What is the likelihood of developing a psychosocial condition following an amputation?


Most studies determined depression rates between 20 and 30% in the years after amputation, much higher than the world average of 5.8% of men and 9.5% of women. Depression is very prevalent among amputees of all ages, etiologies and backgrounds [12] .

The greatest risk factors for depressive symptoms are higher levels of pain and comorbidity, both of which are prevalent in persons with limb loss. Education, poverty, marital status, and pain remained predictors of depressive symptoms after controlling for confounders. Additionally, 42% of persons with significant depressive symptoms reported having an unmet need for mental health services. Interventions that target depressive symptoms and pain management, and that bolster self-management skills appear particularly suitable to the needs of this population and may help improve depressive symptoms [13] . Here’s a look into several aspects of amputation that correlate with depression and other psychosocial factors.....


Body Image and Self-Perception


With amputation of a limb, an individual undergoes both physical and mental alterations. Physically, the limb is no longer there. In addition to the physical change brought on by amputation, individuals also must reestablish body image and a sense of self. Development of psychosocial-related conditions following an amputation is related to the individual’s self-perception and how well a prosthetic satisfies the role of the missing limb [1]. This is important to consider in both hospital and clinical settings when working with individuals who have had amputations and are being fit with a prosthetic device.

Incorporation of perceiving oneself as an “amputee” is a crucial milestone in the reinvention of body image and self-perception following an amputation [1]. Individuals who had accepted the physical changes in their bodies were more likely to engage in activities (social, vocational, recreational, etc.) similar to before amputation [1]. The individual is not letting his or her amputation become a defining factor, or a barrier to establishing his or her new identity. Integration of amputation into a person’s body image and perceived sense of self is an ongoing process, but is a critical component for psychosocial well-being of the patient.
http://youtu.be/yvTVYwDdbzo

The use of a prosthetic or other assistive device to compensate for limb loss is another factor that contributes to development of psychosocial disorders following an amputation. Not only did individuals who used assistive devices report a greater sense of autonomy, but they had better outcomes relating to social interaction, well-being, functionality, and newly established physical appearance [1].
http://youtu.be/m6JuCPyoN3I

image.jpg

Figure 1. Model for self-identity changes related to lower limb amputation.

Tips For Improving Body Image [2]:
● Smile at people when they look at you.
● Don’t limit yourself with the label of “disabled.” The focus is no longer on what is gone.
● Remember how far you have come.
● Confront your thoughts related to your body
● Talk to your partner about how your changed body looks, feels, and works.
● Focus on learning new ways to do things you enjoyed before the amputation. Be extra clever or creative.
● Have positive experiences with your body.
● Be optimistic by believing that something good has arisen from your amputation.
● Learn to accept and love yourself.
● Learn to develop a healthier more accurate view of yourself.
● Join organizations that support people with limb loss.
● Read articles on body image after amputation.
Remind yourself often that you are so much more than your appearance.

http://www.ncbi.nlm.nih.gov/pubmed/21908476
http://1solutionfocusedcoaching.com/2012/12/22/limb-loss-a-conversation-about-body-image-and-sexual-well-being/



Quality of Life and Functional Loss
The loss of a limb has been equated to the loss of a loved one, and the individual frequently goes through emotional reactions such as shock, grief, denial, anxiety, and depression. Higher rates of depression are common following an amputation, particularly upon discharge. [3] Limb loss can lower one’s satisfaction of life [4], and beyond the physical impairments, these psychosocial factors can also affect function and quality of life.
Improving the quality of life for patients with a limb loss is a crucial goal for rehabilitation care. Satisfaction with one’s prosthesis was found to be one of the main factors in maintaining better overall quality of life (more predictive than pain level). Depression in amputees has been found to be associated negatively with quality of life. [5] This suggests that these more subtle psychosocial aspects of adjusting to life with limb loss should be addressed in addition to physical functional limitations.
Another study also found a high prevalence of depression and anxiety symptoms among the amputee population. These researchers noted that the patient’s mood swings could have a negative impact
on adherence to the rehabilitation program. They suggested that focusing early on treating these issues could have a better functional outcome over time. [6]
Another study showed that a higher level of social integration, based on their perceived support system, was correlated with higher functional outcomes (mobility) and greater satisfaction with life. These highly satisfied people reported more time out of bed, more time out of the house and in the community, and greater participation in social, leisure, and vocational activities. The study mentioned that the perceived quality of social support was much more important than the actual size or integration of the network. Interventions to enhance relationship quality are recommended among non-married, older patients who live alone to promote higher functional outcomes. [7]

