	Transradial	10 (45%)
	Transhumeral	9 (41%)
	Shoulder disarticulation	3 (14%)
Multiple limbs		49 (31%)
	Bilateral lower limbs	43 (88%)
	Upper and lower limbs	3 (6%)
	Bilateral upper limbs	3 (6%)
Time since limb loss (yrs)	2–4	15 (10%)
	5–7	56 (36%)
	8–10	41 (26%)
	10+	44 (28%)
Co-morbid conditions	Musculoskeletal	53 (34%)
	TBI	94 (60%)
	PTSD	89 (57%)
	Hearing	80 (51%)
	Vision	39 (25%)
	Substance Abuse	10 (6%)
	Depression	53 (34%)
	Anxiety	70 (45%)
	Spinal Cord Injury	14 (9%)
	Burn	22 (14%)
Highest Level of Education	College degree	75 (48%)
	High school / Technical training	80 (52%)
Marital Status	Married / Partnered	102 (66%)
	Single	28 (18%)
	Divorced / Separated	25 (16%)
Any children	Yes	107 (69%)
	No	48 (31%)
Service Branch	Army	89 (58%)
	Marine Corps	49 (32%)
	Navy	8 (5%)
	National Guard	5 (3%)
	Air Force	3 (2%)
	Reserves	1 (1%)
Final Rank	E1-E4	50 (33%)
	E5-E9	91 (59%)
	O1-O3	10 (7%)
	O4-O6	2 (1%)
Length of Service	Less than 2 years	4 (3%)
	2–4 years	38 (25%)
	5–7 years	50 (32%)
	8–10 years	23 (15%)
	10+ years	40 (26%)

Summary Status, Prosthesis Usage and Fit

Summary data (Table 2) revealed the respondents were most likely to view their overall status, function and problems with their prosthesis as “Average” (39–43%). Approximately a third reported either a “Good” or “Extremely Good” overall situation and function, while the remaining 23–28% listed “Poor” or “Extremely Poor”. Unlike the previous 2 items, problems with the prosthesis were listed as “Considerable” or “Extreme” by 35% of the respondents while 23% cited the inverse. The Q-FTA global composite score, an aggregate of the 3 items, averaged 51.0±20.0 out of 100. Ratings of prosthesis fit followed a similar pattern as the overall situation and function items with most reporting “Neither Poor or Perfect Fit” (37%) followed by a slightly higher percent rating a more perfect fit (35%) than poorer fit (28%). Resilience was rated as 28.2±7.8 out of 40 on the CD-RISC scale.

Table 2:

Summary of health status, prosthesis usage and fit. Note: frequencies may not sum to N=158 due to missing values.

Survey Question	Levels	N (%)
Global Score	Total Score	51.0 ± 20.0
Overall Situation	Extremely Good	15 (10%)
	Good	37 (24%)
	Average	65 (42%)
	Poor	31 (20%)
	Extremely poor	5 (3%)
Summary of function with prosthesis	Extremely High	18 (12%)
	High	31 (21%)
	Average	57 (39%)
	Low	25 (17%)
	Extremely Low	16 (11%)
Summary of problems with prosthesis	Extremely Small	10 (7%)
	Small	23 (16%)
	Average	63 (43%)
	Considerable	36 (25%)
	Extreme	14 (10%)
Resilience	Total Score	28.1 ± 7.8
Rate the fit of prosthesis	Perfect fit	14 (9%)
	Slightly Perfect fit	38 (26%)
	Neither poor or perfect fit	55 (37%)
	Slightly poor fit	23 (16%)
	Poor fit	18 (12%)
Average daily time wearing a prosthesis (hours)	0	22 (14%)
	1–3	9 (6%)
	4–6	17 (11%)
	7–9	15 (10%)
	10–12	24 (16%)
	13–15	33 (22%)
	15+	33 (22%)
Which walking aid do you normally use when using the prosthesis?	None	111 (73%)
	One crutch/stick	18 (12%)
	Two crutches/sticks	7 (5%)
	Walking frame or similar	1 (1%)
	I do not walk/Use wheelchair	16 (10%)

Daily prosthesis use exceeded 10 hours on average for 58% of the respondents, while only 15% reported not wearing a prosthesis daily. Most respondents (74%) did not use any additional walking aid. Of the remaining, 11% used a single crutch or cane, 10% were non-ambulatory/used a wheelchair, and the rest used multiple crutches/canes or a walker.

