848580

research-article2019
IJLXXX10.1177/1534734619848580The International Journal of Lower Extremity WoundsTsoulou et al

Original Article
The International Journal of Lower

Association of State and Trait Anxiety

Extremity Wounds
1­–10
© The Author(s) 2019
Between Patients Who Had Undergone Article reuse guidelines:
sagepub.com/journals-permissions

Traumatic Amputation and Their Family DOI: 10.1177/1534734619848580

https://doi.org/10.1177/1534734619848580
journals.sagepub.com/home/ijl

Caregivers

Vasiliki Tsoulou, MSc1, Eirini Karamolegou, MSc1, Michael Kourakos, PhD1,

Georgios Vasilopoulos, PhD2 , and Maria Polikandrioti, PhD2

Abstract
The purpose of this research was to explore the association between state and trait anxiety experienced by patients
who had undergone traumatic amputation and their family caregivers. The sample studied consisted of 50 hospitalized
patients who had undergone traumatic amputation and 50 family caregivers. The collected data included patients’ and
caregivers’ characteristics and the State Trait Anxiety Inventory scores. Fifty percent of patients and caregivers scored
below 50 and 47, respectively (median), in trait anxiety. In terms of state anxiety, at least 50% of patients and caregivers
scored below 56 and 50.5, respectively. These values indicate moderate to high levels of the impact of amputation
on the trait and state anxiety of amputees and their caregivers. A positive linear correlation was found between
the trait and state anxiety of the patients as well as between the trait and state anxiety of caregivers, as expected
(ρ = 0.915, P < .001, and ρ = 0.920, P < .001, respectively). A statistically significant positive correlation was also
observed between state patient anxiety and state anxiety of caregivers (ρ = 0.239 and P = .039) and between trait
patient anxiety and trait anxiety of caregivers (ρ = 0.322 and P = .030). More specifically, as the patient’s anxiety score
(either trait temporary) increases, the score of the caregivers’ anxiety increases and vice versa. Nurses should be
aware of the association between anxiety of amputees and caregivers and, therefore, work in multidisciplinary teams to
maximize clinical outcomes for patients after amputation and their families.

