RESEARCH PAPER

Mental health and satisfaction with life among upper limb amputees:a Norwegian population-based survey comparing adult acquired majorupper limb amputees with a control group

KRISTIN ØSTLIE1, PER MAGNUS2, OLA H. SKJELDAL3, BEATE GARFELT1 &

KRISTIAN TAMBS4

1Innlandet Hospital Trust, Department of Physical Medicine and Rehabilitation Ottestad, Jørgen Jensens vei, 2312,

Norway, 2Norwegian Institute of Public Health, Division of Epidemiology, Oslo, Norway, 3Innlandet Hospital Trust,

Department of Research, Brumunddal, Norway, and 4Norwegian Institute of Public Health, Division of Mental Health, Oslo,

Norway

Accepted November 2010

AbstractPurpose. To assess how upper limb amputation affects mental health and life satisfaction.Method. Cross-sectional study comparing the mental health and perceived satisfaction with life among adult acquired majorupper limb amputees in Norway with a control group drawn from the Norwegian general population. The scales used werethe Satisfaction With Life Scale (SWLS) and the Hopkins Symptom Check List 25-item (SCL-25). The groups werecompared using multiple linear regression analyses.Results. The amputees scored significantly lower on life satisfaction than the control group. A tendency to poorer mentalhealth in the amputee group was observed, but there was no clear evidence of such a difference. The amputation effect on lifesatisfaction seemed to be mediated mainly by changes in occupational status and by the occurrence of short- or long-termcomplications related to the amputation.Conclusions. Our findings imply that rehabilitation of upper limb amputees should emphasise facilitating return to work aswell as the prevention of short- and long-term complications, and that this will be of importance not only for the amputees’physical function, but for the maintenance of acceptable life satisfaction. Further studies on the effect of upper limbamputation on mental health are recommended.

Keywords: Amputees, upper limb, anxiety, depression, quality of life, social support

Introduction

Arms and hands are used for most activities of daily

living, and are also important for expression, com-

munication and affection [1,2]. Thus, loss of an

upper limb has an extensive effect on people’s lives,

resulting in major restrictions of function, sensation

and appearance [3]. According to Fitzpatrick [4], the

loss of a limb phenomenologically parallels the death

of a loved one, and it is known that both upper and

lower limb amputees frequently manifest emotional

reactions such as shock, grief, denial, anxiety and

depression [5]. Traumatic amputation may also cause

post-traumatic stress syndrome and other personality

and adjustment disorders [6]. Furthermore, limb loss

has been found to dramatically change a person’s

sense of body image and consequently self image, in

turn affecting the person’s satisfaction with life [1].

Knowledge about these mental and psychosocial

aspects of amputation is important if one is to

succeed with amputee rehabilitation.

In existing literature, there are several reports on

amputee mental health and psychosocial issues

following amputation, as well as specific articles on

the quality of life following lower limb amputation,

and on lower limb amputee mental health. Recent

Correspondence: Kristin Østlie, Innlandet Hospital Trust, Department of Physical Medicine and Rehabilitation Ottestad, Jørgen Jensens vei, 2312 Ottestad

Norway. E-mail: kristin.ostlie@sykehuset-innlandet.no

Disability and Rehabilitation, 2011; 33(17–18): 1594–1607

ISSN 0963-8288 print/ISSN 1464-5165 online ª 2011 Informa UK, Ltd.

DOI: 10.3109/09638288.2010.540293

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reviews have been given by Desmond and

MacLachlan [7] and Horgan and MacLachlan [8].

Emotional aspects of amputation in children have

also been described [9,10], as well as psychiatric

aspects of replantation surgery [11]. Persons with

limb loss have been shown to have poor health-

related quality of life (HRQL) compared to other

illness groups, lower limb loss affecting HRQL more

than upper limb loss [12]. Regarding mental health,

there is inconclusive evidence regarding the long-

term association between amputation and increased

risk for depression, whereas research does not

suggest elevated long-term levels of anxiety among

amputees compared to the general population [7,8].

There are, however, considerable inconsistencies

and ambiguities in terms of both methodology and

sampling in the existing literature, severely limiting

generalisability [7]. Moreover, literature specifically

addressing upper limb amputee quality of life and

mental health is scarce. Some articles are published in

other languages than English: Spikowska analyses the

quality of life after upper limb amputation in Polish

[13], Engelhardt et al. [14] in German and Chevrier

et al. [15] describe psychosocial aspects of rehabilita-

tion in upper limb amputations in French. Other

publications are case studies [16], or address satisfac-

tion with prostheses and functional abilities [17,18]

or the treatment of post-traumatic stress disorder

[19]. One article discusses the team approach in

dealing with the psychosocial aspects of traumatic

upper limb loss [6]. A few recent studies using the

Hospital Anxiety and Depression Scale (HADS)

suggest rates of borderline or significant depression

scores between 18% and 28% and rates of borderline

or significant anxiety scores between 30% and 35% in

samples of upper limb amputees [20,21]. To the

authors’ knowledge, no study specifically comparing

upper limb amputee life satisfaction and mental

health with a control group has been performed.

Given the unique nature and functions of the hand

and the upper limb, the mental and psychosocial

effects of losing an upper limb is likely to be different

from those of lower limb loss. Furthermore, upper

limb amputees differ from lower limb amputees in

several important aspects such as mean age at

amputation, average number and pattern of co-

morbidities and cause of amputation. Upper limb

loss typically results from traumatic injury in

relatively young adults otherwise in good health,

whereas the majority of lower limb amputations are

performed secondary to peripheral vascular disease

in elderly adults commonly experiencing several

concurrent medical conditions [20,22,23]. Thus,

pooled knowledge on both groups or knowledge on

lower limb amputees alone may not be applicable on

upper limb amputees. The need for further informa-

tion is evident.

