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RIGINAL ARTICLE

uality of Life of Persons With Lower-Limb Amputationuring Rehabilitation and at 3-Month Follow-Up

iana Zidarov, PT, MSc, Bonnie Swaine, PT, PhD, Christiane Gauthier-Gagnon, PT, MSc

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ABSTRACT. Zidarov D, Swaine B, Gauthier-Gagnon C.uality of life of persons with lower-limb amputation during

ehabilitation and at 3-month follow-up. Arch Phys Med Re-abil 2009;90:634-45.

Objective: To describe and compare the quality of lifeQOL) of persons with lower-limb amputation (LLA) at ad-ission (T1), discharge (T2), and 3 months after rehabilitation

ischarge (T3) and to explore the relationships between QOLnd demographic and clinical variables including body image.

Design: Longitudinal case series.Setting: Inpatient rehabilitation facility.Participants: Consecutive sample of 19 unilateral persons

ith LLA (14 men, mean age, 53.4�14.6y).Intervention: Interdisciplinary rehabilitation.Main Outcome Measures: Generic and specific QOL mea-

ures and perception of body image at T1, T2, and T3.Results: Subjective QOL was relatively high at T1, T2, and

3 (0.87/2, 1.1/2, and 1.0/2, respectively) except for itemselated to physical functioning. There was no significanthange over time for all but 1 QOL satisfaction measureability to go outside, P�.024). Prosthesis-related QOL wasigh at discharge and follow-up. Body-image disturbancesere absent over the study period. QOL satisfaction and pros-

hesis satisfaction were strongly related to lower-limb pain andsychosocial factors (eg, body image).Conclusions: QOL of persons with LLA was high and

emained relatively stable during inpatient rehabilitation and 3onths after discharge.Key Words: Amputation; Body image; Quality of life;

ehabilitation.© 2009 by the American Congress of Rehabilitationedicine

OWER-LIMB AMPUTATION is a permanent surgicalprocedure that has important functional, psychologic, and

ocial sequelae that can influence the QOL of the person withmputation.1,2 Although rehabilitation aims to address theseequelae,3 measuring the effect of these interventions on reha-ilitation outcomes of people who have had an LLA remains ahallenge. The selected outcomes must be related to rehabili-ation goals that are specific to each person and associated with

From the School of Rehabilitation, University of Montreal (Zidarov, Swaine,authier-Gagnon); Montreal Rehabilitation Institute (Zidarov, Swaine); and Center

or Interdisciplinary Research in Rehabilitation of Metropolitan Montreal (Swaine),ontreal, QC, Canada.Supported by the Montreal Rehabilitation Institute Foundation, the Fonds de la

echerche en santé du Québec, the Ordre professionnel des physiothérapeutes duuébec, and the Faculté des études supérieures of the Université de Montréal.No commercial party having a direct financial interest in the results of the research

upporting this article has or will confer a benefit on the authors or on any organi-ation with which the authors are associated.

Correspondence to Diana Zidarov, PT, MSc, 3600 Av Darlington, Montreal, QC,anada, H3S 2J4, e-mail: dzidarov@yahoo.fr. Reprints not available from the author.

0003-9993/09/9004-00905$36.00/0doi:10.1016/j.apmr.2008.11.003

rch Phys Med Rehabil Vol 90, April 2009

remorbid function.1,4,5 There is currently no consensus onhich outcomes to measure or how to measure them.4,6,7 This

s surprising given that amputee rehabilitation programs haveommon goals to improve mobility and functioning throughrosthetic fitting to assist community reintegration and to ulti-ately improve the overall QOL of persons with an LLA.QOL is increasingly used to measure outcome in rehabilita-

ion.8-12 QOL is complex, and there is no consensus regardingsingle definition or about the domains that constitute

OL.10,13,14 There are 2 aspects that are included in almost allefinitions: multidimensionality and subjectivity of QOL. Mul-idimensionality is taken into account in the numerous toolsvailable to assess QOL because they cover various domains.hese can include health status; physical, social, mental, andmotional function; pain; relationships; life satisfaction; andell-being.9,10,13,15 The subjective aspect of QOL reflects theerson’s own perceptions based on his/her education, life ex-eriences, values, expectations, and environment in which theerson lives.11,16,17

Health-related QOL can be measured with generic or con-ition-specific instruments. Generic instruments are applicableo a wide range of patient populations including those withoutealth conditions.13 An advantage resulting from this broadpplicability is that generic questionnaires can provide popu-ations norms or benchmarks of healthy populations to whichopulations with a specific condition can be compared.13 Fur-hermore, they also permit comparisons across populationsith different conditions and across interventions.13 However,ecause they assess the broadest possible range of QOL di-ensions, they are less sensitive to change and also to specific

ssues of concern to populations with a specific condition (eg,ersons with an LLA).13,18 In contrast, specific instruments arearticular to a certain population and, as such, focus on areas ofnterest relevant for that population and may be closer tolinicians’ interests and interventions.18 One disadvantage ofondition-specific measures is that they do not allow for aomparison of people with disabilities to a general healthyopulation or among groups with different impairments.12,18

nother disadvantage is that because of their narrower focus,

List of Abbreviations

ABIS Amputee Body Image ScaleADLs activities of daily livingANOVA analysis of varianceLLA lower-limb amputationNHP Nottingham Health ProfilePEQ Prosthesis Evaluation QuestionnaireQOL quality of lifeSF-36 Medical Outcomes Study 36-Item Short-Form