Employment and the Impact of Factors on an Ability to Work and QOL

Overall, 37% were employed/self-employed, 14% were students, 26% retired and 23% unemployed/seeking employment (Table 3). Among those employed, 92% did not return to the same job, with unable due to disability cited by 80%. Working full-time hours (82%), a government position (34%), and a non-supervisory role (56%) were most common among those currently employed. Annual employment income was between $45,000 and $90,000 for 55% with another 27% who made over $90,000 per year. Regarding disability income, 52% received less than $45,000 and 42% received $45,000–$90,000.

Table 3:

Summary of employment experience. Note: frequencies may not sum to N=158 due to missing values.

Survey Question	Levels	N (%)
Employment Status	Employed	56 (37%)
	Student	22 (14%)
	Unemployed	35 (23%)
	Retired	40 (26%)
Following limb loss, did you return to same job?	Yes	12 (8%)
	No	144 (92%)
If you did not return to same job, then why?	Unable due to disability	113 (80%)
	Decided that I wanted to leave active duty	7 (5%)
	Decided I wanted to retire	7 (5%)
	Returned to school	5 (4%)
	Did not want to jeopardize other benefits	4 (3%)
	Decided to change career	2 (1%)
	Received a better job offer	2 (1%)
	Did not feel supported	1 (1%)
	Family circumstances	1 (1%)
What industry if currently employed?	Government	19 (34%)
	Unable to classify	10 (18%)
	Professional and business	8 (14%)
	Health services	6 (11%)
	Agriculture	4 (7%)
	Manufacturing	2 (4%)
	Information	2 (3%)
	Transportation	1 (2%)
	Education	1 (2%)
	Leisure	1 (2%)
	Finance	1 (2%)
	Trade	1 (2%)
How many hours on average do you work weekly?	Full-time (30+ hours)	47 (82%)
	Part-time (<30 hours)	10 (18%)
How physically demanding was the job prior to your limb loss?	Not demanding	0 (0%)
	Slightly demanding	0 (0%)
	Neutral	1 (1%)
	Moderately demanding	19 (12%)
	Extremely demanding	136 (87%)
How physically demanding is your current job?	Not demanding	13 (21%)
	Somewhat demanding	11 (20%)
	Neutral	16 (29%)
	Demanding	12 (21%)
	Extremely demanding	4 (7%)
Does your job involve formal supervision of other employees?	Yes	25 (44%)
	No	32 (56%)
Do you think your work productivity is as good as before your limb loss?	Yes	24 (42%)
	No	33 (58%)
Productivity reduced because…	Socket Discomfort	7 (23%)
	Physical problems with environment/travel	5 (16%)
	Unable to physically meet production standards	5 (16%)
	Loss of confidence	4 (13%)
	Mechanical problems with prosthesis	4 (13%)
	Worry	4 (13%)
	Depression	2 (6%)
I am employed in a job I…	Strongly dislike	3 (5%)
	Dislike	5 (9%)
	Neither like or dislike	11 (19%)
	Like	20 (35%)
	Strongly like	18 (31%)
I plan on staying in this job for the next several years.	Yes	37 (66%)
	No	19 (34%)
Annual Income	<$45k	21 (18%)
	$45k–$90k	65 (55%)
	>$90k	32 (27%)
Disability Income	<$45k	61 (52%)
	$45k–$90k	50 (42%)
	>$90k	7 (6%)

99% described their job prior to limb loss as “Moderate” to “Extremely” physically demanding. After limb loss, only 28% rated their job as “Moderate” to “Extremely” demanding while 41% viewed their work as “Somewhat” physically demanding or easier. Those employed perceived themselves as less productive (58%) with socket discomfort (23%), physical problems with the environment/travel (16%) and an inability to physically meet production standards (16%) frequently cited for the loss of productivity. Nevertheless, 66% “Like” or “Strongly Like” their current employment and planned on staying in the job for the next few years.