Purpose of study

The aim of this study was to assess how upper limb

amputation affects mental health and life satisfaction

by comparing the mental health and perceived life

satisfaction among adult acquired major upper limb

amputees in Norway with a control group drawn

from the Norwegian general population.

Method

Design and subjects

We performed a cross-sectional study. Inclusion of

amputees started 1 October 2006 and was termi-

nated 30 May 2008. The control group was

randomly drawn from the National Population

Register (DSP) on 3 November 2006. Inclusion

criteria for both groups were as follows: adult (�18

years of age at 1 October 2006, i.e. born 1 October

1988 or before), resident in Norway at the time of the

survey, and mastering spoken and written Norwe-

gian. An exclusion criterion was severely reduced

cognitive function or general condition (impairing

the ability to give the information called for in the

study). For the amputees, two extra inclusion criteria

were as follows: acquired upper limb loss (congenital

excluded) and level of amputation through the radio

carpal joint or proximal of this level (major ULA).

We identified eligible upper limb amputees

(ULAs) through a search of the databases of the

two companies in Norway that make upper limb

prostheses: Norwegian Technical Orthopaedics AS

(NTO AS) and Sophies Minde Orthopaedics AS

(SMO AS). Amputees not wearing a prosthesis

(‘non-users’) were searched for in the electronic

and manual medical records of three large Norwe-

gian hospitals: Oslo University Hospital Rikshospita-

let (Oslo), St. Olav’s Hospital (Trondheim) and

Haukeland University Hospital (Bergen). Lists of

potential participants from the different sources were

pooled and duplicates removed sequencially. The

final list was checked against the DSP to exclude

patients who had died or emigrated, and against the

inclusion and exclusion criteria listed above.

We identified 390 eligible amputees. 224 filled in

questionnaires. After imputation, 201 had valid

SWLS data and 158 had valid SCL data. 1002

controls were randomly drawn from the DSP. 962

were eligible according to our inclusion- and exclu-

sion criteria. 318 filled in questionnaires. After

imputation, 296 had valid SWLS data and 224 had

valid SCL data.

Demographic features of amputees and controls

are given in Table I. Amputation-specific features are

given in Table II.

Mental health and life satisfaction Norwegian ULA 1595

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Table I. Demographic data.

Group

Amputees (n¼ 390) Controls (n¼962) p*

Variable Responders

Non-

responders Responders

Non-

responders

Between

groups

Within

amputees

Within

controls

n** 224 166 318 644

Sex [% male (95% CI)] 83.5%

(78.6–88.3)

84.3%

(78.8–89.9)

46.5%

(41.1–52.0)

45.5%

(41.7–49.3)

50.001 0.821 0.760

Age at survey***

[mean (95% CI)]

53.7 years

(51.6–55.8)

53.7 years

(50.9–56.4)

55.9 years

(53.6–58.1)

60.0 years

(58.1–61.8)

50.001 0.967 0.009

Place of residence (region)****

[number (% within group)]

East Norway 109

(48.7%)

83

(50.0%)

168

(52.8%)

313

(48.6%)

0.891 0.826 0.237

West Norway 54

(24.1%)

44

(26.5%)

72

(22.6%)

188

(29.2%)

North Norway 24

(10.7%)

16

(9.6%)

28

(8.8%)

56

(8.7%)

Trøndelag 20

(8.9%)

15

(9.0%)

27

(8.5%)

53

(8.2%)

South Norway 17

(7.6%)

8

(4.8%)

23

(7.2%)

34

(5.3%)

Ethnicity (native country)

[number (% within group)]

(n¼311)

Norway 202

(90.2%)

291

(93.6%)

0.150

Other 22

(9.8%)

20

(6.4%)

Marital status at survey

[% within group (95% CI)]

(n¼222) (n¼316)

Married, cohabitant or partner 70.7%

(64.7–76.7)

67.1%

(61.9–72.3)

50.001

Separated or divorced 7.2%

(3.8–10.6)

5.7%

(3.1–8.3)

Single 18.9%

(13.8–24.1)

13.6%

(9.8–17.4)

Widow/widower 3.2%

(0.9–5.5)

13.6%

(9.8–17.4)

Educational level

[% within group]

(n¼222) (n¼308)

No education 2.7% 4.2% 0.100

Primary school 20.7% 14.0%

Comprehensive school,

vocational training 29.7% 25.3%

Comprehensive school,

general education 10.4% 9.7%

College or university �4 years 19.8% 25.0%

College or university 44 years 12.6% 13.3%

Other education 4.1% 8.4%

Occupational status at survey

[% within group (95% CI)]

Working at home 1.8%

(0.1–3.5)

3.1%

(1.2–5.1)

50.001

Student 3.6%

(1.1–6.0)

5.0%

(2.6–7.4)

Employed 30.4%

(24.3–36.4)

44.0%

(38.6–49.5)

Self-employed 7.6%

(4.1–11.1)

4.7%

(2.4–7.0)

Disability pension 32.1%

(26.0–38.3)

4.7%

(2.4–7.0)

Retired 20.1%

(14.8–25.3)

37.1%

(31.8–42.4)

(continued)

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Data collection and questionnaires

Data were collected by postal questionnaires re-

turned by pre-paid mail. Submission of the ques-

tionnaire was taken as consent to participate in the

study. During inclusion, each informant received a

maximum of two written reminders.

The questionnaires were made in consultation with

The Norwegian Institute of Public Health. The

control group questionnaire was identical to a section

of the amputee questionnaire, the latter being part of

a larger survey of the adult acquired major upper limb

amputee population in Norway [24].

Prior to data collection, our study was approved by

the Norwegian Regional Ethics Committee. For the

search for amputees in hospital medical records, we

gained exemption from the duty of confidentiality by

The Norwegian Directorate for Health and Social

Affairs.