Health SurveySQLP Subjective Quality of Life ProfileTF transfemoralTT transtibial

VAS visual analog scale

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635QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

hey may miss measuring an unexpected finding (eg, sexualissatisfaction, financial problems). Because of the comple-entarities and the different level of detail assessed by generic

nd specific instruments, some believe that it is best to use botho capture the majority of the dimensions of QOL.13 Withersons with an LLA, the majority of outcome studies to dateddress mobility, functional abilities, and use of prosthesis ashe most important measures to evaluate rehabilitation out-omes4,19 despite the growing interest in patients’ QOL.10

utcomes studies addressing health-related QOL of personsith an LLA are relatively recent.20-27 These studies have usedostly generic tools such as the Reintegration to Normaliving,28 the NHP,29 and the SF-36.30 In recent years, specificOL tools, such as the PEQ31 and the Trinity Amputation androsthesis Experiences Scales,24 have been developed specifi-ally for use with people with amputation.

Nissen and Newman22 identified areas that were difficultith regards to the reintegration to normal living of 42 elderlyersons with an LLA amputated several years previously. Theost negatively affected areas in order of importance were

articipation in recreational activities, work activities, andommunity mobility. Another study using the NHP to measurehe perceived health status of persons with an LLA (n�130,edian time interval�38 months after limb amputation for

eripheral arterial disease) found reintegration to be poor sec-ndary to restricted mobility.32 Van der Schans et al20 inves-igated potential determinants of health-related QOL of personsith an LLA (n�437, median time since amputation�10y) and

oncluded that persons with phantom limb pain have poorerealth-related QOL, as measured with the SF-36, than personsithout pain. Furthermore, 28.7% of the variance of the meanF-36 score was explained by 3 determinants: walking dis-

ance, stump pain, and diabetes. A recent study by Asano et al33

tudied predictors of QOL with a large sample of 415 personsith a unilateral LLA (0 to �14y since amputation). Symp-

oms of depression accounted for 30% of the variance of QOLollowed by prosthetic mobility (6% of the variance) and socialupport (2% of the variance). This study underscored themportance of psychosocial adaptation after an LLA and itsmpact on QOL. In contrast, Harness and Pinzur23 when usingcondition-specific measure, the PEQ, with a sample of non-

raumatic TT persons with amputation (on average 38.1mofter using their prosthesis), showed that the mobility andunctional domains scores of the PEQ were lower than those ofhe psychosocial domains.

A few studies have investigated the relationships betweenody image of people with LLAs and QOL. Rybarczyk et al34

ound that 53% of the variance of QOL was predicted by theerson’s perceived body image, social stigma, health, and timeince amputation. Breakey35 developed the ABIS and foundhat the body image and psychosocial well-being (a componentf QOL) of persons with an LLA was significantly correlatedith QOL. The more negative the person’s perception ofis/her body image, the less satisfied he/she was with his/herOL. Similar results were obtained by Miller36 with a samplef 51 vascular persons with an LLA; a person’s perception ofody image and self esteem predicted 63% of the variance ofOL.Although these studies have improved our understanding of

he QOL of persons with an LLA, they were all cross-sectionalnd conducted several months or years after the amputation.urthermore, they used either a generic or specific tool, neveroth, except to validate a newly developed specific tool. Con-equently, not all dimensions that may be of importance for aerson with an LLA were assessed in a given period. Rehabil-

tation interventions have a holistic approach of the person, e

hich all aim to impact on the QOL of patients. To determinehether this aim is attained, one must assess QOL at rehabil-

tation discharge. Moreover, QOL is an especially cogent mea-ure of the performance of health care because it incorporatesultiple domains that are addressed during the rehabilitation

rocess, and, most of all, it involves the patient’s own percep-ion of his/her accomplishments during the process.12 To ournowledge, no study has yet investigated, using both genericnd specific measurement tools, the overall QOL of personsith an LLA and whether it changes during and after rehabil-

tation.The purposes of this study were to (1) describe and compare

he QOL of persons with an LLA at admission, discharge, andmonths after rehabilitation discharge and (2) explore the

elationships between QOL and certain demographic and clin-cal variables, including body image.

METHODS

tudy SampleThis exploratory longitudinal study was conducted with per-

ons with an LLA who were consecutively admitted to theontreal Rehabilitation Institute in Quebec, Canada, for inpa-

ient rehabilitation between September 2005 and December006. Patients received an individualized program from a mul-idisciplinary team. This program includes daily physical ther-py and occupational therapy for preprosthetic and prostheticraining and psychologic support to the patient and their family;dditional family support and sociovocational orientation isrovided by a social worker, and leisure activities are offered innd out of the rehabilitation center. Once a week, all patientseet with their rehabilitation team to set rehabilitation objec-

ives for the upcoming week.Inclusion criteria consisted of (1) being 18 years or older and

aving a unilateral TT or TF amputation from any cause exceptongenital, (2) having sufficient cognitive skills and French ornglish comprehension to be able to accurately respond touestionnaires, and (3) being admitted for a first rehabilitationor prosthetic training. The last criterion was chosen to mini-ize the effects of confounding variables (eg, multiple admis-

ions to rehabilitation for subsequent amputation of the residualimb) so the results observed were specific to a first rehabili-ation stay.

