1. Factors influencing psychological adjustment after amputation in adult lower limb amputees: A review Mark Hudson 1, Dr. Nathan Babiker 2, & Dr. Ramesh Munjal 2 1 University of Sheffield & 2 Sheffield Teaching Hospitals NHS Foundation Trust

2. 27/04/2015© The University of Sheffield Contents 1.Background literature 2.Design of the present review 3.Results 4.Clinical and research implications

3. Background literature.

4. Definition 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).

5. 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.

6. 27/04/2015© The University of Sheffield 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.

7. Current review: Design.

8. Rationale 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.

9. 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*”

10. 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 peer- reviewed journals.

11. Paper retrieval

12. Results.

13. Factors linked to better adjustment Greater levels of hope (Unwin, Kacperek, & Clarke, 2009) Positive cognitive processing (Phelps, Williams, Raichle, Turner, & Ehde, 2008) Increased problem solving ability (Desmond & MacLachlan, 2006a). Having a positive appraisal of the amputation (Couture, Desrosiers, & Caron, 2011)

14. Factors linked to better adjustment 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)

15. Factors linked to worse adjustment 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)

16. 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)

17. Common methodological issues Causality cannot be inferred Self-report bias Small sample sizes Selection bias Lack of control groups Variability in measurement tools

18. Clinical and research implications.

19. 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.

20. 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.

21. Critique Search limited to two databases No hand-searching of journals Grey literature not consulted Written by one author Experts were not consulted

22. References 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.

23. References 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 Disease and Treatment, 4, 627-633. Horgan, O., & MacLachlan, M. (2004).Psychosocial adjustment to lower limb amputation: a review. Disability and Rehabilitation, 26, 837–50. 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 Articles, 5, 82-88. 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.

24. References 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. Clinical Rehabilitation, 23, 281-286. 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.

25. Thank-you for listening Any Questions? Contact email: pcp12mh@sheffield.ac.uk

26. To Discover And Understand.