Vocational and Recreational Considerations After Amputation

Helena Burger MD, PhD

Harvey Naranjo COTA/L

Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Burger and Harvey Naranjo.

ABSTRACT

Amputation has a profound influence on an individual’s ability to return to work, sport, and some other leisure activities. The goal of postamputation rehabilitation is to allow individuals to integrate back into their communities as independent, productive members, suggesting a return to meaningful employment, recreation, and leisure activities. To better understand the challenges of returning to work and recreation, it is helpful to separately examine the effects of upper and lower limb amputation using the perspectives of the International Classification of Functioning, Disability and Health.

Introduction

Amputation represents a change in body structure. It has a substantial influence on an individual’s quality of life and societal participation (including their ability to work and pursue leisure activities including sport and recreation) and quality of life. To improve quality of life following both lower and upper limb amputation, it is important to enable them to return to work, to recreation, and other leisure activities that they enjoy. These elements should be considered integral to comprehensive rehabilitation programs.

Return to Work

Amputation represents a change in body structure. It has a substantial influence on an individual’s ability to perform many activities, on their societal participation (including the ability to work as well as leisure activities such as sport and recreation), and on their quality of life.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸ The first article about reemployment and vocational problems after amputation was published in 1955.⁹ Interest has since increased in this topic, with more studies conducted on return to work rates and vocational challenges.³ The number of studies related to return to work among military personnel and veterans has also increased. Such studies have been performed in different countries on five continents, with most originating in North America and several European countries, mainly the Netherlands and the United Kingdom.³

The ultimate objective of postamputation rehabilitation is to allow individuals to integrate back into their communities as independent, productive members, suggesting a return to meaningful employment. Although a change in employment may be required, rehabilitation outcomes are generally successful when a person achieves independence in activities of daily living and returns to active employment.¹⁰

Several factors influence return to work. According to the International Classification of Functioning, Disability and Health,¹¹ the factors can be divided into the topics of health conditions, body functions and structures, activities, and environmental and personal factors. The factors presented in this chapter follow this classification, with separate considerations for individuals after both lower and upper limb amputations for both war veterans and civilians. Individuals affected by lower limb amputation have different activity limitations and participation restrictions than those affected by upper limb amputation. Although both populations have problems with driving and carrying objects, individuals with lower limb amputation also have problems standing, walking, running, kicking, turning, and stamping. In contrast, individuals with upper limb amputation have problems grasping, lifting, pushing, pulling, writing, typing, and pounding.¹²

Lower Limb Amputation: Return to Work Considerations

The rates of successful return to work differ among studies and are difficult to compare because the inclusion criteria vary considerably.¹³^,¹⁴ The rate of employment is largely dependent upon the definition used and varied in one study between 71.5% and 88.4%.¹⁴ Reported return to work rates range from 43.5%⁴ to almost 100%.¹ Most reported rates are between approximately 50% and 66% after a unilateral
lower limb amputation and much lower (approximately 16%) after a bilateral lower limb amputation.¹³^,¹⁵^,¹⁶^,¹⁷ Long-term survivors of high-grade osteosarcoma appear to be unique in that this cohort, experiencing no major problems in their employment, with a return to work rate greater than 95%.¹⁸

Only one study compared the return to work rate of individuals after amputation with the employment rate in the general cohort.¹⁹ The authors found a larger proportion of retired and unemployed individuals among men after amputation and a smaller proportion of students than in the general cohort of Asturias, Spain.¹⁹ Men who had undergone an amputation also attained lower educational levels than the general cohort, whereas no such differences were found in women.

The reemployment rate alone does not provide sufficient information. After lower limb amputation, many patients work only part time or change their job (described in Environmental Factors section). An estimated 15.6% to 50.0% of patients work part time after amputation.⁶^,¹³^,¹⁵ The median return to work was 12 months in most studies, ranging from 1.5 months to 21 years.⁶^,¹³^,¹⁷^,²⁰

Health Status

Negative predictors of return to work include comorbidities,²¹^,²² level of disability,²³ work-related amputation etiology,⁶^,²¹ comorbid major injuries during the event that caused the amputation, problems with residual and contralateral limbs, and phantom and residual limb pain.⁴^,²¹^,²⁴ Only Ide et al¹⁵ found that both residual limb pain and phantom pain did not influence return to work, but among their patients, those with more severe pain were less satisfied with their work. Ide et al¹⁵ and Fisher et al¹⁶ also reported that the etiology of the amputation did not correlate with satisfaction with working life or return to work.¹⁵^,¹⁶^,²⁵ After amputation, secondary impairments may develop, including hip and knee osteoarthrosis, low back pain, and osteoporosis.²⁶ These impairments may also influence the ability to work, but research is needed to confirm this relationship.

Body Functions and Structure

Although some studies demonstrate that lower limb amputation decreases muscle strength, causes balance problems, and may decrease range of motion,²⁷^,²⁸ no studies exist on whether these considerations of body functions create problems at work or adversely affect return to work. A relationship seems likely because these factors influence some activities such as walking on level ground, walking on varied terrain, the ability to carry objects, and climbing stairs.²⁷^,²⁸

Level and Type of Amputation

Between 3.5%¹ and 50.0%¹⁷ of individuals who have undergone lower limb amputation are unable to work.¹³^,¹⁴^,²¹ Approximately 15% of patients (range, 14.0% to 17.6%) retire because of amputation,¹⁶ and 55% stop working within the first 2 years after amputation.¹³ After amputation, approximately 25% of employed persons experience periods of unemployment lasting longer than 6 months.¹⁴

More proximal levels of amputation may decrease return to work rates. Persons with transfemoral amputations have lower return to work rates than those with a transtibial amputation.⁶^,²²^,²⁵ Livingston et al⁶ reported that no individuals within their cohort returned to work after transfemoral amputation. In contrast, Fisher et al¹⁶ reported no correlation between the level of amputation and scores on an employment questionnaire. Return to work has been reported as lower with multiple amputations.¹⁴ In addition, individuals with transtibial amputation are more willing or able to work than those with successful limb salvage.

