Factors influencing psychological
adjustment after amputation in
adult lower limb amputees: A
Mark Hudson1, Dr. Nathan Babiker2, & Dr. Ramesh Munjal2
of Sheffield & 2Sheffield Teaching Hospitals
NHS Foundation Trust
1. Background literature
2. Design of the present review
3. Results
4. Clinical and research implications
02/10/2015 © The University of Sheffield
Background literature.
Psychological adjustment to chronic disease
involves at least five key domains:
1. Cognitive
2. Emotional
3. Interpersonal
4. Functional
5. Disease-related
(Stanton, Revenson, & Tennen, 2007).
Horgan & MacLachlan (2004)
• Factors linked to better adjustment:
• Perceived sense of control
• Social support
• Positive meaning
• Time since amputation
• Cause (trauma or disease) had no relationship.
Horgan & MacLachlan (2004)
• Factors linked to poorer adjustment:
• Body image anxiety
• Social discomfort
• Pain catastrophising
• Phantom limb pain
• Women and younger people in a sub-set.
• B/K amputees more depressed in one study.
02/10/2015 © The University of Sheffield
Current review: Design.
• Horgan & MacLachlan (2004) called for more
qualitative and longitudinal research, and
broader focus on QoL.
• Significant number of studies published since
the last review.
• Increasing awareness of psychological risk
factors in the MDT.
• Increase own understanding to assist with
treatment planning.
Search strategy
• The Psychinfo and Web of Science databases
were searched, from 2004 up until February
2013. The following keyword search strategies
were combined:
• “psychological” or “psychosocial”
• “adjustment” or “adaptation”
• “amputation*” or “amputee*”
Selection criteria
• Population: adults with a lower limb amputation
• Measures: At least one amputation-related,
sociodemographic, or psychological predictor
variable. A validated criterion measure of
psychological adjustment.
• Analysis: at least one statistical test examining
the link between the predictor variables and
criterion measures.
• Article type: English language articles in peerreviewed journals.
Paper retrieval
Factors linked to better
• Greater levels of hope (Unwin, Kacperek, & Clarke, 2009)
• Positive cognitive processing (Phelps, Williams, Raichle,
Turner, & Ehde, 2008)
• Increased problem solving ability (Desmond & MacLachlan,
• Having a positive appraisal of the amputation
(Couture, Desrosiers, & Caron, 2011)
Factors linked to better
• Less phantom limb pain
(Desmond et al. 2008; Whyte & Carroll, 2004)
• Social support
(Williams et al., 2004; Unwin et al., 2009; Hanley et al., 2004; Desmond &
MacLachlan, 2006a; Hawemdah et al., 2008; Jenkins et al., 2008; Nunes et al., 2012;
Singh et al., 2007)
• Below-knee amputation in sub-set
(Desmond & Maclachlan, 2006a; Couture et al., 2011).
• Number of co-morbidties
(Nunes et al., 2012; Singh et al., 2007; 2009)
Factors linked to worse
• Negative cognitive processing
(Phelps et al., 2008)
Avoidance (Desmond & MacLachlan, 2006a)
Pain catastrophising (Whyte & Carrol, 2004; Hanley et al., 2004)
Public self-consciousness (Atherton & Robertson, 2006)
Body-image disturbance (Coffey et al., 2009)
Younger people (Gunawardena et al., 2007; Singh et al., 2009;
Desmond & MacLachlan, 2006a )
• Female gender (Nunes et al., 2012)
Mixed Findings
• Time since amputation
• Recent amputation more distressing (Desmond et al., 2006a;
Nunes et al., 2012)
• Recent amputation less distressing (Singh, 2007; 2009)
• Cause of amputation
• Disease related
(Coffey et al., 2009; Desmond & Maclachlan, 2006a;
Couture et al., 2011)
• Trauma related (Hawemdah et al., 2008; Kratz et al., 2010)
Common methodological issues
Causality cannot be inferred
Self-report bias
Small sample sizes
Selection bias
Lack of control groups
Variability in measurement tools
Clinical and research
Clinical implications
• Highlights those at risk of poor adjustment.
• Indicates models of coping and resilience
(Lazarus & Folkman; 1984; Yates & Masten, 2004)
• Suggests therapy targets:
• Changing meaning
• Developing acceptance or active coping style
• Social support.
Research implications
• Few studies on residual limb pain.
• Pre-operative, longitudinal designs, with
appropriate control groups needed.