Keywords
state and trait anxiety, amputation, caregivers

Traumatic amputation is an unexpected life event associated
with increased morbidity, multiple interventions, prolonged
hospitalization, and increased disability rates.1-3 The main
causes of traumatic amputations are associated with acci-
dents on road, work injuries, falls, and high-voltage electri-
cal burns.4 The prevalence and patterns of traumatic
amputation are varying globally mainly due to insufficient
documentation. More strikingly, nowadays, traumatic ampu-
tation as a result of war injuries or terrorist attacks is increas-
ing at an alarming rate.3,4
Traumatic amputation is a sudden and not common event
in clinical practice as opposed to amputation of lower limbs,
within the context of micro- and macro-angiopathy, which
consist of a preventable complication of diabetes melli-
tus.5-7 Nevertheless, this injury requires immediate treat-
ment and intensive care. Compared with upper extremities,
the lower extremity amputations require surgery more fre-
quently, have more complications, and more often recovery
is longer.1 Advances in the field of microsurgery do not
always entail restoring functionality to preinjury levels.
Interestingly, this injury frequently implies heavy emo-
tional burden to amputees and their families, which is
explained by the imposed changes in daily routines or activi-
ties, the change of body image, the reduced ability to respond
to prior roles, and the loss of autonomy.8 Positive adjustment
to amputation is affected by pain, functional disability level,
cultural issues, supportive network, reactions of caregivers,
and patient’s prior coping style to deal with the loss.4,8
Amputees may experience frustration, anxiety, intense fear,
and depression, while caregivers need support and access to
assistance in coping with amputation of their loved person.4
To the best of our knowledge, few studies have addressed
the association between anxiety experienced by amputees
1
General Hospital Asklipieio Voulas, Athens, Greece
2
University of West Attica, Athens, Greece
Corresponding Author:
Maria Polikandrioti, University of West Attica, Agiou Spiridonos 28,
Egaleo, Athens 12243, Greece.
Email: mpolik2006@yahoo.com
2 The International Journal of Lower Extremity Wounds 00(0)
and anxiety experienced by their family caregivers.
Needless to say, both patients’ and caregivers’ psychologi-
cal state is a matter of great importance for effective treat-
ment that needs to be addressed in providing holistic care
to this sensitive population.
The aim of the present research was to explore levels
and associated factors of state-trait anxiety among ampu-
tees and their caregivers as well as to evaluate the associa-
tion between anxiety experienced by amputees and their
caregivers.
Material and Methods
Study Population
The sample of the study consisted of (1) 50 hospitalized
patients who had undergone traumatic amputation and (2)
50 family caregivers.
This cross-sectional study was conducted in patients
admitted to the public hospital Asklepieio Voulas, a tertiary
health care center in Attica Prefecture during January 2018
to July 2018. In the present study, patients who were referred
to the center due to unintentional traumatic amputations
were included.
This sample was a convenience sample, taken from a
group of patients easy to contact or easy to reach after their
hospital admission. Traumatic amputation is not very com-
mon, and for this reason, there were no other criteria to the
sampling method except that patients were available and
willing to participate.
Criteria for patients’ inclusion in the study were as fol-
lows: (1) age over 18 years old; (2) hospitalization due to
traumatic amputation; (3) ability to write, read, and under-
stand the Greek language; and (4) ability to read and sign
the form of consent. All patients at the day of discharge
were given oral information about their state of health.
The exclusion criteria were as follows: (1) patients
admitted to treat nontraumatic amputation, (2) patients with
cognitive disorders and eye or hearing problems, and (3)
those taking anxiolytics or antidepressants.
Criteria for caregivers’ inclusion in the study were as fol-
lows: (1) declare to be the family member who will provide
unpaid care on a regular basis for the person with amputa-
tion; (2) ability to write, read, and understand the Greek
language; and (3) ability to read and sign the form of con-
sent. The exclusion criteria for caregivers were the same as
for the patients.
Completion of questionnaires took place the day of hos-
pital discharge because during that time all participants
were under the same circumstances as they had no other
tasks to perform (laboratory tests or clinical examinations)
and were ready to transit home. The interview lasted
approximately 25 to 30 minutes for both patients and their
caregivers.
In the present study, there was no intervention group
since this research was cross-sectional and merely recorded
the levels of state and trait anxiety of amputees and their
caregivers.
Ethical Considerations
Patients and their caregivers who met the entry criteria were
informed by the researcher about the purposes of the study
and participated only after they had given their written con-
sent. Participation in the study was on a voluntary basis and
anonymity was preserved. Furthermore, all participants
were informed of their rights to refuse or to discontinue
their participation, according to the ethical standards of the
Helsinki Declaration of 1983. The study was approved by
the Medical Research Ethics Committee of the hospital
(Registration Number 12855/18-10-2017).
Data Variables
Data collection was performed via an interview using a
questionnaire developed by the researchers so as to fully
serve the purposes of the study. The questionnaire com-
prised 2 parts: the “State-Trait Anxiety Inventory” and a
questionnaire that included participants’ characteristics.
First, the data of patients’ were collected followed by data
from caregivers’.
Patients’ Characteristics.  The data collected for each amputee
included the following: (1) sociodemographic characteris-
tics, for example, gender, age, marital status, educational
level, place of residence, occupation, and the number of
children; (2) characteristics regarding amputation, for
example, level of amputation, other injuries, time of trans-
fer to hospital; and (3) other variables as reported by the
patients (13 items), for example, information (whether they
desired to receive written instructions after discharge, or
they believed their family was informed), whether they
believed that family would support them, whether they
believed they would depend on their family, whether they
experienced change in body image, whether they would
face difficulties in social environment and they would limit
their social contacts, whether they believed that their qual-
ity of life would change, whether they would like to have
psychological counseling after hospital discharge, whether
they needed help in daily activities, whether they would
face difficulties when returning to normal life, and finally
whether they would continue to enjoy life as before.
Caregivers’ Characteristics. The data collected for each
caregiver included the following: (1) sociodemographic
characteristics, for example, gender, age, marital status,
educational level, occupation, place of residence, and the
number of children, and (2) other variables as reported by
Tsoulou et al 3