Variables/scales

Data were collected on demographic features, mental

health, life satisfaction, perceived social support,

physical activity and the occurrence of co-

morbidities. Demographic features were as follows:

sex, age at survey, ethnicity, marital status at survey,

current place of residence (region), educational level,

gross yearly income and occupational status at survey.

Table I. (Continued).

Group

Amputees (n¼ 390) Controls (n¼962) p*

Variable Responders

Non-

responders Responders

Non-

responders

Between

groups

Within

amputees

Within

controls

Unemployed 1.3%

(–0.0–2.8)

0.9%

(–0.0–2.0)

Occupational rehabilitation 3.1%

(0.8–5.4)

0.3%

(–0.0–0.9)

Gross yearly income

[% within group]

(n¼200) (n¼300)

No income 2.5% 2.7% 0.140

5150,000 NOK 15.5% 21.7%

150–199,000 NOK 17.5% 15.0%

200–299,000 NOK 24.0% 22.7%

300–399,000 NOK 22.0% 19.0%

400–499,000 NOK 6.5% 11.7%

4500,000 NOK 12.0% 7.3%

*Comparison between groups by either Pearson Chi square test (for frequencies) or independent samples t-test (for continuous variables).

The between groups p-value is for the comparison between responders.

CI, confidence interval.

**Where missing data reduces n, the actual n is given in the relevant cell for each variable.

***Age at survey is given as age at response for responders, and as age at the time of mailing questionnaires for non-responders.

****Norway is divided into five geographic regions based on county; East Norway: Østfold, Akershus, Oslo, Hedmark, Oppland, Buskerud,

Vestfold, Telemark. West Norway: Rogaland, Hordaland, Sogn og Fjordane, Møre og Romsdal. North Norway: Nordland, Troms,

Finnmark. Trøndelag: Sør-Trøndelag, Nord-Trøndelag. South Norway: Aust-Agder, Vest-Agder.

Table II. Amputees: amputation specific features, n¼224.

Variable Value

Age at amputation Mean 29.6 years (95% CI¼27.4731.9)

Range 0.0780.8 years

Time since amputation Mean 24.0 years (95% CI¼21.8726.3)

Range 0.3776.3 years

Unilateral amputation n¼ 214 (95.5%, 95%

CI¼ 92.8798.2)

Bilateral amputation n¼ 10 (4.5%, 95% CI¼ 1.877.2)

Level of amputation*

Forequarter 3.7% (95%CI¼ 1.276.2)

Through shoulder joint 3.2% (95%CI¼ 0.975.6)

Upper arm 24.3% (95%CI¼ 18.6730.0)

Through elbow joint 6.4% (95%CI¼ 3.279.7)

Fore arm 39% (95%CI¼ 32.5745.5)

Through wrist 23.4% (95%CI¼ 17.8729.0)

Unilateral, unknown level n¼ 1

Bilateral, not same level

on both sides

n¼ 5

Cause of amputation**

Trauma*** 84.5% (95% CI¼79.8789.3)

Cancer 6.8% (95%CI¼ 3.5710.1)

Infection 6.4% (95%CI¼ 3.179.6)

Arteriosclerosis/poor blood

circulation/diabetes

1.4% (95%CI¼70.272.3)

Overdose 0.9% (95%CI¼70.372.2)

*% of 218.

**n¼ 220 (4 missing).

***Includes occupational accidents, traffic accidents, war injury,

explosion, high voltage, other accidents, torture and self-inflicted

damage.

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Ethnicity was recorded as native country, Norway or

other. For marital status, the categories in the

questionnaire were: Married, cohabitant, partner,

separated, divorced, single, widow/widower. The

categories married, cohabitant and partner were

combined in the analyses, and so were the categories

separated and divorced. Educational level was re-

corded as: No education, primary school, comprehen-

sive school, vocational training, comprehensive school,

general education, college or university �4 years,

college or university 44 years, other education. In the

analyses, the category ‘other education’ was combined

with the category ‘primary school’. The categories for

the variables ‘Occupational status at survey’ and

‘Gross yearly income’ are displayed in Table I.

Mental health was assessed by the Hopkins

Symptom Check List 25-item (SCL-25), a 25-item

self-report symptom rating scale that measures

current anxiety and depression [25,26]. We also

obtained a report describing SCL-25 data from the

Statistics Norway population survey ‘Health in Nor-

way’. ‘Health in Norway’ describes the Norwegian

general population aged 16–79 years, and conven-

tionally divides the SCL-25 scores into three groups,

where scores 1.00–1.54 indicate good mental health,

scores 1.55–1.74 indicate a risk of mental illness and

scores �1.75 may be considered a high probability of

mental illness [27].

Satisfaction with life was assessed by the Satisfac-

tion With Life Scale (SWLS) [28–30]. The SWLS is

a 5-item measure asking respondents to rate their

agreement to statements such as ‘In most ways my

life is close to my ideal’ on a 7-point Likert scale. The

SWLS measures global life satisfaction, which can be

defined as ‘a global assessment of a person’s quality

of life according to his chosen criteria’. How satisfied

people are with their lives is based on a comparison

with a standard each individual sets for him or

herself, it is not externally imposed. The SWLS is

narrowly focussed on life satisfaction, not tapping

related constructs of subjective well-being such as

positive affect or loneliness [28].

Four yes/no questions assessed the extent of

support from the informants’ social network. Per-

ceived social support was estimated as a sum score

based on the number of yes-answers. The questions

were: ‘Have you in the last 14 days talked to (a)

Someone inside the family about joys and sorrows?

(b) Someone inside the family about health-related

matters? (c) Someone outside the family about joys

and sorrows? d) Someone outside the family about

health-related matters?’.

The informants were asked whether during the last

12 months they had been exercising on a regular

basis, more than 30 min each time and so intensely

that they were sweating. The alternative answers

were ‘Yes’ and ‘No’.