Over 40% reported “Considerable to Great” pain in the residual limb and in other locations (back, shoulder, other leg). Less than a quarter reported “No to Slight” pain. However, while almost 40% reported pain impacted an ability to work or QOL, an equal proportion reported “No or a Slight” impact. A similar response pattern occurred with half reporting prosthesis related skin problems (chafing, sores, irritation), but fewer than 40% indicating it impacted an ability to work or QOL. A majority reported “No or Slight” difficulty participating in social or community activities, and “No or Slight” impact on the ability to work or QOL. 23% reported “Considerable to Great” difficulty in participating in social or community activities. A similar number (21%) reported this difficulty with social and community activities as impacting QOL, but only 15% indicated the same difficulties impacted their ability to work.

Use and Satisfaction with Support Service and Providers

Healthcare, mental health counseling, and educational services were used by at least 80% of the respondents. While 72% were “Satisfied” with the educational services, fewer were “Satisfied” with healthcare (54%) and mental health services (46%), and approximately a quarter (25–30%) were “Dissatisfied”. Employment services were used by 61% though nearly half (44%) were “Dissatisfied”, the highest percent of dissatisfaction with services included in the survey. Other support services were used to varying degrees with the majority “Satisfied” with the service when used, except for family counseling in which only 38% were “Satisfied”. A limited number identified a support service they wanted but could not access. Employment (10%), education (10%), and financial services (16%) were most frequently identified as needed but unavailable.

Use of services provided through the Department of Defense (DoD) and VA was reported by nearly all respondents. While a majority were “Satisfied” with DoD and VA providers, the VA also had the highest level of dissatisfaction among providers. The highest level of satisfaction was reported for charity/non-profit support services (84%). 85% used services provided through VA vocational rehabilitation with 67% “Satisfied” with the providers. Receipt of vocational services from state entities was less common (25%) and was viewed as “Neutral” (neither “Satisfied” or “Dissatisfied”) by 67%.

Discussion

In this study we explored themes relating to life experiences of OEF/OIF Veterans with limb loss. Our questionnaire characterized current functional status, employment and the use and satisfaction with services providers. In our focus on employment, we also inquired about characteristics of their work, as well as potential barriers and enablers of a return to work. Prior research suggested OEF/OIF Veterans who were a mean age of 29 years and 3 years past their limb loss were adjusting well to their condition and thought to have a very good long-term prognosis based upon the experiences of Vietnam war Veterans with limb loss (Reiber et al., 2010). However, it was unclear if positive outcomes over a longer-term were achieved. Our study offers a more current assessment of the cohort. To that end, changes in the age and time since limb loss are consistent with the time between studies, suggesting our sample is reasonably reflective of those who participated in the earlier sample. As such, it is appropriate to judge potential changes over time through comparisons of the current sample to the previous survey study of this cohort.

Status, Posthesis Use and Fit

The Q-TFA global score was 51 and the largest percentage (40%) summarized their overall situation as “Average”. Approximately another third viewed their overall situation “Good” or “Extremely Good” as compared to 23% for the inverse. Though not using the same items, results for a similar question in the previous survey of OEF/OIF participants asked them to rate their “health status” on a 5-point ordinal scale. Results showed 39% identified themselves as “Good”, equivalent to our “Average”, and another 46% rated themselves as “Excellent” or “Very Good”, the equivalent of our “Good” or “Extremely Good” (Gailey et al., 2010). These results suggest the overall status of the OEF/OIF Veterans with limb loss may have changed only modestly since the survey at 3 years after the limb loss. However, the prior survey study reported the Vietnam Veterans had a lower health status than the OEF/OIF participants with only 27% reporting “Excellent” or “Very Good” health status, and an increase from 15% reporting “Fair” or “Poor” health in the OEF/OIF respondents to 32% among the Vietnam Veterans (Gailey et al., 2010). It is possible a downward trend in health may become more apparent as the group ages.

