Quality of life for veterans and servicemembers with major traumatic limb loss from Vietnam and OIF/OEF conflicts.
Subject: Quality of life (Analysis)
Amputation (Usage)
Disabled veterans (Care and treatment)
Disabled veterans (Psychological aspects)
Authors: Epstein, Richard A.
Heinemann, Allen W.
McFarland, Lynne V.
Pub Date: 07/01/2010
Publication: Name: Journal of Rehabilitation Research & Development Publisher: Department of Veterans Affairs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Department of Veterans Affairs ISSN: 0748-7711
Issue: Date: July-August, 2010 Source Volume: 47 Source Issue: 4
Product: Product Code: 9105601 Veterans Pensions & Disability NAICS Code: 92314 Administration of Veterans' Affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 241861748
Full Text: INTRODUCTION

Technological advances, such as body armor, rapid casualty evacuation, and increased tourniquet use, have significantly decreased the number of lethal combat injuries in Operation Iraqi Freedom and Operation Enduring Freedom (OIF/OEF) in comparison with other modern wars [1-4]. There has been a corresponding increase in the number of nonlethal combat injuries [5]. The vast majority of nonlethal combat injuries are wounds to the limbs [6-7], and a sizable proportion of wounds to the limbs result in limb loss [8-9]. Identifying factors associated with quality of life (QOL) for veterans and servicemembers with combat-associated limb loss may provide critical information vital for their rehabilitation.

Consensus opinion is that health-related QOL is a multidimensional construct, but consensus has not yet emerged regarding how QOL should best be measured. Multiple QOL dimensions can be measured and may include domains such as physical function, income, spirituality, psychosocial status, and pain [10]. QOL can also be measured as a global construct [11] using either multiple-item scales [12] or a single-item measure [13-17]. Multiple-item scales evaluate a number of factors that might be important aspects of global QOL, but may add to the survey length. Calibrated item banks and computerized adaptive testing have been used to limit the number of items while retaining validity [18-19].

We decided that a single-item measure of global QOL was appropriate and a minimally burdensome strategy for our exploratory survey. Single-item global QOL measures have been shown to provide reliable and valid assessments of QOL [13-14]. Common examples include the Uniscale [16], the Functional Assessment of Cancer Therapy/Functional Assessment in Chronic Illness Therapy scales [20-21], the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire [22], and the World Health Organization Quality of Life (WHOQOL BREF) [23]. Further, one recent study assessing QOL in persons with non-combat-associated lower-limb loss using a single-item measure for global QOL identified seven significant predictors of QOL (depression, perceived prosthetic mobility, social support, comorbidity, prosthesis problems, age, and social activity participation) [15].

Prior research on QOL among veterans and servicemembers with combat-associated limb loss is limited [24-26]. Dougherty followed 23 Vietnam war veterans with bilateral transfemoral amputations for a mean of 25 years and compared them with age- and sex-matched controls but found few differences using standardized questionnaires on mental and physical health, except that those with limb loss had significantly lower physical functioning scores [25]. In another study reported by Dougherty, 72 Vietnam war veterans with transtibial amputations were followed for a mean of 28 years and compared with controls. Those with limb loss had a significantly increased use of psychological support services [26]. Hoaglund et al. followed 132 Korean and Vietnam war veterans with transtibial limb loss for a mean of 17 years and found an increase in pain but did not report on QOL [24].

The current study uses data collected from veterans and servicemembers with combat-associated major limb loss from the Vietnam war and OIF/OEF conflicts who participated in the national Survey for Prosthetic Use [27] to identify factors associated with overall QOL and to determine how specific types of co-occurring combat injuries affect QOL.

METHODS

Survey Participants

Participants in this cross-sectional, descriptive survey are veterans and servicemembers from the Vietnam war and OIF/OEF conflicts with at least one combat-associated major traumatic amputation (excluding digit-only loss). We sent veterans and servicemembers with major limb loss that occurred during the Vietnam war (1961-1973) or OIF/OEF conflicts (2000-2008) an invitational letter to participate in a survey on prosthetic use. We invited all servicemembers with major limb loss from OIF/OEF and a selection of Vietnam war veterans to participate (all unilateral upper-limb loss, all multiple limb loss, and a subsample of unilateral lower-limb loss) to obtain a similar number to the total OIF/OEF invitees. Survey participants include 298 from the Vietnam war (65% response rate) and 283 from OIF/OEF (59% response rate). We surveyed participants during 2007 to 2008, and they took the survey by one of three methods (mail, telephone interview, or Web site). A description of the detailed study methods and survey are provided elsewhere [28].

We based this survey on the conceptual framework provided by the Aday and Anderson model of healthcare utilization [29] and we modified it by Bradley et al. to include psychosocial factors [30]. This model posits that predisposing, need, enabling, perceived control, and knowledge factors determine healthcare use, outcomes, and costs. QOL is influenced in this model by predisposing, need, and enabling factors; knowledge and coping; and adjustment factors.

Survey Measures

Quality of Life and Health Status

We used a modified version of a commonly used single-item measure of global QOL for our study [23]. We also asked participants to rate their overall QOL: excellent, very good, good, fair, or poor. The concordance of responses to the QOL item was similar (61% agreement) to survey responses on the single-item self-rated health question from the 36-Item Short Form Health Survey (SF-36) (kappa = 0.47) [12,31]. For this study, we compared those responding "better QOL" (excellent or very good) and "worse QOL" (fair or poor) with those responding "good QOL." For logistic regression analyses, our goal was to distinguish participants with unequivocally high QOL from those with intermediate or low QOL; thus, we created a bivariate outcome QOL measure comparing "better QOL" (excellent or very good) with those with "worse QOL" (good, fair, or poor responses). We assessed self-rated health status using a validated single-item measure from the SF-36 [13,31].

