Factors influencing quality of life following lower limb amputation for peripheral arterial occlusive disease: A systematic review of the literature

Abstract

Background:

The majority of lower limb amputations are undertaken in people with peripheral arterial occlusive disease, and approximately 50% have diabetes. Quality of life is an important outcome in lower limb amputations; little is known about what influences it, and therefore how to improve it.

Objectives:

The aim of this systematic review was to identify the factors that influence quality of life after lower limb amputation for peripheral arterial occlusive disease.

Methods:

MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science and Cochrane databases were searched to identify articles that quantitatively measured quality of life in those with a lower limb amputation for peripheral arterial occlusive disease. Articles were quality assessed by two assessors, evidence tables summarised each article and a narrative synthesis was performed.

Study design:

Systematic review.

Results:

Twelve articles were included. Study designs and outcome measures used varied. Quality assessment scores ranged from 36% to 92%. The ability to walk successfully with a prosthesis had the greatest positive impact on quality of life. A trans-femoral amputation was negatively associated with quality of life due to increased difficulty in walking with a prosthesis. Other factors such as older age, being male, longer time since amputation, level of social support and presence of diabetes also negatively affected quality of life.

Conclusion:

Being able to walk with a prosthesis is of primary importance to improve quality of life for people with lower limb amputation due to peripheral arterial occlusive disease. To further understand and improve the quality of life of this population, there is a need for more prospective longitudinal studies, with a standardised outcome measure.

Clinical relevance

This is of clinical relevance to those who are involved in the rehabilitation of persons with lower limb amputations. Improved quality of life is associated with successful prosthetic use and focus should be directed toward achieving this.

Keywords

Lower limb amputation quality of life prosthesis walking trans-femoral amputation trans-tibial amputation peripheral arterial occlusive disease

Background

Peripheral arterial occlusive disease (PAOD) affects approximately 20% of adults above the age of 55 years in Europe and Northern America¹ and is a manifestation of systemic atherosclerosis, most commonly within the lower extremities.² Approximately 6% of the UK population are living with diabetes which increases the risk of PAOD.³ PAOD can cause pain from ischaemia and infection of the lower limb and can be treated with wound management, orthotics or limb salvaging surgery.⁴ However, between 1% and 2% of those with the most severe form of PAOD will require a lower limb amputation (LLA).¹ Those with PAOD have limited mobility pre-amputation, attributable to the existence of co-morbidities such as ischaemic heart disease and cerebrovascular disease which often co-exist with PAOD. If diabetes is also present, many will have neuropathic, visual, renal and weight-related problems.³

There are more than 6000 primary LLAs per annum in the United Kingdom and approximately 85% are due to PAOD.^1,5 Those undergoing a LLA due to PAOD are generally above 65 years old, and approximately 50% will have multi-morbidities.⁶ Life expectancy post LLA is only 2–5 years.⁷ This is predominately due to a 6-fold increase in mortality from coronary artery disease.⁸ It is therefore imperative that quality of life (QoL) post LLA is optimised to ensure that major surgery for PAOD is not a futile intervention.

Following LLA, the focus of rehabilitation is to optimise function, especially walking.⁹ Despite this, approximately 60% of people following LLA will be wheelchair-bound which may impede their physical capability, independence and thus their QoL.⁶

The surgical success of a LLA is often measured in terms of survival or receiving a prosthetic limb.¹⁰ Approximately 40% of those who undergo a LLA receive a prosthetic limb.⁶ Those who have a trans-tibial amputation (TTA) have a greater likelihood of walking with a prosthesis than those with a trans-femoral amputation (TFA) or through-knee amputation (TKA).¹¹ The energy expenditure required to walk with a prosthesis following TFA is higher due to the loss of the knee joint.¹² Consequently, only 26% of those with a TFA will receive a prosthesis, compared to 75% of those with a TTA.⁶ Successful outcome following a LLA should take into account the person’s QoL, a concept which has become increasingly more important in rehabilitation.¹³ QoL is defined as ‘an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’.¹⁴ There are no validated QoL outcome measures for those with a LLA; therefore, generic QoL outcome measures are used. These generic measures focus on the function/disability areas of the International Classification of Functioning and Disability Framework rather than the contextual factors such as the environment.