The research protocol was approved by the Research Ethicsommittee of the Center for Interdisciplinary Research inehabilitation of which the Montreal Institute is a site. Subjects

igned an informed consent form before participating.

rocedureData were collected at 3 times: during the 7 days after

dmission to the inpatient rehabilitation program (T1), duringhe 7 days before discharge (T2), and at the 3-month follow-upT3). All data were collected by using questionnaires that wereither self-administered or administered during the interviewepending on the participant’s ability to answer (eg, no visualroblems or difficulty in understanding certain questions). In-erviews were conducted by the same evaluator (D.Z.), a seniorhysical therapist with over 10 years of experience. The fol-owing information was extracted from the patient’s medicalhart: age, highest level of completed education, level and datef amputation, duration of prosthetic training, length of stayrehabilitation), associated medical conditions, and marital and

mployment status at the time of amputation.

Arch Phys Med Rehabil Vol 90, April 2009

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636 QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

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easurement InstrumentsSubjective Quality of Life Profile. General QOL was mea-

ured with a generic tool, the SQLP.16,37,38 This questionnaireas selected, in part, because it was originally developed inrench and the majority of patients admitted to the Montrealehabilitation Institute are French speaking. Furthermore, itllows respondents to report their level of satisfaction (satis-action scale) with regards to each domain evaluated; to indi-ate the importance of each item and domains in their lifeimportance scale); and, most of all, to express the changeshey expect to occur over time with regards to their rehabili-ation services (anticipated change scale). Finally, this ques-ionnaire has the advantage of being flexible in that it contains7 core items as well as optional items (n�54) that can bedded depending on the population studied. The core itemsover 4 domains: functional life (physical and mental health),ocial life (relationships, social roles), material life (income),nd spiritual life (religious experiences, ability to think, futurexpectations). The SQLP was used and validated with healthyubjects and with populations with psychiatric or somatic dis-rders39 but never with persons with an LLA. The convergentalidity between the SQLP and the World Health Organizationuality of Life questionnaire was shown (r�.45).40 The SQLPas shown to have high internal consistency (Cronbach�0.9) and moderate to fair test-retest reliability (Spearmanrange, 0.3–0.5, P�.005).37

In the present study, we collected data for the 27 core items,nd 9 additional questions from the optional list of the SQLPere added based on both our literature review and the authors’

linical experience. Participants were questioned about theiryesight, hearing, body weight, overall physical aspect, inde-endence, future, relations and dependency on family, andeeling different from other people. For each item, 3 measuresere obtained. The respondents rated their satisfaction/dissat-

sfaction level (–2, very unsatisfied; 0, indifference; 2, veryatisfied). Next, they indicated the importance of each item (0,nimportant to 3, extremely important), and, finally, they re-orted the change they expected during their rehabilitation (–2,hange very unfavorably; 0, no change expected; 2, changeery favorably). Results are presented in the form of profiles; aean score is calculated for each item and for each of the 3

lobal scores.Prosthesis Evaluation Questionnaire. The PEQ31 was

sed to evaluate the function of a lower-limb prosthesis and therosthesis-related QOL of the persons with an LLA. It contains2 items grouped into 9 validated independent subscales: am-ulation, appearance of the prosthesis, residual limb health,erceived responses, frustration, social burden, prostheticounds, utility, and well-being. It also includes additional ques-ions (not contained in the subscales) about satisfaction withhe prosthesis, pain, transfers, prosthetic care, self-efficacy, andther aspects of the prosthesis. The PEQ subscales and theubscales of the SF-36, the Sickness Impact Profile, and therofile of Mood States–short form were found to be signifi-antly correlated (r�.49–.61).31 The PEQ has also shown goodo excellent internal consistency (Cronbach � varies from .73o .89 for each of the 9 subscales) and moderate to excellentest-retest reliability for a mean retest period of 30 days (intra-lass correlation coefficient�.56–.90, for the 9 subscales).31

In this study, we used only 4 of the 9 subscales: appearance,tility, sounds, and well-being. The questions addressing sat-sfaction with prosthesis (n�1) and self-efficacy (n�3) werelso included for a total of 21 items. Patients indicated theiresponses on a VAS (10-cm line) with the 2 boundaries rep-

esenting extremes of possible answers (eg, never or all of the s

rch Phys Med Rehabil Vol 90, April 2009

ime). A score for each subscale was calculated by computinghe arithmetic mean of all the questions that were applicable toach respondent within the particular subscale. The PEQ wasdministrated only at discharge and at the 3-month follow-upecause patients do not have their prosthesis on admission.Amputee Body Image Scale. The ABIS35 assessed per-

ons’ perception of their body image with and without pros-hesis. It contains 20 items measured with a 5-level Likert scaleanging from none of the time to all of the time. A total scorean be calculated that ranges from 0 to 100, where low scoresndicate the relative absence of body image concern. Thenternal consistency was shown to be high (Cronbach�.88).35 Although there is a lack of information regarding the

ool’s other psychometric properties, to our knowledge, theBIS is the only tool developed to specifically address body

mage with persons with an LLA.