The informants gave information on the present

and/or past occurrence of the following diseases/

complaints: musculoskeletal pain, lower limb ampu-

tation and upper limb trauma other than amputation.

There was also a space for comments on this in the

questionnaire.

Data analysis

Data were processed using the Statistical Package for

the Social Sciences (SPSS1) version 14.0. For hypo-

thesis testing, the significance level was set at 0.05.

For SCL-25 data, missing data analyses were

performed, and missing values replaced by imputed

values calculated by EM (expectation-maximisation)

analyses for cases missing �10 of 25 answers. For

SWLS data, imputation based on EM analyses was

performed for cases missing �two of five answers.

The effect of upper limb amputation on the SCL-

25 and SWLS scores (between group differences) was

studied with multiple linear regression analyses. The

imputed SWLS- and SCL-scores were z-scaled before

the regression analyses. The SCL scores were

logarithm (ln) transformed in order to remove a

strong skewness of the distribution, and then z-scaled.

The variables age, educational level and perceived

social support showed nonsignificant non-linear ef-

fects and were entered in the analyses as continuous

variables. The variable gross yearly income showed

significant non-linear effects on the SWLS and on the

SCL depression scores and was included in the anal-

yses of all outcome variables as a categorical variable.

First, multiple linear regression was performed

with possible confounders in the model. Confoun-

ders included were as follows: sex, age, marital

status, birth country, place of residence, educational

level and the occurrence of leg amputation.

Second, possible mediator variables were included

in the model one at a time. Possible mediators

included were as follows: occupational status at

survey, gross yearly income last year before survey,

physical activity, social support, the occurrence of

upper limb trauma other than amputation and the

occurrence of musculoskeletal pain.

Finally, possible interaction effects between upper

limb amputation and the variables sex, age, marital

status, physical activity and perceived social support

were tested. New variables were computed as the

products between amputation and each of the other

variables. New regression analyses were run con-

secutively with all the covariates and one of the

product variables at a time.

To assess the representativeness of our control

group, we also compared the report describing SCL-

25 data from the Statistics Norway population survey

‘Health in Norway’ [27] with our data on the control

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group responders. For completeness, our amputee

responder SCL-25 scores were also compared with

our control-group scores and with the Statistics

Norway survey scores, as a supplement to the

regression analyses described above.

Results

Response rates

In sum, we identified 390 eligible ULAs. 224

returned questionnaires (responders), yielding a

57.4% response rate. This amputee population is

described elsewhere [24].

From a list of 1002 randomly drawn control group

subjects, 962 were found eligible according to our

inclusion- and exclusion criteria. 318 returned ques-

tionnaires (responders), yielding a 33.1% response rate.

Demographic data

Demographic data for the whole sample of amputees

and controls are shown in Table I and described

below.

Demographic data: differences between responders and

non-responders. There were no significant differences

within the groups regarding gender distribution or

place of residence. Within the amputee group there

was no significant difference in mean age. The non-

responder controls, however, had a slightly higher

mean age than the responder controls. The mean

difference was 4.1 years (55.9 vs. 60.0 years).

Demographic data: between group differences: responders

only. There were significant differences between

amputees and controls regarding gender distribution

and age at survey. The number of males was

considerably larger in the amputee group, whereas

the control group had a slightly higher mean age at

survey than the amputees (mean difference 2.2

years). There were no significant differences regard-

ing place of residence or birth country. All Norwegian

regions were represented. The pattern of residence

was concurrent with the number of residents in each

region [31]. Most responders in both groups were

born in Norway. There were significantly more

widow/widowers in the control group. The amputees’

educational level and gross yearly income did not

differ significantly from that in the control group, but

there were significant differences in occupational

status at the time of the survey between amputees and

controls. A considerably larger proportion of ampu-

tees received disability pension, whereas the number

of employed controls exceeded that of employed

amputees. Furthermore, significantly more controls

than amputees were retired.

Other between group differences: responders only

The amputees had a significantly higher occurrence

of lower limb amputation and of upper limb trauma

other than amputation than the control group. The

occurrence of lower limb amputation in the amputee

group was 4.5%, in the control group 0.6%,

p¼ 0.003. The occurrence of upper limb trauma

other than amputation in the amputee group was

43.3%, in the control group 3.8%, p5 0.001. There

were no significant between group differences

regarding social-support score (p¼ 0.261), physical

activity (p¼ 0.820) or the occurrence of musculos-

keletal pain (p¼ 0.109). 50.9% of amputees reported

to be exercising regularly (controls 51.9%) and

43.3% of amputees reported musculoskeletal pain

(controls 36.5%). The average social-support score

among amputees was 2.03 (controls 2.18).

SCL-25: comparison with statistics Norway’s population

survey ‘Health in Norway’

SCL-25 scores in the Health in Norway sample, our

control responder group and our amputee responder

group were compared. There were no significant

differences between either of the groups in any of the

score categories. In the Health in Norway sample

(n¼ 6192), 10% scored �1.75 [27]. In our control

group (n¼ 224), 8.9% scored �1.75 (95% CI¼ 5.2–

12.7). The CI shows that the difference is not

significant at the 5% level, indicating that our control

group responders do not differ significantly from the

general population. In our amputee group (n¼ 158)

14.6% scored �1.75 (95% CI¼ 9.1–20.1). Although

the difference from the control group or the

population sample is not significant at the 5% level,

there is a non-significant trend towards higher scores

in the amputee group.

Missing data analyses

There were 29.5% missing or incomplete SCL data

after imputation. Because of the high percentage of

missing SCL data, the group with missing SCL data

was compared with the remaining sample regarding

sociodemographic and amputation specific features.

For the SWLS scores, 91.7% had valid data after

imputation, and missing data analyses were not

performed.