A person who has a LLA for dysvascular reasons has a poorer QoL compared to someone who has a LLA for other reasons such as trauma or tumour.¹⁵ To maximise rehabilitation outcomes, an understanding of the factors that influence a person’s QoL following dysvascular LLA is essential for healthcare professionals. A previous literature review assessed QoL in those with a LLA for all aetiologies, including trauma, tumour, orthopaedic complications and dysvascular causes.¹⁶ The majority of the 26 articles included had amputee populations of mixed aetiologies such as trauma or tumour (n = 16), did not distinguish between upper limb amputation and LLA (n = 2) and compared major LLAs to other surgeries (n = 2).¹⁶ To date, no systematic review has been undertaken on QoL in those with LLA for PAOD. The aims of this systematic review were to report the QoL of those with a LLA due to PAOD and to identify the factors that influence QoL after a major LLA due to PAOD.

Methods

Search strategy

A systematic literature review was undertaken in December 2015 using EBSCO and OVID which searched MEDLINE, CINAHL, PubMed and PsycINFO databases. Web of Science and Cochrane databases were searched separately, and all literature published from database inception to the end of 2015 were included. The search strategy included specific keywords and combined Medical Search History (MeSH) headings which were exploded for greater depth, and the following terms were used: foot or feet, ‘lower limb’, knee, leg, amput*, ‘above knee’, ‘below knee’, ‘lower extremity stumps’, ‘limb absence’, ‘limb loss’, ‘limb removal’, ‘quality of life’, quality of life, ‘Peripheral Vascular Disease’, ‘peripheral arterial occlusive disease’, ‘diabetes mellitus’, ‘diabetes’, ‘DM’, ‘type II diabetes’, ‘Activities of daily living’, ‘Physical and Rehabilitation medicine’, ‘Rehabilitation Centres’, Rehabilitation, ‘Mobility Limitation’, ‘Phantom Limb’, ‘Phantom Pain’. The use of Boolean terms ‘AND’ and ‘OR’ enhanced the search. Citations of relevant articles were also reviewed for possible inclusion.

Inclusion/exclusion criteria

Articles were included if the entire amputee study population had a LLA due to PAOD, participants were 18 years old or above, the full-text article was published in English, had a sample of more than 10 participants, reported the results of one or more QoL outcome measures and was empirical research. Articles were excluded if they were case-studies, reviews, editorial opinions, testimonies, biography/interviews, books, progress reports, conference abstracts or posters, discussion papers, guidelines, discussed other people’s QoL, for example, a carer’s or family member’s rather than a patient’s QoL, and did not use an objective outcome measure which meant all qualitative studies were excluded. Also excluded were articles that were a development or validation of an outcome measure to assess QoL, if the populations studied were of mixed aetiology or if participants underwent an amputation for reasons other than PAOD.

The literature search produced 333 articles: 201 from OVID, 122 from EBSCO, 4 from Web of Science, 1 from Cochrane and 5 from reference lists. Two systematic reviews were identified, one was not relevant¹⁷ and the other provided back referencing of articles to include.¹⁶ Fifty-four duplicate articles were removed. The titles of 279 articles were screened initially by one reviewer (F.C.D.-S.) which resulted in 209 being excluded. Then, two reviewers (F.C.D.-S. and E.C.) examined the abstracts of the remaining 70 articles and excluded a further 58 articles. This resulted in 12 full-text articles for review and assessment (Figure 1).

Figure 1.

Schematic diagram of literature search when inclusion and exclusion criteria applied.