Similar to the rating on overall situation, results suggest the current sample of Veterans with limb loss have maintained a good level of physical functioning. 39% of the current sample summarized their function with a prosthesis as “Average”, 33% felt their function was “High” or “Extremely High”, and 28% “Low” or “Extremely Low”. Other items reflecting physical function showed 86% of the current sample wore a prosthesis daily with 58% wearing the prosthesis for at least 10 hours a day, and that 73% did not require use of additional walking aids (i.e., crutch, cane or walking frame). These results are comparable to previous studies showing at least 85% of survey respondents used a prosthesis, with a majority using the device for 10 hours a day or longer (Gailey et al., 2010; Gauthier-Gagnon et al., 1999; Pezzin et al., 2004; Reiber et al., 2010). Regarding additional walking aids, one study reported approximately 50% required one while other studies described use of an aid for indoor versus outdoor walking, a distinction not made in the current survey, and found that while 84% used no additional walking aide indoors, only 15–60% reported themselves able to forego use of one while walking outdoors (Dajpratham et al., 2008; Gauthier-Gagnon et al., 1999; Hagberg & Branemark, 2001). In this light, it is not surprising to find 49% of the OEF/OIF group reported “No or Slight” difficulty participating in social and community activities as extensive daily use of a prosthesis and not using an additional walking aid are related to functional and social independence, employment, feeling functionally satisfied, and feeling less social restricted (Schoppen et al., 2001; Sinha et al., 2014).

Despite positive findings on physical functioning, our results offer further evidence of potentially significant problems related to the prosthesis. While problems with their prosthesis were rated “Average” most often, a larger number rated their problems as “Considerable” or “Extreme” (35%), than “Small” or “Extremely Small” (23%). This larger proportion reporting significant problems is dissimilar to the other summary items. In addition, roughly 75% experienced at least “Moderate” pain in the residual limb or elsewhere in the body, and at least “Moderate” problems with chafing, sores, or other skin irritation. The prevalence of these problems are largely within ranges reported in previous literature (Berke et al., 2010; Meulenbelt et al., 2011; Oosterhoff et al., 2020). However, most studies only report the problem prevalence, and not the severity of the problem. Compared to the ones that do, the current results suggest OEF/OIF Veterans had a larger proportion reporting considerable residual limb pain, other bodily pain, and pain during activity (Ehde et al., 2000; Ehde et al., 2001; Hagberg & Branemark, 2001; Oosterhoff et al., 2020). The current sample also exhibited a higher number experiencing considerable skin problems and being bothered by sweating inside the socket problems than prior studies (Hagberg & Branemark, 2001). The severity of these problems likely contributed to the 14% of the participants who reported abandoning use of a prosthesis. A percent that is double the 7% reported for the OEF/OIF sample at 3 years, and slightly above the 11% of Vietnam Veterans at 29 years after the limb loss (Gailey et al., 2010).

Even though it is unclear why the current sample of OEF/OIF Veterans were more likely to experience considerable problems related to prosthesis, the impact of the problems on an ability to work and on quality of life was dampened. There was a clear shift toward perceiving the prosthesis related problems having less of an impact than the severity prevalence results would suggest. This paradox between problem severity and impact may reflect that the individuals accepted these undesirable complications as normal. Previous survey results suggested coping skills develop with greater time since the limb loss (Epstein et al., 2010). Though the authors suggested the OEF/OIF Veterans had not developed the coping skills within the first 3 years after their limb loss, it is possible the skills were developed in the years since. However, we cannot rule out other factors relating to a person’s psychological state, physical functioning, and engagement in family/social/work communities that might have influenced their perceived ability to work and quality of life. Researchers should continue to explore strategies limiting the impact of prosthesis related complications in order to maximize an individual’s overall physical functioning.

Employment

A focus of the survey was on employment experiences because of the critical role in shaping life experience. Our results showed fewer of the respondents were employed (37% compared to 53.6%) or were students (14% compared to 22.6%), while a marginally higher percent of the Veterans were retired (26% compared to 21.3%) than what Reiber reported (Reiber et al., 2010). Our survey identified another 23% as unemployed, a category the Reiber study did not report. The current results are also lower than employment numbers for persons with limb loss in the general population (Darter et al., 2018; Perkins et al., 2012). Of those who did return to work, only 8% returned to the job they held prior to the limb loss. This result is in line with prior literature indicating military service members with limb loss remaining on active duty at a rate of 11–13% (Darter et al., 2018). Our data also shows a clear trend toward employment in the government, a likely reflection of hiring practices encouraging the hiring of Veterans.