the caregivers (11 items), for example, whether they were Table 1.  Sociodemographic Characteristics of Patients
well informed—about health of their loved person, (N = 50).
whether they would support their loved person to restore N (%)
body image, whether they would support the their loved
person, whether they believed that their loved person Gender  
would depend on them, whether they would face difficul-  Male 35 (70.0%)
ties in the personal relationship, whether they would limit  Female 15 (30.0%)
their social contacts, whether they believed their quality Age (years)  
of life would change, whether they would face financial   <30 2 (4.0%)
 30-40 7 (14.0%)
worries, whether they would continue to enjoy life as
 41-50 5 (10.0%)
before, whether they would like to have psychological
 51-60 12 (24.0%)
counseling after hospital discharge, and finally whether
 61-70 17 (34.0%)
they experienced stress about responding to the care of
  >70 7 (14.0%)
their loved person. Marital status  
 Married 27 (57.4%)
Anxiety Assessment  Single 7 (14.9%)
 Divorced 1 (2.1%)
The State-Trait Anxiety Inventory (STAI) was used to  Widow 12 (25.5%)
assess anxiety of amputees and their caregivers.9,10 The Education level  
State Anxiety Scale (S-Anxiety) evaluates the current   Primary school 26 (54.2%)
state of anxiety, and the Trait Anxiety Scale (T-Anxiety)   High school 15 (31.3%)
evaluates relatively stable aspects of “anxiety prone-  University 7 (14.6%)
ness.” In a clinical setting, it is essential to differentiate Occupation  
between temporary condition of state anxiety and the   Private or public employees 15 (30.6%)
long-standing trait anxiety that one experiences on a day-  Household 3 (6.1%)
to-day basis.  Pensioner 31 (63.3%)
The STAI has 40 items, 20 items allocated to each of Place of residence  
the S-Anxiety and T-Anxiety subscales. Respondents had   Attica Prefecture 26 (54.2%)
the ability to answer each question on a 4-poing Likert-   Large city 13 (27.1%)
type scale. In each of the 4-point gradients, scores are   Small town 6 (12.5%)
scored from 1 to 4. Responses for the S-Anxiety scale  Village 3 (6.3%)
assess intensity of current feelings “at this moment”: (1) No of children  
not at all, (2) somewhat, (3) moderately so, and (4) very  0 12 (25.0%)
 1 11 (22.9%)
much so. Responses for the T-Anxiety scale assess fre-
 2 13 (27.1%)
quency of feelings “in general”: (1) almost never, (2)
  >2 12 (25.0%)
sometimes, (3) often, and (4) almost always. The scores
attributed to the questions are summed leading to a final
score of state and trait anxiety. Higher scores indicated
higher levels of anxiety. Results
Sample Description (Patients)
Statistical Analysis
Table 1 presents the sociodemographic characteristics of the
Nominal data are presented in absolute and relative (%) fre- patients. In particular, men accounted for 70% of the sample,
quencies, while the continuous data are presented with while 48% of the sample was over 60 years of age. Moreover,
mean, standard deviation, median, and interquartile range. 57.4% were married, 54.2% had primary level education, and
The normality of data was checked by the Kolmogorov- 63.3% were retired. The majority of patients were living in
Smirnov test and graphically with Q-Q plots and histo- Attica Prefecture (54.2%), while 75% had children. Table 2
grams. Anxiety scores are graphically presented with presents data related to the patients’ clinical characteristics.
boxplots. Spearman’s ρ criterion was used to evaluate the According to the level of traumatic amputation, it was
association between patient and caregivers scores. Stratified found that 8% had amputation in the upper limp, 58% in the
analysis on the level of amputation was also conducted to lower limp, and 34% in the finger(s) of the upper or lower
investigate any differences. The observed significance level limb. Furthermore, 75% of participants had other injuries.
of 5% was considered statistically significant. All statistical The median transport time from the time of the accident to
analyses were performed with SPSS version 20 (SPSS Inc, the hospital was 30 minutes. In Table 3, other variables as
Chicago, IL). reported by patients are presented.
4 The International Journal of Lower Extremity Wounds 00(0)

Table 2.  Clinical Characteristics of Patients (N = 50). Table 3. (continued)

N (%) N (%)

Level of amputation    Little 6 (12.5%)