Quality assessment

The included articles were scored using a quality assessment tool with 19 criteria, adapted from a previous systematic review.¹⁶ To bring the quality assessment in line with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines,¹⁸ one further criterion was added: evidence of limitations, creating a 20-criteria tool (Figure 2).¹⁸ These additional criteria assessed whether the authors had accounted for potential bias and discussed any limitations of their research. The maximum quality assessment score was 38 points; this was based on three sub-categories: (1) the source population (11%), (2) study population characteristics (42%) and (3) methodological characteristics (47%).¹⁶

Figure 2.

Quality assessment criteria and scores used to rate the articles.

Each article was independently scored by two of three assessors (F.C.D.-S., E.C. and L.P.), and when agreement could not be met, the third assessor was consulted to ensure consensus was reached. A pilot assessment was conducted where all three reviewers read one article independently and scored it, and then met to discuss the scoring and agreement was achieved. From this successful pilot, the remainder of the articles was scored with two assessors.

Results

The 12 studies that were eligible for inclusion are presented in Table 1. This highlights each study’s aims, population, QoL outcome measure and findings; these were grouped by methodological design (Table 1).

Table 1.

Evidence of literature.

Author, year, design and quality assessment score	Aim of study	Sample population	Time point (s)	QoL outcome measures (s)	Main findings
(2) Buijck et al.¹⁹ QA = 47%	To determine what affects QoL in the home environment following LLA after a period of in-patient rehabilitation in the elderly population.	n = 27 people; mean age 75 years Major LLAs 8 TFAs, 4 TKAs and 15 TTAs. All elderly and discharged from in-patient care to home.	3 months after in-patient discharge	RAND-36	21 People were fitted with a prosthesis; 8 were fitted for cosmetic purposes and were immobile, 11 achieved limited mobility with a walking aid and 2 were mobile without walking aids. Mean QoL score ranged from 22 to 87, and low QoL (on physical function) was correlated positively to poor functional ambulation score. High QoL scores were associated with low scores for depression and neuropsychiatric symptoms. Pain was not associated with any factors.
(5) Fortington et al.²⁰ QA = 71%	To describe changes in HRQoL from amputation to 18 months post amputation in lower limb amputees and compare this to a normal population.	Mean age 67.8 years (±13 years) n = 82 LLAs, 30 TFAs/TKAs and 52 TTAs	At LLA and 6 and 18 months post LLA	RAND-36 Dutch version	TK and TF levels of amputations were linked to a significantly lower level of physical function than TTA.
					The ability to walk was related to improved social function and higher QoL.
					Most change in QoL occurred in first 6 months post LLA.
					Age was a significant factor in HRQoL in physical function.
					Lower QoL in LLAs was reported in all domains compared to population norms.
					All able to walk 500 m pre-LLA (n = 82).
					At 6 months, (n = 46), 21 were able to mobilise 500 m, 9 had improved and 16 were not mobile.
					Between 6 and 18 months (n = 35), 17 maintained their mobility and 11 improved, 7 were not mobile.
(8) Norvell et al.²¹ QA = 92%	Examine factors associated with mobility success during first year following first major unilateral LLA ± DM.	n = 87 Mean age 62 years at time of LLA and (TMA = 27, TTA = 52, TFA = 8) n = 75 at follow-up (TMA = 26, TTA = 42, TFA = 7)	At LLA and 12 months post LLA	SWLS	Decline in mobility in all groups over time from pre LLA; however, this was greatest in TFAs.
					If mobility success was achieved, then participants were more likely to have improved satisfaction with life.
					Although 50% of the group reported low to moderate levels of mobility, this was associated with mobility satisfaction.
					Mobility measured with LCI-5 change score from pre LLA to 12 months post LLA. All reported a decline in mobility at 12 months post LLA.
(7) Mac Neill et al.²² QA = 68%	To examine long-term outcome, prosthetics and QoL, after bilateral trans-tibial amputation.	n = 82 at baseline Mean age 68.5 years and n = 34 followed up at 3.7 years post amputation	~3.7 years post LLA	Houghton SF-12 Qualitative measures of ADL	85% Of those who survived at 3.7 years were wearing their prosthesis daily (69% were able to mobilise for 15 min outdoors once a week) with higher SF-12 scores in the mental health aspect than the physical aspect. Those living alone reported better mental health and were more independent than those who lived with others.