Demographic Characteristics and Social Situation

Participants provided information on demographics (age, sex, and race) and current social situation (current marital status, whether or not participants have children, current employment status, current military status), as shown in Table 1. We collapsed response categories for race, current employment status, and current military status into a limited number of categories because of infrequent responses in some subcategories.

Comorbidities

Participants provided information on the presence or absence of 15 types of comorbidities (including arthritis, posttraumatic stress disorder [PTSD], depression, traumatic brain injury, stroke, diabetes, and migraines) and pain (including phantom pain, residual-limb pain, and chronic back pain).

Functional Capability and Need for Assistance

We categorized functional capability into three levels based on answers to questions about graded level of lower-limb functional capability: (1) nonambulatory (cannot walk, with or without assistance to transfer), (2) ambulatory (can walk, including household or community walkers), and (3) highly active (performs low- to high-impact recreational activities). We recategorized need for assistance with daily activities as "needing no assistance" with daily activities or "needing any assistance" from another person with daily activities.

Prosthetic Devices

The survey also collected data on current prosthetic device and assistive device use, including the number, type, daily frequency of use, and satisfaction with current prostheses and services. We asked participants to rank their current satisfaction with their prostheses on a scale ranging from 0 (not at all satisfied) to 10 (completely satisfied). We also asked survey participants to identify the types of prosthetic and assistive devices they might want to try in the next 3 years.

We asked participants to identify the number and type of prostheses they had received in the past (total for the first year postamputation and then total since that time). We collected data on the number of prostheses that wore out and the average replacement time by type of device. For prostheses that were discontinued due to dissatisfaction, we collected the number and type of device as well as the reasons why participants discontinued the prosthesis. Survey participants reported any prosthetic device receipt, regardless if received through military, Department of Veterans Affairs, or private sources. Survey participants also included prototype prosthetic devices received. Detailed descriptions of the types of prosthetic devices in current use, replaced, or stopped due to dissatisfaction are provided elsewhere for those with unilateral upper-limb loss [32], unilateral lower-limb loss [33], multiple limb loss [34], and satisfaction with services [35].

Combat-Associated Injuries

We asked participants to report the date and location of all amputations, number of associated surgeries, level of limb loss, and types of combat injuries. They reported the level of amputation as partial foot, ankle, transtibial, knee disarticulation, transfemoral, hip, transpelvic, partial hand, wrist, transradial, elbow disarticulation, transhumeral, shoulder, or forequarter. We grouped the types of limb loss into three categories: unilateral upper limb, unilateral lower limb, and multiple limb loss. We also created a survey question to determine how much participants' amputation affects their current QOL. We defined this as the "amputation impact rank." Survey participants rated the effect of their amputation on a scale of 0 (does not affect QOL at all) to 5 (moderately affects QOL) to 10 (strongly affects QOL). We interpreted higher values of the amputation impact rank as having more effect on current life. Although the survey did not specifically state whether the effect of their amputation was negative or positive, we queried a subsample of survey participants and all reported they interpreted the survey question to mean a negative effect on their life.

We asked survey participants if they sustained any of seven specific types of other combat injuries (besides their amputation): injury to limb(s) with no amputation, head injury, eye injury, hearing loss, chest injury, abdominal injury, and burns. We created a "combat injury impact rank" for this study to determine the degree to which specific combat injuries affect current QOL. Survey participants ranked each type of combat injury on a scale of 0 (does not affect QOL at all) to 5 (moderately affects QOL) to 10 (strongly affects QOL). For veterans and servicemembers reporting specific types of combat injuries, we calculated mean combat injury impact scores.

Statistical Analysis

We examined current data (demographic, health status, comorbidities, functional capability, and current prosthetic use) and retrospective data (combat injuries, type and number of prior prosthetic devices) for their association with current overall QOL using Stata 9.2 (StataCorp; College Station, Texas). For univariate analyses, we based statistical significance on chi-square (categorical data), Mann-Whitney U-test (ordinal data), Student's t-test (continuous data), and Fisher's exact test for cell sizes <5. The level of significance is for a two-sided p [less than or equal to] 0.05. We tested variables significant in univariate analyses in multivariate logistic regression models. To avoid overfitting the model, we added variables significant in univariate analyses using forward step wise selection based on the log likelihood ratio and significance of the coefficient. We then compared the model with the previous model using the log likelihood ratio chi-square test. We kept variables in the model if their inclusion significantly improved model fit. We assessed interactions using the log likelihood ratio and the goodness of fit of the final model using the Hosmer-Lemeshow chisquare test statistic. A p > 0.05 indicates a well-fitted model [36-37]. The outcome of the logistic models is a bivariate variable using two groups of overall QOL data: better overall QOL compared with worse overall QOL. We fit type of limb loss as a dummy variable with unilateral lower limb as the comparison group and unilateral upper limb and multiple limb loss as independent variables.

RESULTS

Sample Description

A detailed description of the demographic characteristics of the Vietnam war and OIF/OEF groups with major limb loss is reported in another article in this issue [28]. These groups represent two distinct time periods in the recovery process. The Vietnam war group represents veterans who have had more time to adapt to their limb loss (an average of 38.8 years postamputation), are older (mean age 61 years), and may be dealing with age-related and other chronic conditions. In contrast, the OIF/OEF group are servicemembers and veterans with relatively recent limb loss (average 3.0 years postamputation), are younger (mean age 29 years), and may be still dealing with healing and rehabilitation from combat injuries and their complications. Of the OIF/OEF group, 9 percent were still receiving rehabilitation services.