Emphasizing measures in rehabilitation that facilitates return to work is one of the most important factors in improving physical function and self-perceived life satisfaction and mental health.




Amputation Level


Amputation level appears to be an important factor in predicting successful rehabilitation, which in turn plays a large role in the ability to cope with the residual limb.

Common amputation levels:
Lower Extremity-
Partial toe
Excision of portion of 1 or more toes
Toe disarticulation
Disarticulation at MTP joint
Partial foot/ray resection
Resection of 3rd, 4th, and/or 5th MTs and digits
Transmetatarsal
Amputation through long axis of all MTs
Syme’s
Ankle disarticulation with preservation of heel pad
Long transtibial
Retains > 50% of tibial length
Short transtibial
Retains < 50% of tibial length
Knee disarticulation
Amputation through knee with intact femur
Long transfemoral
Retains > 50% of femoral length
Short transfemoral
Retains <50% of femoral length
Hip disarticulation
Amputation through hip joint; pelvis intact
Hemipelvectomy
Resection of half of the pelvis
Hemicorporectomy
Amputation of both LEs and pelvis below L4-5

LE_Amp_Levels.png
http://www.cdha.nshealth.ca/amputee-rehabilitation-musculoskeletal-program


Upper Extremity -

Partial digit
Excision of one or more fingers
Digit disarticulation
Disarticulation at MCP joint
Transmetacarpal
Resection of through long axis of metacarpals
Transcarpal
Amputation of hand with preservation of wrist
Wrist disarticulation
Amputation of hand and carpals
Transradial
Amputation through radius and ulna
Elbow Disarticulation
Disarticulation of elbow
Transhumeral
Amputation through humerus
Shoulder disarticulation
Amputation through shoulder joint
Forequarter amputation
Amputation humerus, scapula, and clavicle
UE_Amp_Levels.png

http://www.cdha.nshealth.ca/amputee-rehabilitation-musculoskeletal-program


Prosthesis use decreased as level of amputation increased. The greater the degree of amputation, the greater amount of energy is required to operate the prosthesis [8]. For example:

Level of Amputation
Increase in Energy Cost
Unilateral Below Knee
20%
Unilateral Above Knee
49-65%
Bilateral Below Knee
< Unilateral Above Knee
Hip disarticulation
200%
Bilateral Above Knee
280%

To no surprise, when activity level was monitored, people with above the knee amputations were much more likely to be restricted in their daily activities than those with below the knee amputations. Here are a few videos that display how the difficulty of don/doff and ambulating progressing from a bilateral BKA -> AKA -> bilateral AKA.

Bilateral BKA Prosthetics
http://www.youtube.com/watch?v=1_8Io-L2PAo
žUnilateral AKA Prosthetics
http://www.youtube.com/watch?v=u_ltzVd1zQw&feature=related
žBilateral AKA
http://www.youtube.com/watch?v=D49YKNM1Kr8

Even though above the knee amputations are associated with poorer rehabilitation outcomes and higher levels of activity restriction, as compared with below the knee amputees, they have not been found to be associated with increased levels of anxiety, social discomfort, depression, or adjustment to amputation [9].

Additionally, public self-consciousness in conjunction with degree of amputation has a strong correlation. In fact, higher levels of self-consciousness were shown to be a stronger predictor of activity restriction than was the degree of amputation.