ata AnalysisDescriptive statistics were computed for the questionnaires

cores as well as for the sociodemographic and clinical char-cteristics. Mean and SD were used for the continuous data andrequencies and percentages for the categoric data. The differ-nces between the means of each item of the SQLP at the 3valuation times were tested with a 1-way repeated-measuresNOVA with time of measurement as a within-subjects factor.hen significant results were obtained (P�.05), post hoc com-

arisons were performed by using the Bonferroni correction forultiple comparisons. Paired t tests were used to test differ-

nces in means between discharge and the 3-month follow-upor the PEQ and ABIS questionnaires. Independent t tests weresed to examine the influence of sex, level and cause ofmputation on duration of stay, duration of prosthetic training,nd ABIS scores at discharge and at follow-up. Pearson cor-elation coefficients were used to test relationships betweenlinical, sociodemographic, and questionnaire scale or subscaleariables regrouped under 4 categories (appendix 1). The sig-ificance level was set at .05 for all analyses. All analyses wereerformed with SPSS, version 14.0 for Windows.a

RESULTS

emographic and Clinical VariablesOf the 114 persons with an LLA admitted to the program

uring the study period, only 29 (26%) met the eligibilityriteria. Of the 85 remaining, 30% were readmissions, 34% hadbilateral amputation, 11% insufficiently understood French ornglish, 16% had important cognitive or psychiatric problems,nd 9% were not considered as potential prosthetic wearers. Ofhe 29 eligible subjects, 6 (21%) refused to participate, 1 diedt follow-up, and 3 had an unplanned discharge. Data for the 3valuation times were obtained for 19 participants. Table 1ummarizes their clinical and demographic characteristics. Theain cause of amputation was peripheral vascular disease

63%) with or without diabetes. They suffered from severalssociated medical conditions; 52.6% had high blood pressure,2.1% had visual problems, 21.1% had hearing problems, and6.3% had chronic kidney failure. The mean time betweenmputation and admission to rehabilitation did not significantlyiffer (P�.05) according to the level or cause of amputation.he same results were obtained for the mean duration of staynd the mean duration of prosthetic training.

ubjective Quality of Life ProfileThe mean global satisfaction scores of the SQLP at admis-

ion, discharge, and follow-up were 0.87, 1.10, and 1.01,

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637QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

espectively (fig 1). At admission, the items for which theowest satisfaction was expressed were the ability to go outside.26) and overall fitness (.26). The most satisfaction was re-orted for items relating to relationships with other people (1.7)nd material conditions (1.65). At discharge, sexuality (.42)nd body weight (.42) had the lowest scores, whereas ability tohink (1.79) and relationships with others (1.74) were theighest. At follow-up, the items with the highest scores werehe same as those at discharge, and sexuality (.37) and physicalbilities (.42) scored the lowest.

With regards to the patients’ importance of the variousomains of life, the mean global scores for the 3 evaluationimes were all 1 or more, indicating that they were perceived asery important (fig 2). In general, the importance slightlyecreased from admission to follow-up. At admission, thebility to think (2.52) and independence (2.43) were the mostmportant items, whereas spirituality (.61) and surroundingorld (.96) were the least important. At discharge, eyesight

2.21) followed by independence, going outdoors, sleep, andbility to think (2.16) were the most important items for theersons with an LLA. Group participation (.63) and surround-ng world were the least important (.79). At the 3-monthollow-up, the same items were rated as unimportant, whereasoing outdoors (2.16) and companionship (2.11) were judgedhe most important.

The mean scores for the anticipated changes indicated thatersons with an LLA expected a fairly favorable change in thearious domains of life during rehabilitation (fig 3). Meancores slightly decreased from admission to follow-up. Atdmission, the greatest changes were expected in the ability to

Table 1: Clinical and Demographic Characteristics of the Sample

Variable n Frequency (%)

Cause of amputationVascular 12 63.2Traumatic 3 15.8Tumor 2 10.5Infection 2 10.5

Level of amputationTT 16 84.2TF 3 15.8

SexMen 14 73.7Women 5 21.7

Marital statusMarried/committed 9 47.4Single 5 26.3Divorced/widowed 5 26.3

EducationPrimary 2 10.5Secondary 10 52.7Post secondary 7 36.8

Employment status at the amputationEmployed 12 63.2Retired 7 36.8

Variable Mean � SD Range

Time since amputation (d) 73.3�87.7 7–384Duration of rehabilitation stay (d) 84.3�23.3 59–146Duration of prosthetic training (d) 49.2�19.2 29–105Age (y) 53.4�14.6 26–78

o outside and independence (1.43), and the least change was A

xpected in spirituality (.09), hearing, and relationships (familynd relatives�.13). At discharge, going outdoors, overall fit-ess, and view of the future (1.32) were expected to change theost, whereas hearing (0.11), relations with others, and meals

.21) were not. At follow-up, participants still expected theirhysical abilities (1.05) and their overall fitness (.89) to im-rove, whereas spirituality and meeting friends (.11) were notxpected to change.