(1) Abdelgadir et al.²³ QA = 68%	To compare two groups of people with differing durations of diabetes, one group had LLA.	n = 60 major LLAs (44 TTAs and 16 TFAs) Mean age 57.4 years (±10.5 years) compared to 60 people without LLAs, all of whom had DM	~5.3 years since LLA	MOS questionnaire SOC scale	Reduced mobility in LLAs was highly correlated to the role physical aspect of the QoL scores.
					Increased duration of diabetes, worsening symptoms and undergoing a LLA were associated with poor QoL.
					Longer time since LLA was associated with lower QoL compared to more recent LLA.
					QoL was greatest in those with improved family satisfaction and better sleep.
					No prosthetic wearing time or mobility distance was recorded.
(3) Cox et al.²⁴ QA = 58%	To determine QoL and functional independence of diabetic amputees.	n = 87 (64 TTAs and 23 TFAs) Mean age 62 years (±9.9 years), all with DM	From 1 to 3 years since LLA	WHOQOL-BREF scale	Those with a TTA recorded improved QoL and functional independence compared to those with a TFA.
					Females had a higher QoL in all four domains.
					Positive correlation was found between functional independence and QoL in all participants.
					No prosthetic wearing time or mobility distance was recorded.
(4) Deans et al.²⁵ QA = 63%	Investigate the link between physical activity and associated QoL.	n = 25 Mean age 66 years of possible 75 unilateral LLAs (22 TTAs and 3 TFAs) who were fitted with a prosthesis	Discharged from out-patient prosthetics for >2 years from LLA	TAPES WHOQOL-BREF scale	Correlation between functional score on the TAPES and the physical function aspect of the QoL measure.
					Correlation between social aspects of both scales suggesting that LLAs place more emphasis on their social status and interactions than on physical fitness.
					No prosthetic wearing time or mobility distance was recorded.
(6) Harness and Pinzur²⁶ QA = 60%	To assess prosthesis-related QoL.	60 Unilateral TTAs Mean age 65.9 years (±1.4 years)	Minimum of 6 months prosthetic use (median 24 months)	PEQ	Social burden correlated positively with the ability to mobilise with prosthesis.
					Satisfaction correlated with less pain and the ability to mobilise.
					Weak association between pain and residual limb health and ability to mobilise with a prosthesis.
					No prosthetic wearing time or mobility distance was recorded.
(9) Pell et al.²⁷ QA = 63%	To assess the effect of LLA on QoL and compare this to population norms.	n = 130 Median age 73 years (86 TTAs and 44 TFAs)	Median of 38 months since time of LLA	NHP	Those with a LLA have a lower QoL than population norms.
					QoL is directly linked to mobility.
					87% Wore their prosthesis and 42% were mobile with their prosthesis.
					Isolation is more pronounced in those with a LLA despite social situation even when compared to controls who lived alone.
(10) Remes et al.²⁸ QA = 79%	To assess QoL of amputees with PAD.	59 Unilateral amputees (13 TTAs, 28 TFAs, 18 bilateral) Mean age 75.2 years (±10.7 years)	2 years after LLA	RAND-36 SSQ6 GDS 15D HRQOL SWLS	Home-dwelling amputees had good QoL compared to those in institutions and those who could not walk.
					Mini-mental score lower in those with LLA.
					More co-morbidities in those with LLA.
					Reduced mobility was an independent factor in poor QoL.
					25 were prosthetic wearers and 4 had no issues mobilising 100 m, 21 reported limited mobility with prosthesis.
					Similar health satisfaction and social support between controls and LLAs.
					More depression in those who were in care homes or could not mobilise.
					Although LLAs had reduced physical function, they had larger social support structure than those without a LLA.
(11) Tennvall and Apelqvist²⁹ QA = 68%	Compare HRQoL in people with DM who attended foot clinic.	n = 26 major LLAs (level not stated) Mean age 67 years A total of 310 people were surveyed, the remainder had foot ulcers or minor amputationsResponse rate of 70%	1–3 years post LLA	EQ-5D-5L Swedish version	People who had major LLA had lower QoL compared to those with current foot ulcer or minor LLA.
					People who had minor LLA had higher QoL than those with no LLA and a current foot ulcer.
					No prosthetic wearing time or mobility distance was recorded.