Of 298 participants from the Vietnam war group, 178 (59.7%) have unilateral lower-limb loss, 47 (15.8%) have unilateral upper-limb loss, and 73 (24.5%) have multiple limb loss (153 limbs). Of the 283 in the OIF/OEF group, 172 (60.8%) have unilateral lower-limb loss, 50 (17.7%) have unilateral upper-limb loss, and 61 (21.5%) have multiple limb loss (129 limbs).

Univariate Analysis of Overall Quality of Life

Overall, the Vietnam war group reported worse QOL than the OIF/OEF group. In the Vietnam war group, 297 of 298 self-reported their current overall QOL as excellent (33 [11.1%]), very good (67 [22.6%]), good (116 [39.1%]), fair (64 [21.5%]), or poor (17 [5.7%]). In the OIF/OEF group, 282 of 283 self-reported their current QOL as excellent (49 [17.4%]), very good (86 [30.5%]), good (104 [36.9%]), fair (39 [13.8%]), or poor (4 [1.4%]).

Type of Limb Loss

To identify whether type of limb loss is associated with overall QOL, we conducted analyses by type of limb loss separately for each group (Figure 1). Interestingly, multiple limb loss is associated with better QOL in both the Vietnam war and OIF/OEF groups. In the Vietnam war group, of participants with unilateral lower-limb loss, 26.4 percent report better QOL, 44.9 percent report good QOL, and 28.7 percent report worse QOL. In the Vietnam war group with unilateral upper-limb loss, significantly more report better QOL (40.4%); those with multiple limb loss (47.2%) also reported better QOL. In the OIF/OEF group with unilateral lower-limb loss, 50.3 percent report better QOL, 38.0 percent report good QOL, and 11.7 percent report worse QOL. For those in the OIF/ OEF group with unilateral upper-limb loss, significantly more (30.0%) report worse QOL compared with unilateral lower-limb loss. We found no other significant differences by type of limb loss and QOL for OIF/OEF participants with multiple limb loss.

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Demographic Characteristics and Social Situation

In both groups, demographic (age, sex, and race) and current social situation (marital status, children, current employment status) variables are not associated with overall QOL (Table 1). Current military status is significantly associated with QOL in the OIF/OEF group but not in the Vietnam war group. Significantly fewer OIF/ OEF participants with medical discharges report better QOL (42%) compared with those with nonmedical discharges (75%). We found no significant differences in the OIF/OEF group for QOL by those on Active Duty, National Guard duty, or in rehabilitation.

Comorbidities

In both groups, an association exists between QOL and mean number of current comorbidities. Higher number of comorbidities is significantly associated with worse overall QOL (Table 1). The mean number of comorbidities in the Vietnam war group is significantly higher in the worse QOL group (7.1 [+ or -] 2.6) than the good QOL group (5.1 [+ or -] 2.5, p < 0.001). The mean number of comorbidities in the OIF/ OEF group is also significantly higher (6.3 [+ or -] 2.3) in the worse QOL group than the good QOL group (5.3 [+ or -] 2.3, p = 0.01). The mean number of comorbidities is significantly fewer for those reporting better QOL in both the Vietnam war group (3.6 [+ or -] 2.2, p < 0.001) and OIF/OEF group (3.7 [+ or -] 2.3, p < 0.001). All data presented as mean [+ or -] standard deviation unless otherwise noted. When we examined specific types of comorbidities, we found several types were associated with current QOL within each group (Table 1). In the Vietnam war group, we found worse QOL significantly associated with PTSD (42.9%), depression (52.0%), and traumatic brain injury (80.0%). In the OIF/ OEF group, we found worse QOL significantly more frequent in those reporting arthritis (30.0%), PTSD (21.7%), depression (35.3%), and migraines (24.2%). In the Vietnam war group, we found three types of pain also significantly associated with worse QOL: phantom pain (33.0%), residual-limb pain (36.1%), and chronic back pain (44.4%), while pain was not associated with worse QOL in the OIF/ OEF group.

Functional Capability and Need for Assistance

We found lower-limb functional capability not associated with QOL in either group (Table 1). We found the only significant difference in the Vietnam war group who reported being highly active (64.0% reported better QOL compared with 24.0% who reported only good QOL). For the OIF/OEF group, we found no significant association between lower-limb functional level and QOL. In contrast, we found a significant association between overall QOL and needing assistance with activities of daily living in both groups. Of the Vietnam war group participants who need assistance with daily activities, 48.3 percent report worse QOL compared with 37.9 percent reporting good QOL (p = 0.01). Of the OIF/OEF group who require assistance, most (43.2%) report only good QOL and significantly fewer (28.4%) report better QOL (p = 0.04).

Prosthetic Devices

We found no statistically significant associations between overall QOL and the number of current prosthetic devices (Table 1). We found no significant association between overall QOL and the number of prosthetic devices ever received or the type (myoelectric, electronic, body-powered, cosmetic, sports leg, etc.) of prostheses (data not shown). In both the Vietnam war and OIF/OEF groups, veterans and servicemembers who report better overall QOL also report higher satisfaction scores with their current prosthetic devices than do veterans and servicemembers with worse overall QOL (Table 1).