One study that did find a relationship between amputation level and psychological outcome revealed that individuals with a below the knee amputation were more likely to be depressed than those with an above the knee amputation. To explain this, it was suggested that because individuals with below the knee amputations are less severely disabled in terms of functioning than those with above the knee amputations, they might be in a closer position to compare their functional abilities with their previous abilities [10]. As a result, they are more sensitive to the differences between themselves and able-bodied individuals.

Right upper limb amputees tend to have significantly more socioeconomic difficulties and a steeper decline in earned income as compared to left upper limb amputees. This is likely due to the fact that most people are right handed, so the amputation results in lower performance levels [11].



Traumatic vs. Non-Traumatic Amputations


It is well known in the medical community that many patients suffer from depression and other psychological conditions following an amputation. This part of our wiki looks at to what extent the way in which the amputation occurred affects the likelihood of the development of a psychosocial condition such as depression.

The prevalence of anxiety and depressive disorders in amputees is much higher than those in the general population without an amputation. As many as 50% of amputees will require psychological intervention at some point after their amputation, and depression is the most common psychological condition post amputation [14]. In a study conducted by the LEAP group, 48% of 505 patients showed a positive result for psychological disorder at 3 months post-surgery. Within 24 months, 42% of the 452 patients who were able to be contacted still remained positive for a psychological disorder [15].

Traumatic Amputation
  • A traumatic amputation is partial or full loss of a limb acquired due to severe trauma, such as in a motor vehicle accident, work accident, or during combat. Loss of a limb due to trauma is very sudden. Patients with a traumatic amputation often wake up after their accident and must adjust to a missing limb. This can result in extreme psychological stress. Patients with traumatic amputations are allowed no opportunity to accept the loss of the limb prior to amputation [15].
  • In those patients with a traumatic acquired amputation, there is a drastic and sudden change in body and self image in response to the sudden loss of a limb [14]. A traumatic amputation often leads to greater initial psychological distress, which in turn leads to a higher prevalence of depression and anxiety in those patients with traumatic amputations in comparison to those with non-traumatic amputations. In a study done in Jordan in 2008, it was found that those individuals with traumatic onset amputations had higher scores on the Hospital Anxiety and Depression Scale in comparison with those who had a non-traumatic amputation [14].
Wiki Picture 1.png [14]

Wiki Picture 2.png[14]

  • Significantly lower scores were recorded in patients with disease related amputation, with a disease related amputation mean score of 2.6± 3.2 in comparison to mean score 6.0± 4.9 in the traumatic amputation group [14].
Wiki Picture 4.png[14]
  • Though non-traumatic amputees are less likely to develop depression or a psychological condition post-amputation, if they do develop depression it is more likely to last past the initial 24 months post-surgery [16]. This could be due to a greater likelihood of comorbidities such as progression of disease, revisions and additional amputations, depression already being present prior to amputation, and other health related factors that may also contribute to depression in addition to the amputation.
  • In those patients with traumatic amputations, patients often define their lives as “before the injury” and “after the injury,” [17] showing a possible correlation between the sudden change in function and independence that can be lost after an amputation with increased incidence of depression in traumatic amputation patients in comparison to non-traumatic.

Non-Traumatic Amputation

  • A non-traumatic amputation is acquired due to a progressive disease process, infection or a congenital condition, such as peripheral vascular disease, osteomyelitis, or as a complication of diabetes. There are several studies that suggest that those patients with a non-traumatic amputation have a lower chance of developing a psychological condition after their amputation. Lower depression and anxiety scores were shown within groups of non-traumatic amputation patients in comparison with those who had a traumatic amputation. This study showed a “significant reduction of anxiety and depression scores in… patients with amputation due to disease” [14].
  • Those patients with non-traumatic amputation have the opportunity to take the time to adjust to the imminent loss of the limb and altered body image. Therefore, it appears that they are less likely to suffer from depression immediately following amputation [16].
  • Only one study that we found has shown that having a conversation with a patient prior to amputation about the necessity of the operation was associated with lower levels of depression post-amputation. The remaining studies maintain that there is no direct relationship between cause of amputation (traumatic vs. non-traumatic) in determining level of depression post amputation [9].
  • However, levels of depression in those with traumatic amputation tend to be higher than in non-traumatic. It is evident that a combination of several factors, such as employment status, prior health status, social and familial support and additional social factors may play a larger role in the development of depression in addition to the cause of amputation.