Looking at amputees and controls separately,

there were no significant differences between SCL

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responders and SCL non-responders regarding sex,

place of residence, native country, marital status,

gross yearly income, time since the amputation, level

of amputation or cause of amputation. There were

significant differences regarding age at survey,

educational level and occupational status at survey.

Details on these variables are shown in Table III.

Differences between amputees and controls in satisfaction

with life and mental health

SWLS. In sum, 33 amputees and 39 controls were

missing one or more SWLS answers. For 10

amputees and 17 controls imputation was performed,

leaving 201 amputees and 296 controls eligible for

SWLS analyses. Mean standardised SWLS score

(zSWLS) for amputees was 70.20 (95% CI¼70.35

to 70.05). Mean zSWLS for the control group was

0.14 (95% CI¼ 0.03–0.24). Controlling for age and

gender, there was still a significant difference between

amputees and controls, p5 0.001. The mean differ-

ence in zSWLS in this model was 70.381 (95%

CI¼70.574 to 70.188). Controlling for age,

gender, marital status, birth country, place of resid-

ence, educational level and the occurrence of leg

amputation, the mean difference between amputees

and controls in zSWLS was 70.333 (95%

CI¼70.488 to 70.104), p¼ 0.001. Detailed effects

in this model are shown in Table IV.

Introducing possible mediator variables in the

model one at a time (Table V), it appears that the

effect of upper limb amputation on life satisfaction is

mediated mainly by changes in occupational status

and by the occurrence of short- or long-term

complications noted by the amputees as ‘other upper

limb trauma’. Based on the amputees’ comments in

the questionnaire, ‘other upper limb trauma’ include

various stump complaints, various overuse com-

plaints on the non-amputated side and sequelae of

other traumas concurrent with the amputation such

as nerve damage affecting stump function, extensive

scarring and contra lateral finger amputations. The

effect seems to a lesser extent also to be mediated by

effect on gross yearly income, a variable strongly

correlated with present occupational status.

Including all confounder and mediator variables

simultaneously, the effect of group was in the

opposite of the expected direction and no longer

significant, B¼ 0.046, p¼ 0.687. No significant

interaction effects were detected.

SCL-25. In sum, 80 amputees and 112 controls were

missing one or more SCL-25 answers. For 14

Table III. SCL responders and SCL non-responders: significant differences.

Group

Amputee responders

(n¼224)

Control responders

(n¼318) p*

Variable SCLþ SCL7 SCLþ SCL7Within

amputees

Within

controls

n** 158 66 224 94

Age at survey [mean, in years] 52.5 56.8 52.5 63.9 0.063 50.001

Educational level [% within group] (n¼ 157) (n¼65) (n¼ 220) (n¼88)

No education 0.6% 7.7% 2.7% 8.0% 0.020 0.045

Primary school or other education 17.8% 27.7% 11.8% 19.3%

Comprehensive school, vocational training 30.6% 27.7% 24.5% 27.3%

Comprehensive school, general education 11.5% 7.7% 10.5% 8.0%

College or university �4 years 21.7% 15.4% 29.1% 14.8%

College or university 44 years 14.6% 7.7% 13.6% 12.5%

Other education 3.2% 6.2% 7.7% 10.2%

Occupational status at survey [% within group (95% CI)]

Working at home 1.9% 1.5% 2.7% 4.3% 0.068 0.001

Student 4.4% 1.5% 6.7% 1.1%

Employed 34.2% 21.2% 50.0% 29.8%

Self-employed 7.6% 7.6% 5.4% 3.2%

Disability pension 28.5% 40.9% 4.0% 6.4%

Retired 20.3% 19.7% 30.4% 53.2%

Unemployed 0% 4.5% 0.9% 1.1%

Occupational rehabilitation 3.2% 3.0% 0% 1.1%

SCLþ : SCL responders (after imputation) SCL7: SCL non-responders (missing or incomplete data).

*Comparison between groups by either Pearson Chi square test (for frequencies) or independent samples t-test (for continuous variables).

**Where missing data reduces n, the actual n is given in the relevant cell for each variable.

There were no significant differences detected for the variables sex, place of residence, birth country, marital status, gross yearly income,

time since amputation, level of amputation and cause of amputation.

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amputees and 18 controls imputation was per-

formed, leaving 158 amputees and 224 controls

eligible for SCL-25 analyses.

SCL-25 anxiety score. Mean logarithm transformed

and z-scaled SCL anxiety score (zANX) for ampu-

tees was 0.040 (95% CI¼70.120 to 0.199). Mean

zANX for the control group was 70.028 (95%

CI¼70.158 to 0.102). Controlling for age and

gender, there was a significant difference between

amputees and controls, p¼ 0.040. The mean differ-

ence for zANX in this model was 0.226 (95%

CI¼ 0.01170.442). Controlling for age, gender,

marital status, birth country, place of residence,

educational level and the occurrence of leg amputa-

tion, the difference between amputees and controls

in zANX was not statistically significant, p¼ 0.177,

B¼ 0.148. Detailed results from this model are

shown in Table VI.

Introducing mediator variables one at a time in

the model (Table VII) to a greater or lesser degree

reduced the estimated B for group, suggesting

mediator effects. Including all confounder and

mediator variables simultaneously, the effect of

group remained nonsignificant, p¼ 0.201, and the

trend of the effect was in the opposite of the

expected direction, B¼70.153 (95% CI¼70.389

to 0.082). No significant interaction effects were

detected.

SCL-25 depression score. Mean logarithm transformed

and z-scaled SCL depression score (zDEP) for

amputees was 0.026 (95% CI¼70.135 to 0.186).

Mean zDEP score for the control group was 70.018

(95% CI¼70.148 to 0.112). Controlling for age

and gender, the difference between amputees and

controls was not statistically significant, p¼ 0.063,

B¼ 0.206 (95% CI¼70.011 to 0.423). Controlling

for the other confounders, the difference was clearly

not significant, p¼ 0.199, B¼ 0.143. Detailed results

from this model are shown in Table VI.