The change in subjective QOL was analyzed item by itemor each measurement scale (satisfaction, importance, antici-ated change) by using a repeated-measures ANOVA. Pair-ise comparisons (Bonferroni correction applied) were per-

ormed for comparisons reaching significance (table 2) toetermine when the differences occurred. After applying theonferroni correction, 5 were still significant (see table 2).here was a significant increase in patients’ mean total satis-

action score concerning the ability to go outside betweendmission and discharge (F2,34�5.77, P�.007). The impor-ance perceived concerning ADLs significantly decreased be-ween admission and discharge (F2,34�3.89, P�.03). The im-ortance attributed to the ability to think and concentrate alsoecreased between admission and follow-up (F2,34�5.39,�.009). Change anticipated with rehabilitation decreased sig-ificantly from admission to follow-up concerning the ability too outside (F2,34�5.09, P�.012) and sleep (F2,34�4.80,�.015).

rosthesis Evaluation QuestionnaireIn general, patients’ overall perception was very favourable,

ith no significant differences found between scores at dis-harge and follow-up (P�.05) for the 4 selected PEQ subscalestable 3). The mean prosthesis satisfaction scores were alsoigh, indicating greater satisfaction with the prosthesis at dis-harge and at follow-up (7.4 and 7.0, respectively), and thesecores did not differ significantly. Patients indicated that if thet and the comfort of their prosthesis were both poor at dis-harge, they completed on average 55% of their daily activities.esults were similar at the 3-month follow-up, and there wereo significant differences between scores at discharge and atollow-up. Regarding the amount of activities performed with-ut the prosthesis, on average, patients performed significantlyess activities without their prosthesis at follow-up than atischarge (t17�3.43, P�.003).

mputee Body Image ScaleThe mean ABIS score at discharge was low, and it did not

iffer significantly from that at follow-up (see table 3). Sub-roup analyses revealed that at discharge persons with a TFLA (47.5�22.6) reported a significantly poorer perception ofody image compared with that of persons with a TT LLA25.5�11.4, t17�–2.63, P�.017). At the 3-month follow-up,omen (50.9�24.7) had a significantly higher body imageisturbance compared with men (23.3�13.3, t17�–3.088,�.007).

elationship Between Patient/Clinical Variables anduality of Life and Prosthesis SatisfactionAt discharge, strong and significant relationships were found

etween QOL satisfaction and bothersome pain in the nonam-utated leg, adaptation to amputation, presence of phantomimb pain, and adaptation to prosthesis (table 4). At the-month follow-up, QOL satisfaction was significantly corre-ated with the PEQ’s well-being and utility subscales, adapta-ion to amputation, body image, and adaptation to prosthesis.

t discharge, prosthesis satisfaction was strongly correlated

Arch Phys Med Rehabil Vol 90, April 2009

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638 QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

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ith the perception of the utility of the prosthesis and therequency of back and residual limb pain (table 5). At 3onths, prosthesis satisfaction was still strongly associatedith the utility of the prosthesis and prosthesis adaptation andody image.

DISCUSSIONThis is the first study to document the QOL of persons with

n LLA and to determine whether it changes during and after

-2 -1.5 -1 -0.5 0

mean global score

ADLs

going outside

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sleep

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self opinion

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health

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aterial conditions of everyday life

physical abilities

feeling of freedom

how you regard your future

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eyesight

weight

hearing

physical appearance

relationship with family

independence

dependence on family

with regard to the future in general

feeling close/different from people

Admission Disch

period of intensive inpatient rehabilitation. Results obtained p

rch Phys Med Rehabil Vol 90, April 2009

ith the SQLP showed that at admission persons with an LLAended to be mostly unsatisfied with items related to theirealth and physical functioning (eg, ADLs, going outside,verall fitness, independence, physical abilities). These do-ains were judged very important to the subjects, and theyere associated with the highest expectations for favorable

hange during inpatient interdisciplinary rehabilitation. Againt discharge and follow-up, items related to physical function-ng (physical abilities, overall fitness, personal future) were still

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639QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

xpected improvements before discharge and in the months toome.

These results are difficult to compare directly with thosebtained by others mainly because of the differences in thentervals of time between the completion of rehabilitation and

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he evaluations and the tools used to measure QOL. Studies N

ere conducted months or years postrehabilitation and usedrimarily a single-item question33 or generic tools providingither a total or subscale scores.20-22,25,32 The SQLP provided aore detailed profile (item by item) in relation to 3 measure-ent scales: satisfaction, importance, and anticipated change.

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640 QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

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f others who found that physical functioning20,21 and mobil-ty32 were problematic months and even years after an ampu-ation.

When our results are compared with the mean total SQLPatisfaction scores of nondisabled persons (.77),39 we find thathe mean total satisfaction scores of persons with an LLA areenerally higher at admission (.87), discharge (1.10), and atollow-up (1.01). The participants satisfaction profile concern-

-2 -1.5 -1 -0.5 0

mean global score

ADLs

going outside

overall fitness

pain

relationship with other people

sleep

ability to think and concentrate

sexuality

people's attitude

meals

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health

close relationships

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living with someone

aterial conditions of everyday life

physical abilities

feeling of freedom

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faith

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eyesight

weight

hearing

physical appearance

relationship with family

independence

dependence on family

with regard to the future in general

feeling close/different from people

Admission Discharge

ng interpersonal relationships was similar to that obtained with p

rch Phys Med Rehabil Vol 90, April 2009

normal sample.39 Surprisingly, physical appearance was per-eived more satisfactory at all 3 evaluation periods by personsith an LLA compared with the normal sample. However,

tems related to health and physical functioning, such as inde-endence, physical abilities, and dependence on family, werecored lower by the participants than by healthy individuals.exual satisfaction was also scored lower by the participants inll 3 evaluation periods when compared with the normal sam-

1 1.5 2

3-month follow-upFig 3. Persons with LLA anticipatedchange scale of the SQLP on admission,discharge, and 3-month follow-up.