To sum it up:
  • In patients with diabetes, those with an amputation had a higher incidence of depression than those with diabetes without a prior amputation [16].
  • Those patients with the same disease without an amputation were less likely to be depressed than those who had already been through at least one amputation.
  • It appears that amputation related psychological conditions also have much to do with a combination of factors, including social support, current employment status, gender, level of amputation, and marital status [14].
  • Though there is some evidence to point to a traumatic cause of amputation in causing a larger incidence of depression and psychological conditions than a non-traumatic amputation, more studies need to be done to prove this correlation outright, as most studies look at a combination of factors in their analysis.
  • Regardless of the cause of the amputation, depression levels in patients post-amputation from any cause are higher than in the general public. After 24 months, it appears that the prevalence of depression in amputees return to the same level as the general population who do not have amputation [14].
  • Currently, there is research to see if presence of depression in those with non-traumatic and disease-related amputations may actually indicate a higher probability of additional amputations in the future. This research shows a 33% higher risk of incident non-traumatic major lower limb amputation in veterans with diabetes who present with depression [18]. This opens a door to the idea that screening and treatment for depression in amputees with non-traumatic disease-related amputation could actually decrease risk for future amputation.

Links:
Congenital Amputee
Traumatic Amputation
Diabetic Amputation


Comorbidities/Phantom Limb Pain (PLP)


The physical condition of a patient prior to amputation, specifically the presence of comorbidities, is a strong predictor of their functional outcomes [19].

Pell et al. found “amputees had significantly more problems in all domains of quality of life such as mobility, social isolation, energy, pain, sleep and emotional disturbance than controls; however mobility was the only outcome for which the difference between the two groups remained significant after stepwise logistic regression.” [20]

Currently there is not a strong connection directly between comorbidities/phantom limb pain and psychosocial conditions following amputation. Instead the relationship is between the comorbidities/phantom limb pain and functional outcomes, which have been shown to have a direct connection with psychosocial conditions (specifically depression).

Predictive factors for functional outcome after 1 year are best measured at 2 weeks and 6 weeks after amputation. The difference or similarity between these scores will help determine which predictive factors translate to long-term outcomes. The cause for amputation will influence the earlier measure, and especially in the case of traumatic amputation the later measure may be a better predictor of long-term outcomes [19].

Phantom Limb Pain
Discussion of phantom limb pain (PLP) in the literature has been slowed by difficulty consistently differentiating PLP from phantom limb sensation (PLS), residual limb pain (RLP), and post amputation pain (PAP). PLS refers to feelings in the missing part of the limb, not including pain. PLP specifically refers to pain in the missing part of the limb. There is also phantom limb movement, which when noted is commonly related to PLP. A phantom limb that the patient can no longer control, but has become fixed in a painful or uncomfortable position can be debilitating.

Vilayanur Ramachandran, a neuroscientist credited with the invention of mirror therapy for the treatment of PLP (as well as stroke and complex regional pain syndrome), gave a TED talk titled “3 clues to understanding your brain” that discusses his theory for PLP and why mirror therapy works. He discusses PLP from minute 9-17.



The majority of research on PLP is from Caucasian populations, specifically individuals who have experience traumatic amputation. The reported incidence of PLP ranges from 47-79% in current literature [21].

From a systematic review including van der Schans et al., “Amputees with phantom pain had a poorer health-related quality of life.” [20] The significant variables related to this outcome were walking distance and stump pain, both of which relate to the functional outcomes following amputation.

From a sample of 31 Iranian above-knee amputees from the Iraq-Iran war, PLS was present in 27 patients (87%), PLP in 14 patients (45.1%), phantom movement in 5 patients (16.1%), and stump pain in 20 patients (64.5%) [22]. Eighteen of these patients reported one of the following psychological problems: post-traumatic stress disorder (10), depression (3), difficulty with impulse control (2), and anxiety disorders (5). These eighteen patients were significantly more likely to experience PLP (p = 0.009 fisher’s exact test). Although this particular patient sample might not directly translate to patient populations in the United States, studies of U.S. war veterans find similar prevalence reporting psychological problems in 35-52% of study participants [22].