Introducing mediator variables one at a time in the

model (Table VII) to a greater or lesser degree

reduced estimated B for group, suggesting mediator

effects. Including all confounder and mediator

variables simultaneously, the trend of the effect, just

Table V. Effect of arm amputation on standardised SWLS score (zSWLS) when introducing possible mediator variables one at a time in the

model.

Mediator B for group (unstandardised) 95% CI for B p

None (model as in Table IV) 70.333 70.525 to 70.142 0.001

Occupational status at survey 70.116 70.319 to 0.086 0.260

Gross yearly income last year before survey 70.244 70.438 to 70.050 0.014

Physical activity (yes vs. no) 70.334 70.525 to 70.143 0.001

Social support 70.334 70.530 to 70.137 0.001

Occurrence of upper limb traumaother than amputation* 70.205 70.410 to 70.001 0.049

Musculoskeletal pain 70.304 70.495 to 70.112 0.002

*Many amputees noted in the questionnaires that by this they mean short- or long-term complications to the amputation such as stump

complaints and overuse complaints on the non-amputated side.

Table IV. Effects on standardised SWLS score (zSWLS), all confounders in the model.

Independent variable

B

(unstandardised) 95% CI for B Beta p

Group (amputee vs. control) 70.333 70.525 to 70.142 70.164 0.001

Gender (male vs. female) 0.037 70.158 to 0.231 0.018 0.709

Age at survey 0.003 70.003 to 0.008 0.051 0.323

Native country (other vs. Norway) 70.466 70.799 to 70.133 70.121 0.006

Place of residence:* West Norway 0.188 70.025 to 0.402 0.080 0.084

Place of residence: North Norway 70.098 70.389 to 0.193 70.030 0.508

Place of residence: Trøndelag 0.055 70.251 to 0.362 0.016 0.723

Place of residence: South Norway 0.268 70.073 to 0.609 0.069 0.124

Educational level 0.102 0.039 to 0.164 0.146 0.002

Occurrence of leg amputation 70.362 70.935 to 0.210 70.054 0.214

Marital status:** separated or divorced 70.493 70.844 to 70.142 70.121 0.006

Marital status: single 70.445 70.692 to 70.197 70.161 50.001

Marital status: Widow/widower 70.561 70.902 to 70.220 70.163 0.001

*Reference category: East Norway.

**Reference category: married, cohabitant or partner.

Mental health and life satisfaction Norwegian ULA 1601

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like for the anxiety score, was in the opposite of the

expected direction, B¼70.160 (95% CI¼70.400

to 0.080), p¼ 0.190. No significant interaction

effects were detected.

Discussion

Main findings

In our material, a tendency to poorer mental health

in the amputee group was observed, but there was no

clear evidence of such a difference. However, the

amputees scored significantly lower on life satisfac-

tion than the control group. The effect on life

satisfaction seemed to be mediated mainly by

changes in occupational status and by the occurrence

of short- or long-term complications related to the

amputation such as stump complaints and overuse

complaints on the non-amputated side.

Strength and weaknesses

A relatively low response rate in both groups is a

weakness of our study. This may have led to selection

bias in our sample. However, Table I shows that

there were no large differences between responders

and non-responders. The percentage of missing data

was also high, especially for the SCL-data, even after

imputation. This may have led to information bias.

Comparing the groups, however, such a bias may not

have seriously affected the results, as long as the bias

has the same direction in both groups. Our missing

data analyses suggest that this is the case for the

majority of sociodemographic variables and for all

amputation specific variables compared. Further-

more, comparison to SCL-25 data from Statistics

Norway indicates that our control group responders

may be considered as representative of the Norwe-

gian general population.

However, the high proportion of missing data in

the SCL analyses has reduced the statistical power to

detect systematic differences between the groups.

The sample size with valid anxiety and depression

data permits mean differences higher than approxi-

mately 0.2 SD to be detected with 85% probability,

implying that moderate effects on mental health may

have been left undetected.

Differences between amputees and controls re-

garding the possible confounders sex, age and

marital status were controlled for in the multiple

regression analyses. We did not control for current

occupational status in the initial regression analyses,

because this variable was assumed to be a mediator

of the amputation effect. To the extent that occupa-

tional status was a cause, rather than a result of

amputation, the results from these analyses are not

fully controlled for. The same might be argued for

the other assumed mediators, though a causal link to

the amputation in these cases is considered more

unlikely. On the other hand, including educational

level as a confounder may have obscured a possible

mediator effect of this variable.

Strengths of the study include comparison to a

control group, use of standardised measures and

inclusion of possible mediators as well as the

population-based sample including amputees from

the entire country, and including both prosthetic

users and non-users.

Confounders and mediators: the rationale behind

classification of some variables

Educational level was considered a possible con-

founder as the risk of occupational accidents is

higher in ‘blue collar jobs’ than in ‘white collar jobs’.

Table VII. Effect of arm amputation on logarithm transformed and z-scaled SCL anxiety score (zANX) and logarithm transformed and z-

scaled SCL depression score (zDEP) when introducing possible mediator variables one at a time in the model.

Mediator

Dependent variable

zANX zDEP

B for group

(unstandardised) 95% CI for B p

B for group

(unstandardised) 95% CI for B p

None (model as in Table VI) 0.148 70.067 to 0.362 0.177 0.143 70.076 to 0.362 0.199

Occupational status at survey 70.061 70.284 to 0.162 0.591 70.044 70.270 to 0.183 0.706

Gross yearly income last year before survey 0.116 70.101 to 0.332 0.295 0.090 70.126 to 0.305 0.414

Physical activity (yes vs. no) 0.139 70.072 to 0.350 0.196 0.135 70.081 to 0.350 0.219

Social support 0.140 70.077 to 0.357 0.205 0.160 70.060 to 0.380 0.154

Upper limb trauma other than amputation* 0.012 70.218 to 0.241 0.920 70.029 70.261 to 0.203 0.806

Musculoskeletal pain 0.117 70.094 to 0.327 0.276 0.123 70.094 to 0.340 0.267

*Many amputees noted in the questionnaires that by this they mean short- or long-term complications to the amputation such as stump

complaints and overuse complaints on the non-amputated side.