Combat-Associated Injuries

The incident responsible for combat-associated limb loss typically results in multiple other types of combat-associated injuries. Figure 2 shows these other types of combat-associated injuries. The most frequent types of other combat injury in the Vietnam war group include hearing loss (47%) and injuries to the nonamputated limb(s) (33%). The most frequent in the OIF/OEF group included hearing loss (48%), injuries to the nonamputated limb(s) (45%), and injuries to the head (34%). The OIF/ OEF group reported significantly more injuries to the nonamputated limb(s) (p = 0.01), head (p < 0.001), and burns (p = 0.04) than did the Vietnam war group (Figure 2). In the Vietnam war group, we found the mean number of combat injuries (excluding amputation) was significantly higher (3.7 [+ or -] 2.4,p < 0.01) in those reporting worse QOL than in those reporting good (2.7 [+ or -] 1.7) or better (2.8 [+ or -] 1.9) QOL. In contrast, in the OIF/OEF group, those reporting better QOL had significantly more combat injuries (3.1 [+ or -] 1.7, p = 0.02) than those with good QOL (3.6 [+ or -] 1.9). For those in the OIF/OEF group with worse QOL, we found the mean number of combat injuries (4.3 [+ or -] 2.2) not significantly different from those reporting good QOL.

We also examined combat injuries by the type of limb loss (Table 2) to determine if the types of combat injuries changed by conflict. Nearly one-third of the Vietnam war group reported injuries to the nonamputated limb(s), but we found no difference by type of limb loss group. Injury to the other nonamputated limb(s) occurs more frequently in the OIF/OEF group than in the Vietnam war group. Of the OIF/OEF group, 50.6 percent with unilateral lower-limb loss and 42.6 percent with multiple limb loss report injuries to nonamputated lower limbs (p < 0.01). We found head injuries were significantly more frequent across all limb-loss groups in the OIF/OEF group (29.6%-46.0%) than in the Vietnam group (10.1%-22.2%). Hearing loss is significantly more frequent in the OIF/OEF group with unilateral upper-limb loss (62.0%) than the Vietnam war group (34.0%).

[FIGURE 2 OMITTED]

We assessed the effect of combat injuries on current life for the Vietnam war group (Figure 3) and the OIF/ OEF group (Figure 4). In the Vietnam war group, those with unilateral lower-limb loss reported their amputation had the highest effect on current life (amputation impact rank = 7.5 [+ or -] 2.7, p < 0.05) compared with unilateral upper-limb loss (7.0 [+ or -] 3.0) or multiple limb loss (7.1 [+ or -] 3.1). In the Vietnam war group, we found other types of combat injuries also associated with a higher impact rank depending on the type of limb loss. For those with unilateral lower-limb loss in the Vietnam war group, we found the highest effect for injury to the nonamputated lower limb (mean combat injury rank = 5.4 [+ or -] 3.1); for those with unilateral upper limb loss, eye injuries were highest (7 [+ or -] 3.4); and for those with multiple limb loss, hearing loss had the highest effect (5.7 [+ or -] 2.4). In the OIF/OEF group (Figure 4), amputation has the highest effect for those with unilateral upper-limb loss (mean impact rank = 8.1 [+ or -] 2.3, p < 0.05) compared with unilateral lower-limb loss (6.8 [+ or -] 2.6) or multiple limb loss (7.9 [+ or -] 2.7). In the OIF/ OEF group, injury to the nonamputated limb had the greatest effect on current life for all three limb loss groups: unilateral lower limb (mean impact rank = 5.0 [+ or -] 3.4), unilateral upper-limb (5 [+ or -] 3.5), and multiple limb loss (5.9 [+ or -] 3.5).

Multivariate Analysis of Overall Quality of Life

As many of these variables may be correlated with QOL or one another, we used logistic regression to estimate the effect of these variables on QOL (Table 3). In the Vietnam war group, multivariate analysis found multiple limb loss (adjusted odds ratio [aOR] = 3.07, 95% confidence interval [CI] = 1.57-6.02) and satisfaction with current prostheses (aOR=1.20, 95% CI = 1.05-1.38) were associated with better QOL, while a higher amputation impact rank (aOR = 0.66, 95% CI = 0.59-0.74) and depression (aOR = 0.21, 95% CI = 0.08-0.54) were associated with worse overall QOL. In the OIF/OEF group, after adjusting for the type of limb loss, we found three factors significantly associated with worse overall QOL: combat-associated head injury (aOR = 0.78, 95% CI = 0.61-0.99), combat-associated injury impact rank to the nonamputated limb (aOR = 0.71, 95% CI = 0.57-0.88), and needing assistance with activities of daily living (aOR = 0.12, 95% CI = 0.02-0.72). We found no significant interactions between variables in either model, and no other variables examined in the univariate analysis improved the model fit.

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DISCUSSION

Improving QOL for veterans and servicemembers with combat-associated limb loss is an important goal for rehabilitation care. The current study used an adapted version of the WHOQOL-BREF single-item measure because it has been shown to be valid in persons with a number of health conditions, including traumatic spinal cord injury, that can present similar challenges to those associated with traumatic limb loss [38]. Predictors of this single-item QOL measure are useful in identifying how healthcare may be improved for veterans and servicemembers with limb loss.