For those that changed employment the reason why was overwhelmingly attributed to their disability. A characteristic of the new employment was a significant change in some work conditions. Consistent with previous literature, employment transitioned from extremely demanding prior to limb loss, to a less physically demanding occupation after (Perkins et al., 2012). The positions were also less likely to involve supervision and created a sense of lost productivity. Nevertheless, respondents mostly viewed their job favorably and planned to stay in the job for the next several years. However, as many were working in government positions, the desire to stay in a job may be related in part to retirement benefits that may not exist as commonly in private sector jobs. Other factors like the presence of co-morbidities and polytrauma are also known to impact a return to work (Darter et al., 2018; Wyse et al., 2020). Additional analysis of demographic and employment related factors for the survey respondents are reported elsewhere (Hawley et al., 2022).

Service and Provider Use and Satisfaction

The current survey is the first to inquire about use of a large set of services and providers to Veterans with limb loss. Finding that virtually all respondents received healthcare services and used the DoD and VA as providers was expected given the sample was obtained through the VA CDW. Nevertheless, our results reflect a transition of services used from the DoD to the VA or private sector providers (Berke et al., 2010; Melcer et al., 2020). Overall usage of mental health and education services also exceeded 80%, potentially reflecting increased awareness of a need for these services during the post service-connected limb loss experience. Importantly, at most 16% responded a service was needed but unavailable. While we cannot tell if the service was indeed available but unknown to the Veteran, the lack of availability of a service does not seem to be a widespread barrier to the ongoing post-limb loss recovery process.

Dissatisfaction with most support services was below about 20%. However, nearly a quarter were dissatisfied with healthcare and counseling services (mental health and family counseling), and almost half were dissatisfied with employment services. Likewise, dissatisfaction with most services providers was generally low. Charities/non-profits enjoyed the highest rates of satisfaction with their services while a third reported dissatisfaction with VA services. The later likely aligning with services provided through the VA that were rated as unsatisfactory most often. While we are unable to pinpoint specific areas for improving the satisfaction with services received or the providers, previous research on prosthetic prescription found a disconnect between client expectation and the experience provided by the clinicians(Van der Linde et al., 2007). It is possible rates of dissatisfaction could lower if providers help clients set appropriate expectations for the service received and solicit client feedback regularly to assess if expectations were met. Satisfaction could also be enhanced by rehabilitation professionals evaluating patients for factors enabling or inhibiting immediate and long-term community integration, QOL and well-being. Further research is needed examining why respondents were dissatisfied with certain services as is developing potential strategies to improve service delivery in these areas. Moreover, evidence based clinical practice guides (CPGs) for individuals with limb loss with recommendations addressing the necessity of certain services (i.e., vocational rehabilitation) and lifelong follow-up are unmet needs that could also improve service delivery (Heyns et al., 2021).

Limitations

Of the almost 1,700 individuals who experienced limb loss related to military service in OEF/OIF 714 valid mailing addressed were obtained. Out of date contact information, potential omission of limb loss related ICD-9 codes, and/or the Veteran not seeking healthcare through the VA likely contributed to the inability to capture greater numbers. We also cannot rule out self-selection biases among those we were able to contact when evaluating the results. Finally, the survey was anonymous so we could not determine how many in our sample participated in the prior surveys to which we compare to our results. It is unknown if some unquantified differences between the current sample and previous samples influenced the interpretation of our findings.

Conclusions

Overall, our results provide evidence a majority of OEF/OIF Veterans with limb loss have persevered through ongoing issues common after loss limb to maintain a satisfactory health status and QOL. Furthermore, despite potential barriers such as pain, skin health problems, an ability to work and reintegrate into the community was maintained. Further exploration of how best to provide relevant supports including mental health and employment is warranted. Providing access to accommodations and support services that meet the person’s needs within the workplace and community remain critical objectives for helping this cohort to thrive over the long-term.