(12) Thompson et al.³⁰ QA = 37%	To compare distal bypass surgery with major LLA in terms of QoL.	n = 24 LLAsMedian age 69 years compared to n = 48 bypass	Retrospective but no date given	A self-assessment QoL includingHADSNine-point scale of social functionFour-point mobility scale	Bypass group had lower levels of depression, impairment and greater mobility than LLA group in terms of QoL.QoL was lower overall for those with a LLA indifferent of whether bypass had failed or not.No prosthetic wearing time or mobility distance was recorded.

QA: quality assessment; QoL: quality of life; LLA: lower limb amputation; TKA: through-knee amputation; TTA: trans-tibial amputation; RAND-36: Research and Development Corporation Measure of Quality of Life; TFA: trans-femoral amputation; HRQOL: health-related quality of life; SWLS: Satisfaction With Life Scale; LCI-5: Locomotor Capabilities Index; SF-12: 12-item Short Form survey; ADL: activities of daily living; DM: diabetes mellitus; MOS: Medical Outcome Study; SOC: Sense of Coherence; WHOQOL-BREF: World Health Organization Quality of Life-BREF; TAPES: Trinity Amputation and Prosthetic Experience Scale; PEQ: Prosthetic Evaluation Questionnaire; NHP: Nottingham Health Profile; SSQ6: Six Item Brief Social Support Questionnaire; GDS: Geriatric Depression Scale; 15D HRQOL: 15D Health Related Quality Of Life; EQ-5D-5L: five-level version of the EuroQol five-dimensional questionnaire; HADS: Hospital Anxiety and Depression Scale.

Numbers in parenthesis in column 1 refer to column 1 of Table 2.

Scoring of quality assessment

Quality assessment scores ranged from 36% to 92%. Reviewers reached agreement all final scores. The majority of the included articles were of good quality, with 10 of the 12 articles scoring more than 50%. Analysed by sub-categories, 10 of the 12 articles achieved the maximum score for source population; however, only 4 articles achieved a score more than 50% for study population characteristics. The methodological characteristics subcategory had higher quality scores, with the majority (11 of 12) scoring more than 60% (Table 2).

Table 2.

Quality assessment scores.

S.no.	Study	Source population				Study population characteristics										Methodological characteristics												Quality scores
S.no.	Study	A	B	Total	%	C	D	E	F	G	H	I	J	Total	%	K	L	M	N	O	P	Q	R	S	T	Total	%	Overall total	%
1	Abdelgadir et al.²³	2	2	4	10	2	2	1	0	0	0	0	2	7	18	2	1	1	2	2	1	2	1	1	2	15	40	26	68
2	Buijck et al.¹⁹	2	0	2	5	1	2	0	0	0	0	0	2	5	13	2	3	1	2	2	0	0	0	1	0	11	29	18	47
3	Cox et al.²⁴	2	2	4	10	2	2	0	0	0	0	0	2	6	16	1	1	1	2	2	0	2	1	1	1	12	32	22	58
4	Deans et al.²⁵	2	2	4	10	1	2	2	0	2	0	0	2	9	24	2	1	1	2	2	0	0	0	1	2	11	29	24	63
5	Fortington et al.²⁰	2	2	4	10	2	2	0	0	0	0	0	2	6	16	2	3	1	2	2	2	1	1	1	2	17	45	27	71
6	Harness and Pinzur²⁶	2	2	4	10	2	2	0	0	0	1	0	2	7	18	2	1	1	2	2	0	2	1	1	0	12	32	23	60
7	Mac Neill et al.²²	2	2	4	10	2	2	0	0	0	2	0	2	8	21	2	2	1	1	2	1	2	0	1	2	14	37	26	68
8	Norvell et al.²¹	2	2	4	10	2	2	2	2	2	2	2	2	16	42	1	3	1	1	2	2	2	0	1	2	15	40	35	92
9	Pell et al.²⁷	2	2	4	10	1	2	0	0	1	0	0	2	6	16	2	1	1	2	2	2	2	1	1	0	14	37	24	63
10	Remes et al.²⁸	2	1	3	8	2	2	2	0	2	2	0	2	12	31	2	1	1	2	2	1	2	1	1	2	15	40	30	79
11	Tennvall and Apelqvist²⁹	2	2	4	10	2	2	0	0	0	1	0	2	7	18	2	1	1	2	2	2	1	1	1	2	15	40	26	68
12	Thompson et al.³⁰	2	2	4	10	1	0	0	0	0	0	0	1	2	5	1	1	1	1	2	0	1	1	0	0	8	21	14	36