The current study identified specific factors associated with overall QOL for two distinct groups of veterans and servicemembers from the Vietnam war and OIF/OEF conflicts. The advantage of assessing these different groups is that we can compare QOL at two different times in the post limb-loss lives of veterans and servicemembers with combat injuries. As expected, the Vietnam war group is both older and has experienced a much longer time interval between limb loss and the survey. The Vietnam war group has had more time to adapt to their limb loss and to improve their coping skills but has also had time to develop comorbidities and other age-related health problems. For the Vietnam war group, better overall QOL was reported by persons with multiple limb loss and those who report greater satisfaction with their current prostheses. Self-reported overall QOL was significantly worse in the Vietnam war participants who report their amputation has a greater effect on their life and those who report depression. An unexpected finding was the better QOL reported by those with multiple limb loss compared with those with unilateral lower-limb loss. Survey participants with multiple limb loss often experience more severe combat injuries, but they also reported a shift in life priorities and were thankful to be alive. The Vietnam war group has had nearly 38 years to adapt and develop coping skills. This improvement in QOL was not apparent in the OIF/OEF group with multiple limb loss, but they have had an average of only 3 years to develop coping skills. In another survey of people with limb loss, participants with bilateral limb loss more frequently reported that they considered something good had happened to their life (character building, more appreciation for life, developing coping abilities) as a result of their amputations [39]. Taken together, these findings suggest that reported QOL of survivors of catastrophic injuries may shift as they gain new perspectives on life priorities and develop improved coping skills as a result of their injuries. This "response shift" has been described in other studies of disability and needs to be further explored [40]. Individuals may also change how they appraise their QOL over time as life priorities shift [41]. We found the QOL of OIF/OEF participants was not significantly associated with pain, while in the Vietnam war participants, we found pain was associated with QOL. Response shift may explain why OIF/OEF servicemembers with recent limb loss (who are involved in acute rehabilitation and recovery issues) may view pain with less priority. Vietnam war participants (who are older and have more comorbidities) may view pain as a higher priority as they are no longer focused on the strenuous rehabilitation process.

In the Vietnam war group, we found satisfaction with current prostheses was associated with slightly better QOL, but no other measure of prosthetic device use or specific satisfaction measure associated with QOL. This finding may indicate that issues other than prosthetic device problems play an important role in determining overall QOL in older veterans. When asked about the overall effect their amputation had on their QOL, those in the Vietnam war group with worse QOL reported their amputation had a greater effect. Our survey did not reveal the specific effects of amputation on QOL. We found prosthetic use by number or type, number of surgeries, most comorbidities, and family support were not associated with QOL. Depression was the only factor we found associated with worse QOL in the Vietnam war group, which is not surprising. Asano et al. reported that depression accounted for 30 percent of the variance in QOL in his study of 415 people with lower-limb loss [15].

The OIF/OEF group is earlier in their recovery and adaptation process. For this group, we found worse overall QOL was associated with combat-associated head injury, a greater effect of the injury to the nonamputated limb, and need for assistance with activities of daily living. These factors are more proximal to the time of amputation and may reflect that the OIF/OEF group is still in the process of developing coping skills. Differences may also reflect changes in types of combat injuries and early medical care received [42-43]. It is also interesting to observe that not all combat-associated injuries have the same effect on a person's life with limb loss. In contrast to the Vietnam war group, the OIF/OEF servicemembers did not report that their amputation affected their QOL as strongly as other factors. Significant variables associated with QOL in the two groups reflect variables that have high priority at the time. As the veteran ages, other variables have greater effect on their current QOL, such as satisfaction with their prosthetic devices and other comorbidities. These other injuries should not be neglected in the care and management of patients with limb loss. As we did not collect information on the severity of the combat injuries and their effect on QOL, future studies could collect this data and evaluate the association between the severity of combat injuries and overall QOL later in life.

These findings expand our understanding of combat-related limb loss. Prior studies have found that, in comparison with matched controls, veterans from the Vietnam and Korean war conflicts with combat-associated limb loss report lower physical and physical role functioning [25], more pain [24], and increased use of psychological support services [26]. While we found these associations in the univariate analysis of our survey data, after controlling for other variables, lower function and pain were not associated with QOL.

QOL in people with noncombat limb loss (due to injury or disease) has also been reported. Our results are generally consistent with findings reported in non-combat-associated limb loss, but there are important differences. Consistent with the results of the current study, these studies demonstrate that age, depression, perceived prosthetic mobility/ problems, and comorbidity are associated with worse QOL [15]. Social support and social functioning have been associated with better QOL [15,44-45]. We did not directly measure social support, but employment status and family support were not associated with better or worse QOL in either group. Another study demonstrated that physical role functioning and pain [46] were also associated with overall QOL in those with noncombat traumatic amputations. These differences may reflect differences between civilian and military medical and rehabilitation care or differences in etiology (isolated trauma vs congenital or dysvascular disease) resulting in a different clinical experience than combat-associated limb loss, which typically results in complex blast injuries and significant tissue destruction [3,5-6,24].

The strengths of our study include use of a standard survey for two distinctly different combat groups (Vietnam war and OIF/OEF). In addition, the use of three modes of survey administration (mail, telephone interview, or Web site) achieved a good response rate in both Vietnam war (65%) and OIF/OEF (59%) groups. The preferred survey response method differed by group, as 65 percent of veterans from the Vietnam war group preferred the mail-out/mail-back method, whereas only 26.5 percent of the OIF/OEF group selected this option. Significantly more OIF/OEF servicemembers took the survey on our Web site (40%) or by telephone interview (33%) than Vietnam war veterans (23% and 12%, respectively, p < 0.001). While some other studies have reported differences in survey responses depending upon the mode of administration [47-48], other studies have found no effect by mode of administration [49-50]. We did not find that the mode of administration significantly influenced the responses of survey participants.