In a sample of patients from one university hospital and five general hospitals in the Netherlands with limb amputations due to peripheral vascular disease (with or without DM), ulcer, infection, cancer, trauma, or complex regional pain syndrome the incidence of PLP was much lower than the Iranian war veteran sample. This study found PLP decreased over time from 32% at 6 months to 27% at 1 ½ years to 23% at 2 ½ years and to 27% at 3 ½ years after amputation. They also found that the chance of developing PLP decreases over time. The prevalence of PLP remains relatively stable, but the duration and occurrence of PLP episodes decreases [23]. Most patients will experience PLS beginning right after amputation if at all [24].

There is a significant relationship between PLP and traumatic or oncological causes for amputation, as well as above knee amputations [21]. Comparatively patients with diabetes mellitus or peripheral vascular disease resulting in amputation, although greater in number, are less likely to experience PLP or PLS [22]. However, as the disease process leads to more extensive symptoms and progressively proximal levels of amputation the chances of developing PLP increases.

The level of pain prior to amputation due to the involved disease process has also been found to predict the development of PLP [21]. If a patient’s sensitivity to pain has been heightened prior to amputation, they are more likely to experience PLP following the procedure. Some studies have found that “cognitive-emotional sensitization” contributes to the severity of pain in patients and ultimately the development of PLP [21].

Most studies have not found significant differences between the incidence of PLP in men and women. This connection continues to be pursued, as we do know that men and women perceive pain differently. Although up to this point the incidence of PLP between these groups may not be significant, women are more likely to seek health care for PLP [21]. Men are more likely to under-report pain and less willing to seek health care [23]. Other studies suggest that being male is actually a significant protective factor against PLP [23]. However, there is a question of whether this is because they actually experience PLP less or because they simply don’t report it.
In one study of 49 patients who underwent lower limb amputations at the National University Hospital, Singapore found that ¾ of patients with PLP didn’t consult a doctor even though they rated their level of pain as moderate to severe [21].

PLP can decrease the ability of a patient to successfully transition to prosthetic use and functional independence. It has also been suggested that prosthetic use can decrease the likelihood of PLP. It is known that a strong relationship exists between the two, but the explanation for this relationship remains controversial [23].

Diabetes Mellitus/Peripheral Vascular Disease
Patients with diabetes mellitus (DM) and a history of unilateral chronic foot ulcers are already significantly more likely to be dissatisfied with their personal lives than those without a history of chronic foot ulcers. Patients with a unilateral lower limb amputation show a level of satisfaction better than those with unilateral chronic foot ulcers, but worse than those with no history [20]. Living with a health partner also increased quality of life [20].

Cardiopulmonary Disease
Presence of cardiopulmonary disease influeces functional outcomes because of the extra energy needed for ambulation using a prosthesis [19]. More specifically, a poor cardiopulmonary status leads to deconditioning and balance deficits detrimental to functional prosthetic use. Balance is an important predictor of functional outcomes, and any comorbidity that is a detriment to balance in the unaffected or residual limb will result in a poor functional prognosis [19].

Individuals with unilateral trans-femoral amputation from non-peripheral vascular disease were found to have considerable problems with amputation and prosthesis that negatively affected quality of life. These problems included heat/sweating in socket, sores/skin irritation, instability walking on uneven surfaces, and inability to walk quickly. Almost half of participants experienced some form of limiting pain: PLP, RLP, back pain, or unaffected limb pain [20].

Chronic Low Back Pain
For those with high functional mobility following amputation, chronic LBP is a common symptom. In a survey of 92 patients following lower limb amputation, 68% reported LBP [25]. Another study reported a higher incidence of LBP for transfemoral amputees (81%) than transtibial amputees (62%) [26]. In addition, knee pain of the unaffected limb suggests progressive joint degeneration, as this joint will experience more wear and tear following the amputation of the contralateral limb [22].