Sample populations

There was large variation in sample size, sampling techniques and comparator groups throughout the 12 studies. Sample sizes ranged from n = 24³⁰ to n = 130.²⁷ Sampling techniques included purposive,^{20–24,25,27–30} convenience^19,22 and random sampling.²⁶ Comparison groups included age- and gender-matched controls,^23,27,28 those with limb salvaging surgery³⁰ and those with foot ulcers.²⁹

Study designs

Study designs were cross-sectional (n = 8),^23–30 prospective (n = 3)^19–21 and mixed methods (n = 1).²² The time points chosen to assess QoL ranged from 3 months after in-patient discharge¹⁹ to 5.3 years after LLA.²³ The length of time between outcome measurements in prospective longitudinal studies also varied from date of LLA, 6 and 18 months post LLA²⁰ to 6 weeks and 12 months post LLA.²¹

Outcome measures

A variety of generic QoL outcome measures were used across the studies: the Research and Development Corporation Measure of Quality of Life (RAND-36, n = 3);^19,20,28 the World Health Organization Quality of Life scale (WHOQOL-BREF, n = 2);^24,25 the 12-item Short Form survey (SF-12, n = 1)²² and the five-level version of the EuroQol five-dimensional questionnaire (EQ-5D-5L, n = 1).²⁹ Although none of these measures has been validated for use with the LLA population, Sinha et al.³¹ reported high internal consistency for the Short Form-36 (SF-36) in the LLA population. The same authors found a significant correlation between the Trinity Amputation and Prosthetic Experience Scale (TAPES) and the Physical and Mental component summaries of the SF-36 QoL measure in the LLA population.³¹ The Prosthetic Evaluation Questionnaire (PEQ; n = 1)²⁶ is specific to those who have a prosthesis after LLA. Other scales such as the Satisfaction With Life Scale (SWLS; n = 2),²¹ Sense of Coherence scale (n = 1),²³ Nottingham Health Profile (n = 1)²⁷ and a nine-point scale of social function (n = 1)³⁰ were also used.

Ten studies used a single measure to assess QoL,^19–27,29 whereas one study used four separate measures.²⁸ Seven studies measured QoL alongside other factors such as physical function, depression, social support, prosthetic use and change in walking.^{19,21,22,24,25,28,30}

Factors influencing QoL

Walking ability and use of prosthesis

Walking with a prosthesis was the most notable factor that influenced QoL and was reported by all 12 studies. The other factors that were identified that influenced QoL were gender, age, diabetes and family support (Table 2).

When comparing QoL of people after LLA to age- and gender-matched controls, after controlling for social isolation and emotional distress, the ability to walk was still found to significantly influence QoL.^23,27 Norvell et al.²¹ suggested that even small amounts of walking resulted in greater QoL compared to being unable to walk. In addition, Deans et al.²⁵ suggested that the association between QoL and walking was due to the positive influence of walking with a prosthesis on social interaction, rather than improving physical fitness.

