by Gail M. Williamson, PhD, Associate Professor, Department of Psychology, University of Georgia

People over age 65 account for approximately three-fourths of all surgical amputations. Of the 160,000 amputations performed in the United States each year, 85 to 90% involve removal of a lower extremity.

Elderly persons undergoing lower-extremity amputation are at high risk for functional disability, particularly if the level is above knee. However, previous research provides little information about the specific factors that predict such increased risk, nor the depression which accompanies restriction of normal activities.

In a study entitled, "Restriction of Normal Activities Among Older Adult Amputees: The Role of Public Self-Consciousness," the reasons behind greater functional disability were examined using one medical variable (above-knee amputation) and one dispositional variable (feelings of self- consciousness in public). Each variable created more restriction of normal activities such as self-care, household chores, and visiting friends.

Above knee amputation and self-consciousness in public also predict feeling more vulnerable and less able to defend oneself which, in turn, fosters increased levels of activity restriction. The level of amputation was significant in amputees with minimal public self-consciousness. Below knee amputees experienced minor activity restriction compared to above knee amputees. In contrast, amputees uncomfortable in public reported major activity restriction regardless of the level of amputation.

Challenges Facing Amputees

Surviving an amputation means facing major physical, social, and emotional adjustments. Many older adult amputees are never able to walk with a prosthesis.

However, adaptation varies widely. A substantial percentage of even elderly amputees adapt quite well to their disability. Yet, surprisingly little is known about which factors contribute to successful adjustment.

Research indicates that amputees are at high risk for depression and other types of psychiatric problems. Studies suggest that about half of all amputees require some type of psychological intervention.

Predicting Adjustment

An amputee's degree of social discomfort, including acceptance of an amputation or prosthesis, often predicts symptoms of depression. Further, restriction of normal activities seems to play a key role in producing symptoms of depression. Even the beneficial aspects of social contacts, prosthesis use, and adequate household income are counteracted by activity restriction. Amputees less satisfied with their social contacts, prosthesis use, and income reported greater restriction of routine activities as a result of an amputation. Activity restriction, in turn, predicted more extensive signs of depression. Clearly, the ability to carry out normal activities is critical to the psychological well-being of medically compromised people.

Public Self-Consciousness

Individuals differ in the importance they attach to the impression they make on others. Compared to people with little public self-consciousness, those uncomfortable in public are more concerned about their physical appearance, more motivated to present themselves favorably, more anxious to avoid disapproval and conform to a norm endorsed by society. Like those who experience social discomfort, they may be particularly sensitive to attention drawn to their disability.

Above Knee Amputation

Above knee amputation poses considerably more rehabilitation challenges than below knee amputation since the absence of a knee joint greatly impairs an amputee's ability to walk. Yet, researchers have not found the expected relationship between level of amputation and psychological distress. However, above knee amputation would seem a strong predictor of greater activity restriction which, in turn, causes higher levels of depression. One reason is that these amputees feel more vulnerable and less able to defend themselves than do those with greater mobility.

Orthopedic and rehabilitation researchers and practitioners agree it's important to save the knee joint in lower-extremity amputation whenever possible.

Observation suggests that above knee amputees who are self-conscious have greater potential for functional disability. While below knee amputees who are comfortable with their appearance have relatively little activity restriction, a lack of self-consciousness may not be sufficient to overcome the additional functional challenges that accompany an above knee amputation. Elderly, self-consciousness amputees reported the same high level of activity restriction as above knee amputees both low and high in self-consciousness.

Amputees who feel self-conscious in public are at increased risk for functional disability following amputation — regardless of the level of amputation.

It was expected and confirmed that discomfort in public consciousness tends to restrict such visible activities as caring for others, shopping, visiting friends, and maintaining friendships. More difficult to explain, however, are indications that self-care and house-hold chores were also more restricted among those high in self-consciousness. A plausible explanation is that people who are sensitive about conditions that detract from their physical appearance more readily adopt a "sick role" than those less concerned with their appearance.

Among some amputees high in public self-consciousness, once the original reason for activity limitation is no longer an issue, it is replaced by emotional and behavioral factors that continue functional limitation. Feeling insecure about doing some activities may broaden so that these amputees expect to be functionally disabled as a normal part of their illness.

In Conclusion

Removal of a leg above the knee places older amputees at increased risk for functional disability and psychological distress. Identifying which factors further restrict normal activities helps implement early intervention for those predisposed to adapt poorly.

Such factors include inadequate household income, unsatisfactory social resources, and less frequent prosthesis use, high public self-consciousness, and feeling unable to defend oneself. In identifying amputees most at risk for functional limitation, above knee amputation appears critical, while high public self-consciousness affects activity restriction regardless of amputation level. Increasing amputees' ability to defend themselves could encourage performing more routine, independent living activities.

Clearly, adjusting to limb loss involves many factors. To be successful, intervention programs should focus on the full range of social, psychological, financial, medical, and practical problems faced by amputees.

About The Author

Gail M. Williamson is an associate professor in the Department of Psychology at the University of Georgia in Athens. Her paper, "Restriction of Normal Activities Among Older Amputees: The Role of Public Self Consciousness", is to appear in an upcoming issue of the Journal of Geropsychology.

Last updated: 09/18/2008
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