  Upper limp 4 (8.0%)   Not at all 4 (8.3%)
  Lower limp 29 (58.0%) Do you believe that you will need help in everyday activities?
 Finger 17 (34.0%)  Yes 41 (82.0%)
Other injuries    No 9 (18.0%)
 Yes 36 (75.0%) Do you believe that you will face difficulties when returning to
normal life?
 No 12 (25.0%)
 Yes 29 (58.0%)
  Median (Interquartile Range)  No 21 (42.0%)
Would you like to have access in psychological counseling after
Transfer time (minutes) 30 (20-30)
hospital discharge?
 Yes 39 (78.0%)
 No 11 (22.0%)
Table 3.  Other Self-Reported Variables by the Patients Will you continue to enjoy life as before?
(N = 50).
  Yes as before 13 (26.0%)
N (%)   Not so much 14 (28.0%)
 Little 9 (18.0%)
Would you like to have written information after hospital   Not at all 14 (28.0%)
discharge?
 Yes 31 (62.0%)
 No 19 (38.0%) In terms of information, 62% reported they would like
According to your opinion, how informed is your family about to receive written information after hospital discharge,
your health? and 60% stated that their family was well informed.
 Very 30 (60.0%) Furthermore, 82% believed their family would support
 Enough 14 (28.0%) (very and enough), while 36% reported to be “very”
 Little 3 (6.0%) dependent on their family. Moreover, 68.8% reported
  Not at all 3 (6.0%) change in body image, 60% believed they would face dif-
Do you believe that your family will support you? ficulties in social environment (very and enough), 54%
 Very 31 (62.0%) believed they would limit social contacts (very and
 Enough 10 (20.0%)
enough), 79.2% believed that the quality of their lives
 Little 9 (18.0%)
would change (very and enough), 82% reported to need
Will depend on your family after hospital discharge?
help in everyday activities, 58% believed to face difficul-
 Very 18 (36.0%)
ties when returning to normal life, 78% would like to
 Enough 19 (38.0%)
 Little 6 (12.0%)
have access to psychological counseling, and 26% of par-
  Not at all 7 (14.0%) ticipants would continue to enjoy the same things in their
Body change lives as before amputation.
 Yes 33 (68.8%)
 No 15 (31.3%)
Sample Description (Caregivers)
Do you believe that you will face difficulties in social
environment? In Table 4, the sociodemographic characteristics of caregiv-
 Very 15 (30.0%) ers are presented. In particular, men accounted for 42% of
 Enough 15 (30.0%) the sample, while 46% of the sample was over 50 years of
 Little 11 (22.0%) age. Of the participating caregivers, 52% were married,
  Not at all 9 (18.0%) 70% had university education, and 75% had a job. The
Will you limit social contacts? majority of caregivers were living in Attica (58%), while
 Very 14 (28.0%) 58% had children.
 Enough 13 (26.0%)
Table 5 presents data related to variables as reported
 Little 13 (26.0%)
by caregivers. In terms of information, 52% of the care-
  Not at all 10 (20.0%)
givers reported to be very well informed about the health
Do you believe that your quality of life will change?
of their loved person. Furthermore, 58% of participants
 Very 19 (39.6%)
 Enough 19 (39.6%)
stated they would help their loved person to restore body
image while 54% would support the patient very much.
(continued) Moreover, 40% and 28% of caregivers believed that their
Tsoulou et al 5

Table 4.  Sociodemographic Characteristics of Caregivers Table 5. (continued)