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The possible mediator effect of this variable –

amputees may undertake further education to qualify

for less physically demanding jobs – was considered

to be of less importance. In our material, there was a

strong correlation between arm amputation and leg

amputation, 10 of totally 12 leg amputees were also

arm amputees. Leg amputation is known to affect

mental health and life satisfaction [32], and we

therefore included the occurrence of leg amputation

in the analyses as a possible confounder.

Present occupational status is likely to be a

mediator of the effect of arm amputation, as upper

limb loss in many cases leads to either occupational

rehabilitation or disability pension [24]. Present

occupational status was not considered a confoun-

der, as would indeed be the case for occupational

status at the time of the amputation, occupational

accidents accounting for many arm amputations.

However, amputation in our material on average

occurred 24 years ago. Gross yearly income may be

associated with present occupational status and was

therefore also considered a possible mediator of

amputation effect. Physical activity was analysed as a

possible mediator bearing in mind that arm ampu-

tees often exercise as a part of their rehabilitation,

especially amputees with musculoskeletal pain or

difficulties with their prostheses (factors with a

potentially negative impact on life satisfaction).

Social support was considered a possible mediator

rather than a confounder, possibly affected by the

amputation but not likely to be linked to the risk of

amputation. The variable ‘upper limb trauma other

than amputation’ was considered a possible mediator

variable as many amputees noted in their question-

naires that this was directly related to the amputation

either as trauma caused by the same incident as the

amputation or as a short- or long-term complications

to the amputation.

Earlier findings

Existing literature is characterised by considerable

inconsistencies regarding methodology and sam-

pling. In many cases, pooling of upper- and lower-

limb amputees limit generalisability. In a review of

the literature, Desmond and MacLachlan concluded

that whereas research to date does not suggest

elevated levels of anxiety among people with

amputations compared to the general public or

compared to patients with chronic musculoskeletal

pain, there is little consensus regarding whether

amputees face an elevated risk of depressive symp-

toms. According to this review, the prevalence of

depressive symptoms among amputees in some

studies has been reported between 18% and 28% –

higher than the general population, but similar to the

35% prevalence reported for individuals with a

variety of physical disabilities, and to a 24%

prevalence found among individuals with chronic

pain. Other studies have failed to show increased

prevalence of depression compared to the general

population. The Medical Outcomes Study Short

Form (SF-36) scores have in several studies on lower

limb amputees been found to be poorer than in the

general population, with most prominent differences

in physical functioning, role limitation due to

physical health and bodily pain dimensions. How-

ever, mental health was in many cases not found to

be significantly reduced compared to age- and

gender-matched norm groups [7].

Studies specifically addressing upper limb ampu-

tee mental health are scarce. The findings of recent

studies are mainly in accordance with Desmond and

MacLachlan’s review. In a cross-sectional study of

British male amputees with traumatic upper limb

loss, Desmond found a prevalence of clinically

significant anxiety symptoms of 34.6%, broadly

consistent with the general population rates. The

prevalence of depressive symptomatology in this

study, using the HADS to define caseness, was

28.3%, almost three times higher than rates reported

in a non-clinical sample broadly representative of

UK adults [20]. All amputees in Desmond’s sample

had lost their limb serving in Her Majesty’s Forces or

Auxiliary Forces. The prevalence of anxiety in

Desmond’s sample was of the same magnitude as

found by Datta, who studied British patients with

proximal upper limb deficiency (acquired and con-

genital). The prevalence of depression in Datta’s

sample – also using the HADS – was however

considerably lower (18.3%) [21]. Datta’s sample was

recruited from a subregional prosthetic and amputee

rehabilitation unit. Neither compared their sample to

a control group.

In 2003, Demet et al. studied health-related

quality of life (HRQL) in French upper- and lower-

limb amputees using the Nottingham Health Profile

(NHP). The study population consisted of war

victims as well as self-employed people living in the

eastern area of France. The NHP indicated a

relatively poor HRQL for persons with limb loss

compared to other illness groups, mostly for physical

disability, pain and energy level scores. Upper limb

amputees had a better HRQL than lower limb

amputees [12]. In 2008, Saradjian et al. performed

a qualitative study of 11 male upper limb amputees,

looking at psychosocial adjustment, physical/func-

tional adaptation, coping style and the use of

prostheses. The areas of people’s lives found to be

most affected by the amputation were occupational

status, social relationships and activities of daily

living [1]. This has also been noted elsewhere

[17,18].

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Relating our findings to the literature

Regarding anxiety, our findings are undoubtedly in

accordance with the literature. Regarding depression,

our findings are indicative, but not statistically signi-

ficant 7 illustrative of Desmond and MacLachlan’s

review [7]. Our data indicate a somewhat lower

occurrence of depression among upper limb ampu-

tees than found by Desmond [20] and Datta [21],

though the observed tendency to poorer mental

health in our amputee group may be considered

consistent with their findings. Neither of these

samples was population-based or compared to a

control group. On the other hand, our findings of

relatively good mental health among upper limb

amputees may be considered consistent with what

was noted by Saradijan et al., where the amputees

were found to display ‘a positive and accepting

attitude, exhibiting an engagement in life and an

openness and embracement of new experiences

within their rehabilitation and life in general. As a

result, participants’ lives appeared minimally re-

stricted, with all describing the fulfilment of person-

ally meaningful roles, activities and relationships’ [1].