Skin

Up to 41% of patients who have undergone lower limb amputation can have different types of skin problems, including wounds.²⁹ More active individuals have an increased risk for the development of skin problems. Those who are employed, walking without ambulatory aids, and walking in the community have more skin problems than unemployed and retired individuals, than those using two canes, crutches, or a walker, or those walking at home only.²⁹

Activities and Participation

Journey et al²⁵ found that the reintegration into Normal Living Index is a predictor of return to work. However, several studies reporting on return to work after amputation have described the problems individuals reported in their work environments, including walking, climbing stairs, driving, and using public transportation.¹^,⁶^,¹²

The immediate influence of considerations of activities and participation on return to work has not been directly studied. However, walking distance and restrictions in mobility have a substantial, clinically relevant influence on the individual’s ability to return to work.²¹ Better physical functioning 3 months after amputation and a lower disability level are positive predictors for return to work.²³^,²⁴ Basic physical activities are important considerations in going to and from work and also for some working tasks¹² and can therefore reduce productivity when impeded.¹⁶

Environmental Factors

Prosthesis

After amputation, a prosthesis is needed that enables the patient to perform their work and is suitable for physical and environmental requirements. Most patients require a prosthesis that decreases the frequency of stumbles and falls, enables good mobility, and allows the individual to perform activities that require divided attention.³⁰ Some individuals require specific adaptations of the prosthesis. Both the use and wearing comfort of a prosthesis influence return to work in a substantial, clinically relevant manner.²¹ Problems with the prosthesis are among the major reasons for reduced productivity.¹⁶

Climate

Climate is one of the most common environmental barriers for individuals after amputation (in 55.4% of cases).³¹ A hot climate can increase sweating and skin problems; a cold climate can influence battery working time for those with a battery-powered prosthesis. However, no studies exist on the
influence of climate on return to work rates or problems at work.

Geography

Physical environment is the second most common environmental barrier (in 54.7% of cases), especially for individuals after lower limb amputation.³¹ Walking up and down hills and on uneven terrain is more difficult than walking on smooth, even ground. However, as with climate, no studies exist on the influence of geography on either return to work rates or problems at work.

Type of Work

Although Fisher et al¹⁶ found no difference in employment rate associated with the type of previous work (skilled versus unskilled), 4% to 60% of patients have to change to a different job after lower limb amputation. In most studies, the reported proportion is approximately one-third.¹³^,²² A general shift from manual to nonmanual employment has occurred, trending toward more administrative and/or scientific/technical work.⁴^,¹³ Most individuals move between one and three grades below their preamputation employment classification (ie, from skilled to semiskilled or unskilled occupations).⁴ The demands of the job before and after amputation, assessed on a scale ranging from 0 to 16, decreased from a mean of 12.1 to 8.3, respectively.³ Working before an amputation, increased job involvement before amputation, and decreased workload after amputation are all associated with increased success in return to work.¹⁶^,²²^,²⁴

Between 28% and 43% of those who undergo lower limb amputation require job adaptations;⁷^,¹³ almost one-third remain partially dependent on colleagues.¹³ Adaptations needed for each amputation level are well described by Girdhar et al.¹² Two-thirds of patients feel that their productivity is as good as before amputation,¹⁴ and one-fourth work overtime hours.³⁰ The main reasons for decreased productivity are problems with the prosthesis (48%), transportation difficulties (28%), and other physical problems (20%).¹⁴

Approximately 57% of the patients were dissatisfied with work reintegration after amputation, citing fewer possibilities for promotion.¹³ Livingston et al⁶ reported that most patients who returned to work did so at a lower salary, but Wan Hazmy et al¹⁷ found that 40% held the same income. A lower status position and lower income can result in loss of self-esteem and feelings of inadequacy.³² Individuals with higher income before amputation are more likely to return to work.⁶^,²² Low income is one of the most common environmental barriers following both upper and lower limb amputation.³¹

Support

Family support, volunteers in the patient’s community, survivor groups, health professionals, the possibility of vocational rehabilitation, and the support of colleagues and supervisors have been observed as important factors in successful return to work.¹³^,¹⁶^,²²

Transportation Services

After lower limb amputation, many individuals experience problems driving and using public transportation.¹^,⁶^,¹⁶ Difficulty with transportation is one of the main reasons for decreased productivity;¹⁶ hence, accessible transportation may decrease these problems.

Legal and Social Security Services

Social security systems and services differ greatly among countries; therefore, the results are difficult to compare, and results from one country may not apply to another. When disability benefits exceed work income, individuals may have no interest in returning to work, especially those who are not satisfied with their work. The Dutch system, in which it is possible to combine disability and other benefits proportionally with income from work,¹³ seems conducive to stimulating return to work. Importantly, those who return to employment may consume substantially fewer services than unemployed individuals.⁴

Health Services, Systems, and Policies

Only gold members can continue reading. Log In or Register to continue