• Effect of ADM or alcohol/drug use.
• Effect of repeated infections.
• Search limited to two databases
• No hand-searching of journals
• Grey literature not consulted
• Written by one author
• Experts were not consulted
Atherton, R. & Robertson, N. (2006). Psychological adjustment to lower limb amputation
amongst prosthesis users. Disability and Rehabilitation, 28, 1201-1209
Coffey, L., Gallagher, P., Horgan, O., Desmond, D. & Maclachlan, M. (2009).
Psychosocial adjustment to diabetes-related lower limb amputation. Diabetic
Medicine, 26, 1063-1067.
Couture, M., Desrosiers, J., & Caron, C. D. (2011). Cognitive appraisal and perceived
benefits of dysvascular lower limb amputation: A longitudinal study. Archives of
Gerontology and Geriatrics, 52, 5-11.
Desmond, D. M. & MacLachlan, M. (2006a). Coping strategies as predictors of
psychosocial adaptation in a sample of elderly veterans with acquired lower limb
amputations. Social Science & Medicine, 62, 208-216.
Desmond, D., Gallagher, P., Henderson-Slater, D., & Chatfield, R. (2008). Pain and
psychosocial adjustment to lower limb amputation amongst prosthesis users.
Prosthetics and Orthotics International, 32, 244-252.
Gunawardena, N., De A Senevirathne, R. & Athauda, T. (2007). Mental health outcome
of unilateral lower limb amputee soldiers in two districts of Sri Lanka. International
Journal of Social Psychiatry, 53, 135-147.
Hanley, M. A., Jensen, M. P., Ehde, D. M., Hoffman, A. J., Patterson, D. R., & Robinson,
L. R. (2004). Psychosocial predictors of long-term adjustment to lower-limb
amputation and phantom limb pain. Disability and Rehabilitation, 26, 882-893.
Hawemdeh, Z. M., Othman, Y. S., & Ibrahim, A I. (2008). Assessment of anxiety and
depression after lower limb amputation in Jordanian patients. Neuropsychiatric
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Horgan, O., & MacLachlan, M. (2004).Psychosocial adjustment to lower limb amputation:
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Jenkins, L. M., Andrewes, D. G., Hale, T., Coetzee, N., & Khan, F. (2009). Subjective
attributes of depression, part 2: The contribution of self-perceived disability to
depression following stroke. Electronic Journal of Applied Psychology: General
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Kratz, A. L., Williams, R. M., Turner, A. P., Raichle, K. A., Smith, D. G., & Ehde, D.
(2010). To lump or to split? Comparing individuals with traumatic and nontraumatic
limb loss in the first year after amputation. Rehabilitation Psychology, 55, 126-138
Nunes, M. A., de Barros Jr, N., Miranda Jr, F., & Baptista-Silva, J. C. (2012). Common
mental disorders in patients undergoing lower limb amputation: A population-based
sample. World Journal of Surgery, 36, 1011-1015.
Phelps, L. F., Williams, R. M., Raichle, K. A., Turner, A. P., & Ehde, D. M. (2008). The
importance of cognitive processing to adjustment in the 1st year following
amputation. Rehabilitation Psychology, 53, 28-38.
Singh, R., Hunter, J., & Philip, A. (2007). The rapid resolution of depression and anxiety
symptoms after lower limb amputation. Clinical Rehabilitation, 21, 754-759.
Singh, R., Ripley, D., Pentland, B., Todd, I., Hunter, J., Hutton, L., & Philip, A. (2009).
Depression and anxiety symptoms after lower limb amputation: The rise and fall.
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Stanton, A. L., Revenson, T. A., & Tennen, H. (2007). Health psychology: Psychological
adjustment to chronic disease. Annual Review of Psychology, 58, 565-592.
Unwin, J., Kacperek, L., & Clarke, C. (2009). A prospective study of positive adjustment
to lower limb amputation. Clinical Rehabilitation, 23, 1044-150.
Whyte, A. & Carroll, L. J. (2004). The relationship between catastrophizing and disability
in amputees experiencing phantom pain. Disability and Rehabilitation, 26, 649-654.
Williams, R. M., Ehde, D. M., Smith, D. G., Czerniecki, J. M., Hoffman, A. J. & Robinson,
L. R. (2004). A two-year longitudinal study of social support following amputation.
Disability and Rehabilitation, 26, 862-874.
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