Study limitations include potential bias because of exclusion of veterans and servicemembers who did not choose to participate in the survey, recall bias, and the cross-sectional design of the survey. While this survey is unique in obtaining a relatively high follow-up rate, those who were not located or who refused to participate could have a substantially different experience of limb loss. QOL has been shown to change over time, perhaps due to changes in life situations and to transient mood states [51], and reticence to report negative experiences may present additional biases to the measurement of self-reported QOL. Prospective and longitudinal studies would be useful to evaluate causality of factors associated with QOL in those with combat-related limb loss. We also recommend collecting data on the severity of combat-associated injuries and social support to see what future effect these factors have on QOL. In addition, prospective studies could evaluate if shifting from one category of QOL to another has clinical relevance or affects the recovery of veterans and servicemembers with limb loss.

CONCLUSIONS

In summary, these findings have important and direct implications for clinical care and research. The current study suggests resources must be devoted to promote the psychosocial adjustment of veterans and servicemembers with combat-associated limb loss, including the provision of appropriate educational, employment, and recreational options. Regarding clinical care, rehabilitation efforts must not only focus on functional restoration but must also regard as critical the need to address subtle aspects of adjusting to life with limb loss and prosthesis use and encourage veterans and servicemembers to become active members of their treatment teams.

Abbreviations: aOR = adjusted odds ratio, CI = confidence interval, OEF = Operation Enduring Freedom, OIF = Operation Iraqi Freedom, PTSD = posttraumatic stress disorder, QOL = quality of life, SF-36 = 36-Item Short Form Health Survey, WHOQOL-BREF = World Health Organization Quality of Life.

JRRD at a Glance

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Quality of life (QOL) is a valuable indicator of wellbeing. We surveyed overall QOL in veterans and servicemembers wounded in the Vietnam war and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts. Vietnam war participants with higher QOL were satisfied with their current prostheses, had less depression, and felt their limb loss has less affect on their current life. OIF/OEF participants with higher QOL reported fewer combat injuries, fewer injuries to their nonamputated limb, and less need for assistance with daily activities. These results may help guide interventions to increase overall QOL after major limb loss.

ACKNOWLEDGMENTS

Author Contributions:

Study concept and design : L. V. McFarland.

Acquisition of data: L. V. McFarland.

Analysis and interpretation of data: R. A. Epstein, A. W. Heinemann, L. V. McFarland.

Drafting of manuscript: R. A. Epstein, A. W. Heinemann, L. V. McFarland.

Critical revision of manuscript for important intellectual content:

R. A. Epstein, A. W. Heinemann, L. V. McFarland.

Statistical analysis: A. W. Heinemann, L. V. McFarland.

Financial Disclosures: The authors have declared that no competing interests exist.

Funding/Support: This material was based on work supported by the Department of Veterans Affairs, Health Services Research and Development (grant IIR 05-244) and a Career Scientist Award to Dr. Reiber (grant RCS 98-353).

Additional Contributions: The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the Department of Defense.

Institutional Review: We received institutional and human subjects review board approvals from the Department of Veterans Affairs and Department of Defense.

Participant Follow-Up: The authors plan to send each participant copies of selected articles from this issue.

Submitted for publication March 3, 2009. Accepted in revised form November 5, 2009.

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DOI:10.1682/JRRD.2009.03.0023

Richard A. Epstein, PhD; (1) Allen W. Heinemann, PhD; (2) Lynne V. McFarland, PhD (3) *

* Address all correspondence to Lynne V. McFarland, PhD; VA Puget Sound Health Care System, Health Services Research and Development, 1100 Olive Way, Suite 1400, Seattle, WA 98101; 206-277-1095; fax: 206-764-2935.

(1) Department of Psychiatry, Vanderbilt University, Nashville, TN; (2) Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL; and Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL; (3) Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA; and University of Washington, Seattle, WA

Email: lynne.mcfarland@va.gov
Table 1.
Comparison of factors associated with overall quality of life
(QOL) in Vietnam war and Operation Iraqi Freedom-Operation
Enduring Freedom (OIF-OEF) veterans and servicemembers with major
combat-associated limb loss.

                                    Vietnam QOL (n = 297)

Subjects                Excellent or                        Fair or
                       Very Good (%)      Good (%)          Poor(%)
                         (n = 100)        (n = 116)          (n 81)
Demographic

Age (mean [+ or -]     61.1 [+ or - ]   60.6 [+ or -]    60.3 [+ or -]
SD) Sex Male                3.0              3.3              2.5

                        100 (100.0)      116 (100.0)       81 (100.0)

Female                    0 (0.0)          0 (0.0)          0 (0.0)

Race

Caucasian                86 (35.8)        91 (37.9)        63 (26.2)

Other                    13 (23.2)        25 (44.6)       18 (32.1) *

Lifestyle/Social
Support

Marital Status

Married/Living           79 (35.9)        83 (37.7)        58 (26.4)
Together

Other                    19 (25.7)        33 (44.6)        22 (29.7)

Have Children (Yes)      85 (32.7)        104 (40.0)       71 (27.3)

Current Employment
Status

Employed/Student         83 (35.6)        91 (39.1)        59 (25.3)

Retired                  17 (27.0)        25 (39.7)        21 (33.3)

Current Military
Status

Medical Discharge        78 (31.8)        95 (38.8)        72 (29.4)

Nonmedical Discharge     22 (42.3)        21 (40.4)         9 (17.3)

Active Duty               0 (0.0)          0 (0.0)          0 (0.0)

Rehabilitation            0 (0.0)          0 (0.0)          0 (0.0)

National Guard            0 (0.0)          0 (0.0)          0 (0.0)
Comorbidities

Total No. of            3.6 [+ or -]     5.1 [+ or -]     7.1 [+ or -]
Comorbidities (mean        2.2 *             2.5             2.6 *
[+ or -] SD)