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han those of other persons with an LLA who reported beingoderately satisfied with their sexual behavior.41

Concerning the evolution of the subjective QOL, few resultsere significant. This may indicate that the SQLP is not sen-

itive to change or that another phenomenon, not specificallyeasured in this study, may have occurred. Here, we refer to a

esponse shift. A response shift has been defined as a change innternal standards, a change in importance of values, and re-onceptualization of a subjective concept, such as QOL, after aodification of a peron’s health status.42 A response shift may

xplain how persons with an LLA maintain or improve theirOL after a major disability that has an important physical,sychologic, and social impact.43 In our study, the relativelyigh satisfaction scores recorded at all 3 evaluations and theack of significant differences observed over time may indicatehat the rehabilitation interventions were effective in promotinghealthy response shift44 or that the amputation itself may havelleviated some of the subjects’ physical and psychologic suf-ering.

The Importance Attributed Scale of the SQLP could providemeans to measure an aspect of response shift because it

dentifies participants’ personal values and the changes relatedo them during a certain timeframe.16 In our study, the meanotal importance scores tended to decrease slightly during the 3valuation periods. The significant changes in personal valuesbserved could reflect a reduction in the importance attributedo ADLs and the ability to think and concentrate.

A change in expectations is also an indication that a responsehift may have occurred.42 Our results showed that the totalean anticipated change scores tended to decrease from ad-ission to follow-up and that significant results were obtainedith regards to the ability to go outside and to sleep. These

Table 2: Change of Subjective QOL for Each Me

VariableMean Difference

(T2–T1) (P) 95% CI

Satisfaction scaleAbility to go outside 1.00 (.024) 0.12 to 1.89

Importance scaleADLs �0.50 (.024) �0.94 to �0.06Ability to think NS NS

Anticipated change scaleAbility to go outside NS NSSleep NS NS

bbreviations: CI, confidence interval; NS, not significant.

Table 3: Mean Scores for the PEQ Subscales, Prosthesis Satisfact

Variable Possible Score D

PEQ subscalesWell-being 0–10Appearance 0–10Utility 0–10Sounds made by prosthesis 0–10Satisfaction with prosthesis 0–10

Self-efficacy questionsFit of prosthesis 0–10Comfort of prosthesis 0–10Daily activities done without prosthesis 0–10ABIS 0–100

P associated with ANOVA. Significant results indicate differences betwe

esults indicate that patients’ perceptions about their reality andheir expectations converge over time. In other words, it isikely that a response shift occurred indicating that ultimatelyersons with an LLA did report some improvement in theirOL.The authors of another very recent study,33 with a much

arger sample of participants with LLA (n�415), also hypoth-sized that a response shift could possibly explain the relativelyigh QOL scores they observed (mean score, 7.4�2.1 out of0). It is interesting to note that time since amputation of theirample varied from 0 to more than 14 years and QOL scoresended to improve (but not significantly) with time. In contrast,he perception of QOL in our sample tended to decrease oncehe person returned home. One could argue that in the monthsfter discharge, people may experience different real-life situ-tions that make them realize their limitations, which conse-uently can lower their perception of their QOL. On the otherand, the relatively high QOL satisfaction of our participantsay be caused by the relatively short period between the

mputation and their admission to rehabilitation (77.3d) whenheir QOL was first evaluated. In fact, for persons with ampu-ations of vascular causes, the amputation of a leg that mayave caused pain and a low level of functioning for monthsreviously may be seen as a relief and may have contributed tohe high satisfaction responses observed.45 Among personsho sustained an amputation after a trauma, the elevated QOL

cores may be because of their happiness of having survivedheir injury.

rosthesis-Related Quality of LifeConcerning results obtained with the PEQ, participants’ sat-

sfaction with the prosthesis and their perception about the

ment Scale Using Repeated-Measures ANOVA

ean Difference(T3–T2) (P) 95% CI

Mean Difference(T3–T1) (P) 95% CI

NS NS NS NS

NS NS NS NSNS NS �0.61 (.022) �1.14 to �0.08

NS NS �0.67 (.019) �1.24 to �0.10NS NS �0.61 (.005) �1.05 to �0.17

elf-Efficacy Questions, and the ABIS at Discharge and Follow-Up

n atge � SD

Rangeat Discharge

Mean atFollow-Up � SD

Range atFollow-Up P*

1.3 5.6–10.0 7.9�1.5 3.5–10 .7391.6 3.6–8.8 7.5�1.8 2.1–10.0 .2351.3 4.4–9.6 7.5�1.5 3.4–9.5 .8251.7 3.6–10.0 7.9�2.4 1.6–10.0 .1111.5 4.9–10.0 7.0�1.7 3.1–9.1 .498

1.5 1.8–7.7 5.6�2.3 2.0–10.0 .7762.3 0–5.9 5.2�2.7 0–10.0 .4161.7 4.4–10 4.6�2.7 0–9.4 .00315.3 1.3–68.8 29.1�19.3 6.3–73.8 .819

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ppearance, utility, and sounds made by the prosthesis werequally high at discharge and at the 3-month follow-up. Thisay indicate that the quality of the delivered prosthesis was

dequate at discharge and that the timing of delivering aefinitive prosthesis was well targeted by the rehabilitationeam in relation to residual limb issues (maturation, woundealing, and so on). The high mean PEQ subscale scoresbtained in our study are similar to those obtained by Legro,31

arness,23 and colleagues in their cross-sectional studies.owever, in contrast to our results (8.0 at discharge and 7.9 at

ollow-up), these authors reported lower well-being subscalescores (7.2 and 6.7, respectively) when assessed several yearsfter prosthetic rehabilitation. These differences may be be-ause of the fact that well-being is a dynamic concept. Aerson’s perception may change according to his/her life ex-eriences as they are influenced by the person’s physical andocial environment, personality, or new health problems.14,40

his may explain, in part, the slight decrease in well-being orOL after an LLA that occurs later. It remains unclear, how-

ver, when this change occurs and what factors are associatedith this event. Nevertheless, our results, as well those studiesiscussed here, indicate that the perceived well-being of per-ons with an LLA is consistently high after their amputation.