Other Comorbidities
One study using The Sickness Impact Profile to measure restrictions of daily functioning following amputation, found that the presence of other comorbidities besides cardiopulmonary disease or diabetes mellitus explained 51% of scores [19]. In this same study, the age of the participants (mean age at amputation 73.9 ± 7.9 years) contributed to at least part of the results for all tests used to measure functional outcome 1 year after amputation. Age has a confounding effect on the relationship between comorbidity and psychosocial status following amputation. Normal aging comes along with a slew of comorbidities that themselves can lead to psychological disorders. This on top of dementia and end of life emotional stress make it difficult to attribute any specific prognostic factors in this population to outcomes after amputation [21].



Summary

  • Higher rates of depression are rather common following an amputation (~30%), it is the most common psychological condition post amputation
  • Amputees must re-establish body image and a sense of self (Tip: Remind amputees that they are much more than their appearance)
  • Amputees who use assistive devices report a greater sense of autonomy, which in turn gives better outcomes relating to social interaction & well-being
  • Satisfaction with one’s prosthesis was found to be one of the main factors in maintaining better overall quality of life - more predictive than pain level
  • higher level of social integration, based on their perceived support system, was correlated with higher functional outcomes (mobility) and greater satisfaction with life
  • the level of amputation has not been found to be associated with increased levels of anxiety, social discomfort, depression, or adjustment to amputation
  • higher levels of self-consciousness were shown to be a stronger predictor of activity restriction than was the degree of amputation
  • traumatic amputation often leads to greater initial psychological distress, which in turn leads to a higher prevalence of depression and anxiety
  • Prevalence of depression is highest during the first 2 years and usually return to the same level as the general population
  • Relationship between the comorbidities/phantom limb pain and functional outcomes have a direct connection with psychosocial conditions
  • Combination of the above factors contribute to the likelihood of depression, so each individual case must be looked at in whole
    • Factors that increase chance: traumatic injury, PLP/comorbidities, pain
    • Factors that decrease chance: psychosocial counseling, functional independence
  • As a PT, be sure to take all of these factors into consideration when evaluating and treating amputees

References:
[1] Senra H, Oliveira RA, Leal I, Vieira C. Beyond the body image: a qualitative study on how adults experience lower limb amputation. Clinical rehabilitation. 2012;26(2):180–91. doi:10.1177/0269215511410731.

[2] Cone R. Amputation: a conversation about improving your body image and sexual well-being. Site for creative solutions.December 22,2012. Accessed March 27, 2013.

[3] R. Singh, D. Ripley, B. Pentland, I. Todd, J. Hunter, L. Hutton, and A. Philip, “Depression and anxiety symptoms after lower limb amputation: the rise and fall.,” Clinical rehabilitation, vol. 23, no. 3, pp. 281–6, Mar. 2009.

[4] K. Østlie, P. Magnus, O. H. Skjeldal, B. Garfelt, and K. Tambs, “Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group.,” Disability and rehabilitation, vol. 33, no. 17–18, pp. 1594–607, Jan. 2011.

[5] R. a. Epstein, A. W. Heinemann, and L. V. McFarland, “Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts,” The Journal of Rehabilitation Research and Development, vol. 47, no. 4, p. 373, 2010.

[6] M. Vaz, V. Roque, S. Pimentel, A. Rocha, and H. Duro, “Psychosocial characterization of a Portuguese lower limb amputee population,” Acta Med Port, vol. 25, no. 2, pp. 77–82, 2012.

[7] R. M. Williams, D. M. Ehde, D. G. Smith, J. M. Czerniecki, A. J. Hoffman, and L. R. Robinson, “A two-year longitudinal study of social support following amputation,” Disability & Rehabilitation, vol. 26, no. 14–15, pp. 862–874, Jan. 2004.

[8] Bhuvaneswar CG, Epstein LA, Stern TA. Rounds in the General Hospital: Reactions to Amputation: Recognition and Treatment. 2007;9(4):303–308.