Arthritis               52 (27.1) *       79 (41.1)        61 (31.8)

Posttraumatic Stress    19 (17.0) *       45 (40.2)       48 (42.9) *
Disorder

Depression               8 (11.0) *       27 (37.0)       38 (52.0) *

Traumatic Brain           1 (10.0)         1 (10.0)        8 (80.0) *
Injury

Migraines                10 (29.4)        11 (32.3)        13 (28.2)

Pain

Phantom Pain            58 (27.0) *       86 (40.0)       71 (33.0) *

Residual Limb Pain       38 (26.4)        54 (37.5)       52 (36.1) *

Chronic Back Pain       16 (14.8) *       44 (40.7)       48 (44.4) *

Functional
Capability

Lower Limb
Functional Capacity
([double dagger])

Nonambulatory            10 (33.3)        12 (40.0)         8 (26.7)

Ambulatory               37 (22.6)        75 (45.7)        52 (31.7)

Highly Active           32 (64.0) *       12 (24.0)         6 (12.0)

Needs Assistance         8 (13.8) *       22 (37.9)       28 (48.3) *
([section])

Prosthetic Devices

No. of Current          1.4 [+ or -]     1.3 [+ or -]     1.3 [+ or -]
Prosthetic Devices          1.1              1.1              1.2
(mean [+ or -] SD)

Prosthesis              7.8 [+ or -]     6.8 [+ or -]     6.1 [+ or -]
Satisfaction               2.3 *             2.6              2.8
([paragraph])  (mean
[+ or -] SD)

                                     OIF/OEF QOL (n = 282

Subjects                Excellent or                        Fair or
                       Very Good (%)      Good (%)          Poor (%)
                         (n = 135)        (n = 104)         (n = 43)
Demographic

Age (mean [+ or -]     29.1 [+ or -]    29.1 [+ or -]    29.6 [+ or -]
SD) Sex Male                5.2              6.4              6.0

                         129 (47.2)       102 (37.4)       42 (15.4)

Female                    6 (66.7)         2 (22.2)         1 (11.1)

Race

Caucasian                104 (51.0)       77 (37.7)        23 (11.3)

Other                    29 (38.7)        26 (34.7)       20 (26.7) *

Lifestyle/Social
Support

Marital Status

Married/Living           84 (49.7)        62 (36.7)        23 (13.6)
Together

Other                    47 (43.1)        42 (38.5)        20 (18.3)

Have Children (Yes)      64 (46.7)        52 (38.0)        21 (15.3)

Current Employment
Status

Employed/Student         110 (51.4)       76 (35.5)        28 (13.1)

Retired                  22 (36.7)        25 (41.7)        13 (21.7)

Current Military
Status

Medical Discharge        69 (41.8)        70 (42.4)        26 (15.8)
                         ([dagger])                        ([dagger])

Nonmedical Discharge     21 (75.0)         2 (7.1)          5 (17.9)

Active Duty              29 (50.0)        22 (37.9)         7 (12.1)

Rehabilitation           11 (45.8)         9 (37.5)         4 (16.7)

National Guard            5 (71.4)         1 (14.3)         1 (14.3)
Comorbidities

Total No. of            3.7 [+ or -]     5.3 [+ or -]     6.3 [+ or -]
Comorbidities (mean        2.3 *             2.3             2.3 *
[+ or -] SD)

Arthritis                23 (31.5)        28 (38.4)       22 (30.1) *

Posttraumatic Stress    60 (36.1) *       70 (42.2)       36 (21.7) *
Disorder

Depression              15 (22.1) *       29 (42.6)       24 (35.3) *

Traumatic Brain          35 (36.5)        38 (39.6)        23 (24.0)
Injury

Migraines                27 (43.6)        20 (32.3)       15 (24.2) *

Pain

Phantom Pain            90 (42.1) *       89 (41.6)        35 (16.4)

Residual Limb Pain       75 (42.1)        70 (39.3)        33 (18.5)

Chronic Back Pain       47 (39.5) *       50 (42.0)        22 (18.5)

Functional
Capability

Lower Limb
Functional Capacity
([double dagger])

Nonambulatory             3 (50.0)         2 (33.3)         1 (16.7)

Ambulatory               44 (41.5)        44 (41.5)        18 (17.0)

Highly Active            68 (60.2)        37 (32.7)         8 (7.1)

Needs Assistance        21 (28.4) *       32 (43.2)       21 (28.4) *
([section])

Prosthetic Devices

No. of Current          3.8 [+ or -]     3.3 [+ or -]     2.6 [+ or -]
Prosthetic Devices          3.3              3.1              2.3
(mean [+ or -] SD)

Prosthesis              8.1 [+ or -]     7.3 [+ or -]     6.6 [+ or -]
Satisfaction               1.8 *             2.0              2.4
([paragraph])  (mean
[+ or -] SD)

* p < 0.05 compared with "good" QOL within conflict group.

([dagger]) p < 0.04 compared with nonmedical discharge.

([double dagger]) Functional level groups: highly active (low-or
high-impact activities and sports), ambulatory (household,
community, uneven surfaces), nonambulatory (cannot walk). Data
not collected for unilateral upper-limb participants.

([section]) Needs assistance with activities of daily living.

([paragraph]) Prosthesis satisfaction scale ranges from 0 (not at
all satisfied with current prosthesis) to 10 (completely
satisfied).

SD = standard deviation.

Table 2.
Frequency of types of combat-associated injuries by type of limb
loss in Vietnam war and Operation Iraqi Freedom-Operation
Enduring Freedom (OIF-OEF) veterans and servicemembers with major
combat-associated limb loss.