ody ImageOne major finding was that participants were not very con-

erned with their body image at the 3 evaluation periods. Theedian ABIS score observed in our study was lower at dis-

harge (23.8) and at the 3-month follow-up (21.3) comparedith those reported in other studies using this tool.35,36,46

reakey35 reported body image perturbation among males withraumatic amputation of a similar age to be 33.5, whereas

iller36 obtained a score of 53 among nontraumatic personsith an LLA suggesting that older and vascular amputees maye more concerned about their body image than younger trau-atic amputees. Others have, however, reported higher ABIS

cores among persons with amputations of mixed causes (eg,7.5).46 Comparisons between studies are difficult because ofhe differences in sample composition and the timing of thevaluations. In fact, time since amputation may play a role inhe development of body image disturbance. In our study, meanime since amputation was very short (73.3�87.7d) comparedith those reported in Breakey’s (17.0�13.5y) and Miller’s

tudies (5y). It seems that with the passage of time, persons

Table 4: Correlation Coefficients Between Mean Total QOLSatisfaction Score as Measured by the SQLP and Patient/Clinical

Variables Measured at Discharge and at 3-Month Follow-Up

Variables

PearsonCorrelationCoefficient n P

DischargeBothersomeness of pain in

the nonamputated leg 0.705 9 .034Adaptation to amputation 0.741 19 �.001Phantom limb pain �0.497 19 .031Adaptation to prosthesis 0.460 19 .048

3-month follow-upPEQs well-being scale 0.733 19 �.001PEQs utility scale 0.685 19 .001Adaptation to amputation 0.684 19 .001Total score ABIS �0.604 19 .006Adaptation to prosthesis 0.602 19 .006

ith an LLA tend to develop a concern for their body image.

rch Phys Med Rehabil Vol 90, April 2009

owever, more longitudinal studies are needed to clarify whenhis occurs and to determine the contributing factors. Concern-ng the potential influence of sex and level of amputation onerception of body image, in contrast to our findings,reakey35 did not find a significant difference between personsith a TT and TF LLA and Miller36 did not find significantifferences between males and females. Significant results inur study may reflect a tendency toward women having areater concern about their body image once being back home.

elationship Between Patient/Clinical Variables andualtiy of Life and Prosthesis SatisfactionThe present study explored whether a relationship exists

etween demographic, clinical, prosthetic, pain sensation, andsychologic well-being variables and QOL and prosthesis sat-sfaction. Our findings suggest that participants’ perception ofheir QOL satisfaction is more related to pain sensation, pros-hetic factors, and psychosocial well-being (adaptation to am-utation, prosthesis, body image) than to clinical or demo-raphic variables such as age, sex, level, or cause ofmputation. In a sample of 77 persons with an LLA, highermputation-related pain was associated with lower QOL.41

atsen et al47 showed a significant correlation between QOLnd the condition of the contralateral limb and found significantorrelations ranging from .47 to .60 between QOL and thebility of persons with an LLA to walk in confined space oralk while carrying a load. Similar to our results, they did notnd age, sex, or level of amputation to be significantly related

o the perception of QOL. Van der Schans et al,20 whilenvestigating the potential determinants of health-related QOLmong 437 persons with an LLA by using the SF-36, foundhat respondents with phantom limb pain had a poorer health-elated QOL compared with those without phantom limb pain.lthough psychologic well-being and adjustment to an ampu-

ation were not measured directly, anxiety and depression,ocial support, phantom limb pain intensity, concerns withelf-esteem, and body image were associated with their mea-ure.35,48,49 In another study,33 symptoms of depression ac-ounted for 30% of the variance in QOL of a sample of 415ersons with an LLA and factors predicting long-term adjust-ent to an LLA such as phantom limb pain and psychosocial

ariables such as catastrophizing, perceived control over pain,nd coping and social support were found to be importantontributors to adjustment to an amputation.49 Furthermore,reater levels of social support, 1 month after an LLA, wereelated to greater levels of life satisfaction50 and social supportxplained 2% of the variance of perceived QOL.33 Callaghannd Condie27 validated the Patient Generated Index, a genericOL measure, by using the Medical Outcomes Study Short

Table 5: Correlation Coefficients Between Satisfaction With theProsthesis as Measured by the PEQ and Patient/Clinical Variables

Measured at Discharge and at 3-Month Follow-Up

VariablesPearson Correlation

Coefficient n P

DischargePEQs utility scale 0.615 19 .005Frequency of back pain �0.552 19 .014Frequency of residual limb