Two cross-sectional studies compared those with a LLA to people with active foot ulcers²⁹ and bypass graft (limb salvaging surgery).³⁰ Both studies concluded that the QoL of those with a LLA was significantly poorer than those with active foot disease or surgery. Those who underwent a LLA had higher levels of depression and were less mobile than those who underwent a bypass graft.³⁰ Mobility was self-reported on a four-point scale and those with a LLA were significantly less mobile than those with revascularisation; however, no information about prosthetic use or distances covered was given. Although the results are as expected, this article was a retrospective study with a relatively small number of those with LLA (n = 26) compared to those with a bypass graft (n = 86), and the study’s quality assessment score was low (Table 2).

Level of LLA

Two studies of prospective design examined the effect of level of LLA on QoL,^20,21 both achieving high-quality assessment scores (Table 2). Those with a TTA reported better QoL, compared to those with a TFA.²⁰ This was due to improved walking ability and thus greater social function in those who had a TTA. A decline in QoL and walking was observed over 12 months after LLA in all participants with LLA regardless of level;²⁰ however, this decline in QoL was greatest in those with a TFA.²¹ In one study of people with unilateral TTA, a strong association was found between QoL and the ability to walk (n = 60);²⁶ however, all the sample received prosthetic rehabilitation and were therefore more likely to be mobile.

Age, co-morbidities and gender

There was a strong association between being above 65 years of age at the time of LLA and reduced ability to walk, which ultimately had a detrimental effect on QoL.^20,21 With increasing age, there was a higher incidence of co-morbid disease²⁰ which may have affected QoL directly or indirectly through the influence of the co-morbid conditions on walking ability.

The presence of diabetes was associated with a lower QoL following LLA. Furthermore, the longer the duration of diabetes and its associated secondary complications, the poorer the QoL.²³ Other co-morbidities such as hypertension, alcohol dependence, anxiety and depression are reported to negatively influence QoL.²¹ Two studies found that gender influences QoL with women having higher QoL following LLA,^23,24 especially in those below 60 years old.

Social situation

Living at home and being to walk was positively associated with QoL.²⁸ Poor QoL and the presence of depressive symptoms were more prevalent in those living in a care home or in those who were wheelchair-bound within their home environment.²⁸ Mac Neill et al.²² found that those who had bilateral TTAs and lived alone scored higher on the mental health aspect of QoL and higher on the activities of daily living on the Frenchay Activities Index, than those who lived with family. The authors also suggested that poorer QoL was attributed to social isolation, 24% of people were housebound; however, social isolation was reported to be present even if participants did not live alone.²⁷

Conclusion

The aims of this systematic review were to identify the factors that influence QoL after LLA for PAOD. Our findings show that the ability to walk with a prosthesis had the strongest influence on QoL. Many factors affect the ability to walk with a prosthesis such as level of LLA, co-morbid diseases, psychological motivation, living situation and social function. Although there is general agreement that those with a LLA have poorer QoL compared to their healthy peers, walking ability was the central influencing factor, which then determined the ability to live independently and participate in social activities which also impacted QoL.

Our review concurs with some of the findings of Sinha et al.¹⁶ who also found that limited walking ability negatively influences QoL in those with a LLA. Furthermore, our review found that the ability to participate socially, perform activities of daily living and live independently influence the QoL of a person with a LLA due to PAOD. The age range of the populations studied in this review was from 56 to 75 years old. Of all the studies included in this review, only one study reported that QoL declined with increasing age, specifically above 65 years old. Our review is novel as it focuses solely on those who have a LLA due to PAOD as opposed to previous reviews which have examined heterogeneous groups of those with amputations. LLAs due to PAOD are the most common and have the greatest impact on health resources.