                     Frequency (%) by Type of Combat-Associated
                                      Injury

                                   Injuries to
Type of               Amputated    Nonamputated      Head
Limb Loss                Limb         Limb(s)

Vietnam (n = 297)

Unilateral Lower     178 (100.0)    66 (37.1)     18 (10.1)
Limb

Unilateral Upper     47 (100.0)     13 (27.6)      5 (10.6)
Limb

Multiple Limb(s) *   153 (100.0)    41 (26.8)     34 (22.2)

Total Limbs          378 (100.0)    120 (32.0)    57 (15.0)

OIF/OEF (n = 282)

Unilateral Lower     172 (100.0)    87 (50.6)     51 (29.6)
Limb                                ([dagger])    ([dagger])

Unilateral Upper     50 (100.0)     16 (32.0)     23 (46.0)
Limb                                              ([dagger])

Multiple Limb(s) *   129 (100.0)    55 (42.6)     46 (35.7)
                                    ([dagger])    ([dagger])

Total Limbs          351 (100.0)    158 (45.0)    120 (34.2)

                     Frequency (%) by Type of Combat-
                              Associated Injury

Type of                 Eye      Hearing Loss     Chest
Limb Loss

Vietnam (n = 297)

Unilateral Lower     25 (14.0)    89 (50.0)     17 (9.6)
Limb

Unilateral Upper     8 (17.0)     16 (34.0)     5 (10.6)
Limb

Multiple Limb(s) *   42 (27.5)    69 (45.1)     22 (14.3)

Total Limbs          75 (20.0)    174 (46.0)    44 (12.0)

OIF/OEF (n = 282)

Unilateral Lower     19 (11.0)    77 (44.8)     14 (8.1)
Limb

Unilateral Upper     8 (16.0)    31 (62.0) *    10 (20.0)
Limb

Multiple Limb(s) *   32 (24.8)    54 (41.9)     15 (11.6)

Total Limbs          59 (17.0)    162 (46.0)    39 (11.0)

                     Frequency (%) by Type
                     of Combat-Associated
                            Injury

Type of              Abdominal     Burns
Limb Loss

Vietnam (n = 297)

Unilateral Lower     19 (10.7)   17 (9.6)
Limb

Unilateral Upper     9 (19.1)    6 (12.8)
Limb

Multiple Limb(s) *   26 (17.0)   25 (16.3)

Total Limbs          54 (14.3)   48 (13.0)

OIF/OEF (n = 282)

Unilateral Lower     24 (13.9)   26 (15.1)
Limb

Unilateral Upper     9 (18.0)    12 (24.0)
Limb

Multiple Limb(s) *   22 (17.0)   25 (19.4)

Total Limbs          55 (16.0)   63 (18.0)

* Multiple limbs include Vietnam war (378 limbs) and OIF/OEF
(351 limbs) veterans and servicemembers.

([dagger]) p < 0.05 compared with other group within limb-loss
category.

Table 3.
Multivariate analysis of variables associated with better overall
quality of life (QOL) in Vietnam war and Operation Iraqi Freedom-
Operation Enduring Freedom (OIF-OEF) veterans and servicemembers
with major combat-associated limb loss.

Variable                                Vietnam (n = 297)

                                   aOR     95% CI      p-Value

Multiple Limb Loss *              3.07    1.57-6.02     0.001

Prosthetic Satisfaction Score     1.20    1.05-1.38     0.008
([double daggger])

Amputation Impact Rank            0.66    0.59-0.74    <0.001
([section])

Depression                        0.21    0.08-0.54     0.001

Head Injury                        --        --          --

Combat Injury Impact Rank for      --        --          --
Nonamputated Limb ([paragraph])

Needs Assistance **                --        --          --

Unilateral Upper Limb             2.21    0.83-5.87     0.11
                                                      ([double
                                                      daggger])

Variable                                 OIF/OEF (n = 282)

                                    aOR      95% CI      p-Value

Multiple Limb Loss *               0.28     0.06-1.31      0.11
                                                        ([double
                                                        daggger])

Prosthetic Satisfaction Score       --         --          --
([double daggger])

Amputation Impact Rank              --         --          --
([section])

Depression                          --         --          --

Head Injury                        0.78     0.61-0.99      0.05

Combat Injury Impact Rank for      0.71     0.57-0.88     0.002
Nonamputated Limb ([paragraph])

Needs Assistance **                0.12     0.02-0.72      0.02

Unilateral Upper Limb              0.67     0.98-4.58     0.68
                                                        ([double
                                                        daggger])

Note: -- = variable not included in model, goodness of fit for
Vietnam war model [chi square] = 130.3, 139 degrees of freedom, p
= 0.69) and for OIF/OEF model ([chi square] = 62.5, 51 degrees of
freedom, p = 0.13).

* Compared with unilateral lower limb, multiple limbs include
Vietnam war (378 limbs) and OIF/OEF (351 limbs) veterans and
servicemembers.

([dagger]) Adjusted for in model.

([double daggger]) Prosthetic satisfaction rank ranges from 0
(not at all satisfied) to 10 (completely satisfied).

([section]) Amputation impact rank ranges from 0 (limb loss does
not affect QOL today) to 10 (strongly affects) and is specific
for effect of amputated limb(s) only.

([paragraph]) Combat injury impact rank for nonamputated limb
ranges from 0 (does not affect QOL today) to 10 (strongly
affects).

** Needs assistance with activities of daily living.


aOR = adjusted odds ratio, CI = confidence interval.
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