| Summary: | Thesis (M.Sc.(Physiotherapy)), Faculty of Health Sciences, University of the Witwatersrand, 2009 === Background: The impact of non-traumatic lower limb amputation on participant’s
quality of life (QOL) is unknown. In an effort to provide better care for people with
lower limb amputation, there is a need to first know the impact of this body
changing operation on people’s quality of life.
Aim of the study: To determine the impact of lower limb amputation on QOL in
people in the Johannesburg metropolitan area during their reintegration to their
society/community of origin.
Objectives:
1. To establish the pre-operative and post-operative:
QOL of participants (including the feelings, experiences and impact
of lower limb amputation during the time when they have returned
home and to the community).
The functional status of participants.
Household economic and social status of these participants.
2. To establish factors influencing QOL.
Methods: A longitudinal pre (amputation) test –post (amputation) test study
utilized a combination of interviews to collect quantitative data and in-depth semistructured
interviews to gather qualitative data. Consecutive sampling was used
to draw participants (n=73) for the interviews at the study sites pre-operatively.
The three study sites were Chris Hani Baragwanath Hospital, Charlotte Maxeke
Johannesburg General Hospital and Helen Joseph Hospital. Participants were
then followed up three months later for post-operative interviews and key
informants were selected for in-depth interviews (n=12).
Inclusion criteria: Participants were included if they were scheduled for first
time unilateral (or bilateral amputation done at the same time) lower limb
amputation. The participants were between the ages of 36-71 years.
Exclusion criteria: Participants who had an amputation as a result of traumatic
or congenital birth defects were excluded from the study. Participants with comorbidities
that interfered with function pre-operatively were not included.
Procedures:
Ethics: Ethical clearance was obtained from the Committee for Research on
Human Subjects at the University of the Witwatersrand and permission was
obtained from the above hospitals. Participants gave consent before taking part
in the study.
Instrumentation: A demographic questionnaire, the EQ-5D, the Modified
Household Economic and Social Status Index (HESSI), the Barthel Index (BI)
and semi-structured in-depth interviews were used.
Data collection: Participants were approached before the operation for their preoperative
interviews using the above questionnaires and then followed up postoperatively
using the same questionnaires and some were selected to participate
in semi-structured in-depth interviews three months later.
Pilot study: The demographics questionnaire and the modified HESSI were
piloted to ensure validity and reliability.
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Data analysis: Data were analyzed using the SPSS Version 17.0 and STATA
10.0. The significance of the study was set at p=0.05. All continuous data are
presented as means, medians, standard deviations and confidence intervals (CI
95%). Categorical data are presented as frequencies. Pre and post operative
differences were analyzed using Wilcoxon Signed-rank test. A median regression
analysis (both the univariate and multivariate regression) was done to establish
factors influencing QOL. Pre and post operative differences in the EQ-5D items
and the BI items were analyzed using Chi square/Fischer’s exact depending on
the data. Data were pooled for presentation as statistical figures in tables. Both
an intension to treat analysis and per protocol analysis were used.
A grounded theory approach was used to analyze the concepts, categories and
themes that emerged in the qualitative data.
Results: Twenty-four participants (33%) had died by the time of follow up. At
three months, n=9 (12%) had been lost to follow up and 40(55%) was
successfully followed up. The preoperative median VAS was 60 (n=40). The
postoperative median VAS was 70. The EQ-5D items on mobility and usual
activities were reported as having deteriorated significantly postoperatively
(p=0.04, p=0.001respectively) while pain/discomfort had improved (p=0.003).
There was no improvement in QOL median VAS from the preoperative status to
three months postoperatively
The preoperative median total BI score was (n=40). The postoperative median
total BI score was 19. There was a reduction in function (median BI) from the
preoperative status to three months postoperatively (p<0.001).
The ability to transfer was improved three months postoperatively (p=0.04).
Participants were also found to have a decreased ability to negotiate stairs
(p<0.001). Mobility was significantly reduced three months postoperatively
(p=0.04).
During the postoperative stage (n=40), 38% of the participants were married.
Most (53%) of the participants had no form of income. The highest percentage of
participants in all instances (35%) had secondary education (grade10-11), while
25% had less than grade 5. Only one participant was homeless, 18% lived in
shacks, 55% lived in homes that were not shared with other families.
People with LLA in the Johannesburg metropolitan area who had no problem
with mobility preoperatively (EQ-5D mobility item), who were independent with
mobility (BI mobility item) preoperatively, who were independent with transfer
preoperatively (BI transfer item) had a higher postoperative quality of life
(postoperative median EQ-5D- VAS) compared to people who were dependent
or had problems with these functions preoperatively. Being females was a
predictor of higher reported quality of life compared to being male.
Emerging themes from the qualitative data were psychological, social and
religious themes. Suicidal thoughts, dependence, poor acceptance, public
perception about body image, phantom limb related falls and hoping to get a
prosthesis were reported. Some reported poor social involvement due to mobility problems, employment concerns, while families and friends were found to be
supportive. Participants had faith in God.
Conclusion: Participants’ QOL and function were generally scored high both
preoperatively and postoperatively but there was a significant improvement in
QOL and a significant reduction in function after three months although
participants were generally still functionally independent. Good mobility
preoperatively is a predictor of good QOL postoperatively compared to people
with a poor preoperative mobility status
Generally, most participants had come to terms with the amputation and were
managing well while some expressed that they were struggling with reintegration
to their community of origin three months postoperatively with both functional and
psychosocial challenges.
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