Our findings on life satisfaction are consistent with

earlier literature. Whereas the NHP used by Demet

et al. [12] measures quality of life as a sum of defined

categories including pain and physical disability, the

SWLS used in our study measures global life

satisfaction, which leaves the respondent free to

weight various domains and feeling states in what-

ever way he or she chooses [28]. Our statistical

analyses however indicate that the effect of upper

limb amputation in our sample to a large extent is

mediated by impact on occupational status and by

the occurrence of short- or long-term complications

related to the amputation (noted as ‘other upper limb

trauma’). This is in accordance with earlier studies

demonstrating severe consequences in terms of

employment [17,33] and with earlier studies using

both the SF-36 and the NHP, where reduced

physical functioning, pain and role limitation due

to physical health problems have been noted as the

most affected domains of HRQL among amputees

[7,12]. It is interesting that though the effect of upper

limb amputation on mental health in our material

was nonsignificant, the mediators significantly redu-

cing B for anxiety and depression were the same

variables that showed significant mediator effects on

life satisfaction.

The correlation between occupational status and

mental health and life satisfaction is well known, also

from population studies not including amputees

[34,35]. An important effect of falling out of the

labour market might be a feeling of not coping,

known to affect life satisfaction negatively [1,30].

This was demonstrated in Saradijan’s qualitative

study, emphasising the importance of positive coping

among upper limb amputees. High self-worth was

related to successful functional and social adjustment

[1]. The overall differences in occupational status in

our material probably reflect effects of the amputa-

tion, with a high occurrence of disability pension in

the amputee group and a high occurrence of

employed/self-employed and retired (as opposed to

disability pension) in the control group.

The correlation between pain and mental health

and/or quality of life in amputees is well established

[5,36,37], and has also been described in the general

population [38]. In a recent cross-sectional study of

104 upper limb amputees, Hanley et al. [36] found

that self-reported quality of life measured with the

SWLS was significantly lower for individuals experi-

encing each type of: Phantom limb pain, residual

limb pain, back-, neck- and non-amputated-limb

pain compared to those without any pain. A high

occurrence of pain in and problems with the

remaining arm in upper limb amputees has also

been noted [39]. We therefore tested for possible

mediator effects of the occurrence of musculoskeletal

pain in addition to the occurrence of ‘other upper

limb trauma’. Musculoskeletal pain had surprisingly

little effect measured as B-change, probably due to

the many amputees coding amputation-related pain

and problems as ‘other upper limb trauma’ rather

than musculoskeletal pain. This may in part be

explained by the phrasing of the question: ‘muscu-

loskeletal pain (for instance long-lasting back pain)’,

which may have caused the respondents to state the

occurrence of arm or shoulder pain under ‘other

upper limb trauma’ instead.

There is accumulating evidence of the associations

between physical activity and mental health and well-

being [40,41]. However, the lack of experimental

evidence for a causal link between physical activity

and improved psychological well-being has been

noted [41]. Although habitual exercise may improve

psychological well-being, a strong sense of well-being

may also be necessary to comply with a habitual and

intensive exercise programme. However, an increas-

ing number of outcome studies provide evidence for

the efficacy of exercise interventions for clinical

samples. For instance, a meta-analysis examining

data from 36 studies linking physical activity to well-

being in older adults without clinical disorders

showed a small but significant effect of exercise on

well-being [41], and a recent review concluded that

exercise can be a powerful intervention for clinical

depression [40]. In our material, physical activity did

not have a significant mediator effect on the SWLS

or the SCL scores and it was not a significant

interaction variable. Interpreting these results, one

should remember that the low statistical power in our

study does not permit other than quite strong

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interaction effects to be detected. Also, the relation-

ship between exercise and mental health in amputees

might be more complex than in the samples of

clinical depression and healthy older adults referred

above.

Social support is known to be associated with

mental health and well-being [1,42]. Studying social

support in lower limb amputees, Williams et al. [42]

found that the Multidimensional Scale of Perceived

Social Support (MSPSS) was an important predictor

of pain interference, life satisfaction and mobility,

controlling for demographic and amputation-related

factors. In the light of these findings, perceived social

support was analysed both as a possible mediator and

as a possible effect modificator in our material. No

significant between-group differences in social sup-

port were detected, and no significant effects were

found in the regression analyses. This may be

explained by different scales of measurement in

Williams et al.’s and our study, and also by our lack

of statistical power as discussed above.

Conclusions

Knowledge of the mental and psychosocial aspects of

upper limb amputation is important if one is to

succeed with amputee rehabilitation.

According to our data, upper limb loss signifi-

cantly lowers life satisfaction compared to a control

group from the general population. The effect on life

satisfaction appears mainly to be mediated by

reduced ability to work and by the occurrence of

post-amputation arm complications. A tendency to

poorer mental health in the amputee group was

observed, but there was no clear evidence of such a

difference. Further studies are recommended.

Emphasising measures that facilitate return to

work in upper limb amputee rehabilitation is likely

to be of importance for the amputees’ well-being as

well as for their physical function. Furthermore,

focus in amputee rehabilitation should be kept on

preventing complications shown to have an impact

on life satisfaction, such as stump and overuse pain

and prosthetic- and musculoskeletal dysfunction.

Within amputee group factors that may affect

mental health and quality of life such as amputation

level, cause of amputation, time since amputation,

the use of and satisfaction with prostheses, rehabili-

tation experiences and details on pain and physical

function will be addressed in subsequent papers.

Acknowledgements

We thank Espen Røysamb, Professor Dr. Psychol.

for his advices regarding choice of scales for the

assessment of mental health and life satisfaction. We

also thank Nina Gunnes, statistician PhD, for her

statistical advices.

Declaration of interest

The authors report no declarations of interest. Our

work was funded in part by Innlandet Hospital Trust

and in part by The Norwegian Extra Foundation for

Health and Rehabilitation.

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