Table 4:

Prevalence of prosthesis problems, and impact of prosthesis problems on employment and QOL. Frequencies may not sum to N=158 due to missing values

Pain in residual limb during activities?
Survey Answers	Prevalence	Ability to Work	Quality of Life
No to slight	37 (24%)	58 (37%)	60 (37%)
Moderate	53 (34%)	35 (23%)	40 (26%)
Considerable to great	66 (42%)	62 (40%)	56 (36%)
Other pain (back, shoulder, other leg)
Survey Answers	Prevalence	Ability to Work	Quality of Life
No to slight	32 (21%)	58 (37%)	60 (38%)
Moderate	53 (34%)	36 (23%)	39 (25%)
Considerable to great	70 (45%)	61 (39%)	57 (37%)
Prosthesis given rise to chafing, sores, or skin irritation?
Survey Answers	Prevalence	Ability to Work	Quality of Life
No to slight	39 (26%)	62 (41%)	57 (38%)
Moderate	33 (22%)	29 (19%)	36 (24%)
Considerable to great	76 (51%)	60 (40%)	57 (38%)
Difficulty participating in social and community activities?
Survey Answers	Prevalence	Ability to Work	Quality of Life
No to slight	76 (49%)	99 (66%)	82 (54%)
Moderate	42 (27%)	29 (19%)	39 (25%)
Considerable to great	36 (23%)	23 (15%)	32 (21%)

Table 5:

Summary of support services use and satisfaction. Frequencies may not sum to N=158 due to missing values.

Support Service	Usage	N (%)	Level	N (%)	Needed but Unavailable
Housing	Yes	38 (59%)	Satisfied	28 (74%)	10 (6%)
	No	26 (41%)	Neutral	4 (11%)
			Dissatisfied	6 (16%)
Employment	Yes	34 (61%)	Satisfied	12 (35%)	15 (10%)
	No	22 (39%)	Neutral	7 (21%)
			Dissatisfied	15 (44%)
Transportation	Yes	37 (65%)	Satisfied	20 (54%)	3 (2%)
	No	20 (35%)	Neutral	10 (27%)
			Dissatisfied	7 (19%)
Healthcare	Yes	119 (99%)	Satisfied	64 (54%)	6 (4%)
	No	1 (1%)	Neutral	25 (21%)
			Dissatisfied	30 (25%)
Mental Health Counseling	Yes	71 (82%)	Satisfied	33 (46%)	13 (8%)
	No	16 (18%)	Neutral	17 (24%)
			Dissatisfied	21 (30%)
Family counseling	Yes	37 (59%)	Satisfied	14 (38%)	13 (8%)
	No	26 (41%)	Neutral	15 (41%)
			Dissatisfied	8 (22%)
Education	Yes	76 (89%)	Satisfied	55 (72%)	15 (10%)
	No	9 (11%)	Neutral	14 (18%)
			Dissatisfied	7 (9%)
Financial	Yes	59 (74%)	Satisfied	37 (63%)	25 (16%)
	No	21 (26%)	Neutral	11 (19%)
			Dissatisfied	11 (19%)
Food	Yes	28 (48%)	Satisfied	16 (57%)	6 (4%)
	No	31 (52%)	Neutral	11 (39%)
			Dissatisfied	1 (4%)
Childcare	Yes	21 (38%)	Satisfied	10 (48%)	7 (4%)
	No	34 (62%)	Neutral	9 (43%)
			Dissatisfied	2 (10%)

Table 6:

Summary of service provider and satisfaction. Note: frequencies may not sum to N=158 due to missing values.

Service Provider	Usage	N (%)	Level	N (%)
Department of Defense	Yes	69 (85%)	Satisfied	42 (61%)
	No	12 (15%)	Neutral	20 (29%)
			Dissatisfied	7 (10%)
Veterans Administration	Yes	133 (99%)	Satisfied	59 (44%)
	No	1 (1%)	Neutral	30 (23%)
			Dissatisfied	44 (33%)
State Program	Yes	27 (53%)	Satisfied	7 (29%)
	No	24 (47%)	Neutral	15 (63%)
			Dissatisfied	2 (8%)
Federal Program	Yes	27 (53%)	Satisfied	7 (29%)
	No	24 (47%)	Neutral	13 (54%)
			Dissatisfied	4 (17%)
Charity/Non-profit	Yes	55 (71%)	Satisfied	46 (84%)
	No	23 (29%)	Neutral	6 (11%)
			Dissatisfied	3 (5%)
State Vocational Rehabilitation	Yes	12 (25%)	Satisfied	2 (17%)
	No	36 (75%)	Neutral	8 (67%)
			Dissatisfied	2 (17%)
VA Vocational Rehabilitation	Yes	70 (85%)	Satisfied	47 (67%)
	No	12 (15%)	Neutral	10 (14%)
			Dissatisfied	13 (19%)