(stump) pain �0.461 19 .0473-month follow-up

PEQs utility scale 0.653 19 .002Adaptation to prosthesis 0.645 19 .003

ABIS total score �0.488 19 .034

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643QUALITY OF LIFE OF PERSONS WITH LOWER-LIMB AMPUTATION, Zidarov

orm-12 with 42 unilateral TF amputees who had been fittedith a prosthesis at least 1-year postrehabilitation and found a

tronger relationship between mental health and QOL life thanetween physical health and QOL.At discharge, prosthetic satisfaction seems to be mostly

ssociated with pain and prosthetic variables, whereas at fol-ow-up prosthetic variables and psychosocial variables play aole. The reduction of residual limb pain is an importantehabilitation goal. Residual limb pain may impede the use ofhe prosthesis and is associated with lower physical function-ng.51 Furthermore, a recent study found that acute residualimb pain (assessed at 4 and 5 days postamputation) was theest predictor of development of chronic residual limb pain inersons with an LLA.52 Bilodeau et al2 found that pain and theisk of injuries were the main causes of dissatisfaction with therosthesis among persons with LLA and that prosthesis satis-action explained 46% of the variance of prosthesis use. In aurvey of 44 persons with LLA investigating prosthesis satis-action, body image, and phantom pain, Murray and Fox46

ound that higher levels of prosthesis satisfaction were signif-cantly correlated with lower levels of body image disturbancer�–.52) and that the number of hours of prosthetic use wasignificantly related to prosthesis satisfaction (r�.39). How-ver, prosthesis satisfaction was not significantly related toain (r�–.019).

tudy Limitations and Clinical ImplicationsThere are a few limitations to this study. Our sample was

mall; hence, we were not able to detect significant differ-nces over time for all variables. All subjects were inpa-ients in the same rehabilitation facility and were candidatesor prosthetic fitting. As such, our results may not be gen-ralizable to the total population of persons with LLA in-luding those who never received a prosthesis, who haveilateral amputation, and who have severe cognitive disor-ers. Indeed, correlational analyses do not allow one toonclude any causal relationship between functional reha-ilitation and QOL; however, the observed significant cor-elation coefficients, despite the small sample size, under-core the importance of the relationship between the two.

Despite these limitations, there are important points to beearned from this study. The SQLP, as a measure of subjectiveOL, appears to provide valuable information about rehabili-

ation QOL outcomes and patients’ perceptions in differentomains of life that may help the multidisciplinary rehabilita-ion team identify a particular client’s objectives and treatmentlan. Individualized selection of objectives and treatment pro-ote patient involvement in the rehabilitation process.53 How-

ver, the use of the SQLP in routine clinical practice may beifficult because of practicability issues. The mode of admin-stration, frequently by interview, is lengthy (�30min), andlinicians may feel that therapy is more useful to the patienthan administration of a questionnaire even if the responsesrovide them with useful information. Furthermore, generatingnd interpreting the satisfaction profiles can be complex andime-consuming for daily practice. Ideally, more methodologicork is needed to shorten and simplify QOL tools in order toe routinely used in rehabilitation clinical settings.11,14,15,53

The specificity of the PEQ provides practitioners with theerceptions of persons with an amputation regarding aspectsmportant to their QOL such as satisfaction, appearance, andsefulness of their definitive prosthesis. This information canerve as benchmark criteria when delivering a definitive pros-

hesis before discharge. The only practicability issue with re-

ards to using the PEQ routinely was that some older partici-ants found it difficult to understand the VAS and to completehe questionnaire by themselves.

The ABIS is the only tool we are aware of that measures theerception of body image of people with an LLA. Although weid not report body image disturbances over the study period,e believe that certain subgroups of participants, such asersons with TF LLA or women, may start developing bodymage issues during rehabilitation. This hypothesis needs to beested with larger samples. To be able to intervene in a timelyanner, rehabilitation programs should provide regular fol-

ow-up to persons with an LLA to detect a potential problem,ncluding body image, and to be able to provide the necessaryervices.

Finally, future research should include more longitudinalOL studies extending beyond 3 months postdischarge with

arger samples that also include persons with a unilateral andilateral LLA and candidates and noncandidates for prostheticraining. This type of research should have sufficient power toetermine the factors that positively or negatively impact QOL.uch studies should also take into consideration the possible

nfluence of response shift that could occur when someonexperiences a major change in his/her life.

CONCLUSIONSSubjective QOL of persons with an LLA is relatively high

uring and 3 months after the rehabilitation process except fortems related to their physical functioning. Furthermore, per-ons with LLA have a high prosthesis-related QOL in relationo the global satisfaction of their prosthesis and their perceptionf the appearance and the utility of their prosthesis. Althougharticipants did not seem to have a body image disturbanceuring the study period, body image perception was found toe highly related to the perception of QOL. Although theehabilitation process is mainly focused on the physical func-ioning including prosthetic fitting, our findings underscore themportance of also focusing care on pain issues and particularlysychosocial issues such as body image and adaptation tomputation and the prosthesis during the rehabilitation process.his holistic approach should enhance the QOL of persons withLA.

APPENDIX 1: VARIABLES USED INCORRELATION ANALYSES

Demographic and clinicalvariables

Age at admissionSexLevel of amputationCause of amputation

Prosthetic variablesSatisfaction with prosthesisAppearance of prosthesisUtility of prosthesisSounds made by prosthesis

Number of associated medicalconditions

Time since amputationDuration of stayDuration of prosthetic training

Pain sensation variablesFrequency, intensity, and

bothersomeness of:● Phantom pain● Residual limb pain● Nonamputated leg pain

Psychologic well-beingvariables

Body imageAdaptation to amputationAdaptation to prosthesis

● Back pain

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