[9] Horgan O, MacLachlan M. Psychosocial adjustment to lower-limb amputation: a review. Disability and rehabilitation. 2004;26(14-15):837–850. doi:10.1080/09638280410001708869.

[10] Ibrahim AI. Assessment of anxiety and depression after lower limb amputation in Jordanian patients. 2008;4(3):627–633.

[11] Srivastava S, Trivedi JK, Mall CP, et al. Psychosocial Aspects of Amputation. Indian Journal of Psychiatry. 1997;39(3):247–250.

[12] Wellman G. Depression after Amputation : Prevalence and Risk Factors A Literature Review.

[13] Darnall BD, Ephraim P, Wegener ST, et al. Depressive symptoms and mental health service utilization among persons with limb loss: results of a national survey. Archives of physical medicine and rehabilitation. 2005;86(4):650–8. doi:10.1016/j.apmr.2004.10.028.

[14] Hawamdeh ZM, Othman YS, Ibrahim AI. Assessment of anxiety and depression after lower limb amputation in Jordanian patients. Neuropsychiatric disease and treatment. 2008;4(3):627–33. Available at:http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2526369&tool=pmcentrez&rendertype=abstract.

[15] Tintle SM, Keeling JJ, Shawen SB, Forsberg J a, Potter BK. Traumatic and trauma-related amputations: part I: general principles and lower-extremity amputations. The Journal of bone and joint surgery. American volume. 2010;92(17):2852–68. doi:10.2106/JBJS.J.00257.

[16] Coffey L, Gallagher P, Horgan O, Desmond D, MacLachlan M. Psychosocial adjustment to diabetes-related lower limb amputation. Diabetic medicine: a journal of the British Diabetic Association. 2009;26(10):1063–7. doi:10.1111/j.1464-5491.2009.02802.x.

[17] Benetato BB. Posttraumatic growth among operation enduring freedom and operation Iraqi freedom amputees. Journal of nursing scholarship: an official publication of Sigma Theta Tau International Honor Society of Nursing / Sigma Theta Tau. 2011;43(4):412–20. doi:10.1111/j.1547-5069.2011.01421.x.

[18] Williams LH, Miller DR, Fincke G, et al. with diabetes. 2012;25(3):175–182. doi:10.1016/j.jdiacomp.2010.07.002.Depression.

[19] Schoppen T, Boonstra A, Groothoff JW, de Vries J, Goeken LN, Eisma WH. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees. Arch Phys Med Rehabil. Vol 84. United States2003:803-811.

[20] Sinha R, Van Den Heuvel WJ. A systematic literature review of quality of life in lower limb amputees. Disability and rehabilitation.2011;33(11):883-899.

[21] Sin EI, Thong SY, Poon KH. Incidence of phantom limb phenomena after lower limb amputations in a Singapore tertiary hospital. Singapore Med J. Feb 2013;54(2):75-81.

[22] Ebrahimzadeh MH, Fattahi AS. Long-term clinical outcomes of Iranian veterans with unilateral transfemoral amputation. Disability and rehabilitation. 2009;31(22):1873-1877.

[23] Bosmans JC, Geertzen JHB, Post WJ, van der Schans CP, Dijkstra PU. Factors associated with phantom limb pain: a 3½-year prospective study. Clinical Rehabilitation. May 1, 2010 2010;24(5):444-453.

[24] Clarke C, Lindsay DR, Pyati S, Buchheit T. Residual Limb Pain Is Not a Diagnosis: A Proposed Algorithm to Classify Postamputation Pain.Clin J Pain. Jan 16 2013.

[25] Kulkarni J, Gaine WJ, Buckley JG, Rankine JJ, Adams J. Chronic low back pain in traumatic lower limb amputees. Clin Rehabil. Jan 2005;19(1):81-86.

[26] Andersson GBJ PM, Frymoyer JW, Snook S. . Occupational low back pain: Assessment, Treatment and Prevention. St. Louis: Mosby-Year book; 1991.