Factors such as advancing age and co-morbidities, notably diabetes, negatively influence the probability of successfully walking with a prosthesis and therefore QoL.^20,21,23 The majority of those with a LLA due to PAOD are above 65 years old and approximately half will have diabetes. The presence of arterial disease in other organs adds to the co-morbid burden of this patient group, compounded by walking ability which may be impaired prior to LLA;⁶ these factors reduce their life expectancy and ability to walk with a prosthesis. One solution to improving the QoL of non-prosthetic users may be extending rehabilitation and integration with prosthetic users to allow for improvements in morale and social integration.²⁷ QoL was greater in those with a TTA compared to a TFA. Those with distal amputations, for example, TTA, are more likely to have successful prosthetic management, less likely to need walking aids and more likely to engage in meaningful vocational and social activities.¹¹ Hagberg et al.¹² concluded that those with a TFA had poorer QoL, than those with a TTA, as they required a higher level of energy expenditure to walk, due to the loss of the knee joint. In addition, it is possible that lower mood and higher psychological burden may reduce the inclination to participate in rehabilitation which lowers the successful use of a prosthesis.

Two studies in this review examined the gender differences in QoL.^23,24 Improved QoL was reported in females, compared to males, and was attributed to their higher levels of physical function. These findings conflict with previous literature, in which males were found to have greater QoL.¹⁶ However, the review by Sinha et al.¹⁶ included those with LLAs for non-vascular causes. Therefore, it is possible that QoL following a LLA may be greater in females when it is due to PAOD and improved in males when the LLA is due to trauma or tumour. Further research is warranted to examine these gender differences.

Although there were conflicting results regarding family support and its impact on QoL, those who live alone may be more capable, both cognitively and physically, and therefore have a better QoL.²² Mac Neill et al.²² also suggested a cause-and-effect relationship between QoL and living alone. More specifically, those who lived alone were more able to perform activities of daily living independently, a third engaging in social outings on a weekly basis. Consequently, they had better mental health as they felt less burdensome and relied less on others. Conversely, two studies suggested that living with family was associated with better QoL in comparison with those who lived alone.^23,27 Although these studies focussed on living with family, the rating of good QoL may be replicated in a supportive environment such as residential or assisted living complex.

There are no validated QoL outcome measures available for the LLA population, accommodating both wheelchair and prosthetic mobility. The TAPES was used in one study; however, this only assesses the function of prosthetic users.²⁵ The PEQ, which has a sub-section that measures QoL, is the only outcome measure that has been validated for use in those with a LLA. Despite this, it is only relevant for those who receive a prosthesis and was only used in one study included within this review.²⁶ Developing and validating a QoL outcome measure for this population is imperative to allow for more rigorous future longitudinal studies, systematic reviews and meta-analyses.

This review has demonstrated that being able to walk with a prosthesis is the main factor affecting QoL after a LLA for PAOD. A number of factors such as age, level of amputation and the presence of co-morbidities also affect QoL in those with PAOD, but are not modifiable. It is therefore important that rehabilitation focusses on modifiable factors, particularly with regards to walking. Furthermore, LLAs due to non-vascular aetiologies have benefitted from advances in prosthetic technologies and access to rehabilitation.^32,33 The improved technology may benefit amputees in prosthetic comfort, pain relief and energy conservation improving walking ability following LLA.

Study limitations

This review was limited to studies published in English. It was also limited by the heterogeneity of the study designs included. Due to the variety of outcome measures used, it was not possible to conduct a meta-analysis. Studies using qualitative methodologies were excluded from the review; however, they may have added context to the factors that influence QoL.

This review is novel in its focus on those with a LLA due to PAOD and as such has identified the factors that influence QoL in this population. Walking is the main factor that influences QoL following LLA and as such rehabilitation should focus on gait re-education with a prosthesis. To improve the QoL, there is a need for more prospective longitudinal studies with a standardised outcome measure which can examine the possible change in QoL over time.

Footnotes

Author contribution

All authors contributed equally in the preparation of this manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: This study was funded by Diabetes UK through the Sir George Alberti fellowship.

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