(N = 50).
N (%)
N (%)
Do you believe that your loved person will depend on you, after
Gender hospital discharge?
 Male 21 (42.0%)  Very 20 (40.0%)
 Female 29 (58.0%)  Enough 14 (28.0%)
Age (years)  Little 8 (16.0%)
  <30 5 (10.0%)   Not at all 8 (16.0%)
 30-40 11 (22.0%) Will you face difficulties in your relationship with your loved
 41-50 11 (22.0%) person?
 51-60 19 (38.0%)  Very 2 (4.0%)
 61-70 2 (4.0%)  Enough 9 (18.0%)
  >70 2 (4.0%)  Little 20 (40.0%)
Marital status   Not at all 19 (38.0%)
 Married 26 (52.0%) Will you limit your social contacts?
 Single 14 (28.0%)  Very 3 (6.0%)
 Divorced 6 (12.0%)  Enough 13 (26.0%)
 Widow 4 (8.0%)  Little 12 (24.0%)
Education level   Not at all 22 (44.0%)
 Primary 35 (70.0%) Do you believe that your quality of life will change?
  High school 15 (30.0%)  Very 7 (14.0%)
Occupation  Enough 7 (14.0%)
 Unemployed/household 12 (25.0%)  Little 20 (40.0%)
 Employee 36 (75.0%)   Not at all 16 (32.0%)
Place of residence Financial worries?
  Attica Prefecture 29 (58.0%)  Very 23 (46.0%)
  Large city 10 (20.0%)  Enough 10 (20.0%)
  Small town/village 11 (22.0%)  Little 15 (30.0%)
No of children   Not at all 2 (4.0%)
 0 21 (42.0%) Will you continue to enjoy life as before?
 1 15 (30.0%)   Yes as before 32 (64.0%)
  >1 14 (28.0%)   Not so much 11 (22.0%)
 Little 5 (10.0%)
  Not at all 2 (4.0%)
Would you like to have access to psychological counseling?
Table 5.  Other Self-Reported Variables by Caregivers
(N = 50).  Yes 40 (80.0%)
 No 10 (20.0%)
N (%) Do you experience stress about responding to the care of your
loved person?
How informed are you about health of your loved person?
 Very 18 (36.0%)
 Very 26 (52.0%)
 Enough 14 (28.0%)
 Enough 18 (36.0%)
 Little 7 (14.0%)
 Little 6 (12.0%)
  Not at all 11 (22.0%)
Will you help your loved person to restore body image?
Do you experience uncertainty about future?
 Very 29 (58.0%)
 Enough 19 (38.0%)
 Enough 18 (36.0%)
 Little 15 (30.0%)
 Little 2 (4.0%)
  Not at all 16 (32.0%)
  Not at all 1 (2.0%)
Will you support your loved person?
 Very 27 (54.0%)
 Enough 14 (28.0%)
loved person will depend on them (very and enough),
 Little 7 (14.0%) whereas 38% declared not to face difficulties in their rela-
  Not at all 2 (4.0%) tionship, respectively. Additionally, 44% would not limit
social contacts and 23% believed that their quality of life
(continued) would change. Financial worries had 46% of caregivers,
6 The International Journal of Lower Extremity Wounds 00(0)

Table 6.  Impact of Amputation on the Trait and State Anxiety Association Between Trait and State Anxiety of
of Patients and Family Caregivers (N = 50).
Patients and Caregivers
Mean (SD) Median (IQR)
In Table 7, the associations of trait and state anxiety between
Patients patients and caregivers are presented. A positive linear asso-
  Trait anxiety (range 20-80) 51.6 (15.4) 50 (40-69) ciation was found between trait and state anxiety of patients
  State anxiety (range 20-80) 56.9 (15.4) 56 (42-73) as well as between the trait and state anxiety of caregivers
Caregivers (ρ = 0.915, P < .001, and ρ = 0.920, P < .001,
  Trait anxiety (range 20-80) 47.5 (10.5) 47 (39-55) respectively).
  State anxiety (range 20-80) 51.9 (11.8) 50.5 (42-62) A statistically significant positive correlation was also
Level of amputation: upper/lower limp observed between state patient anxiety and state anxiety of
Patients caregivers (ρ = 0.239 and P = .039) and between trait patient
  Trait anxiety (range 20-80) 58.1 (16.0) 57 (44-74) anxiety and trait anxiety of caregivers (ρ = 0.322 and P =
  State anxiety (range 20-80) 53.5 (15.9) 50 (41-70) .030). More specifically, as the patient’s anxiety score, either
Caregivers
trait or state (transient or temporary), increases, the score of
  Trait anxiety (range 20-80) 51.3 (11.6) 50 (44-58)
their caregivers’ anxiety also increases and vice versa.
  State anxiety (range 20-80) 46.4 (10.7) 44 (39-54)
No linear association was observed between the trait
Level of amputation: finger
anxiety of patients and the state anxiety of their caregivers
Patients
  Trait anxiety (range 20-80) 54.5 (14.2) 56 (40-70)
as well vice versa.
  State anxiety (range 20-80) 47.9 (14.2) 45 (34-62) Stratified analysis by level of amputation did not reveal
Caregivers any differences in the association of anxiety scores.
  Trait anxiety (range 20-80) 53.3 (12.5) 54 (42-63)
  State anxiety (range 20-80) 49.6 (10.1) 50 (39-59)
Discussion
According to the present results, men accounted for 70% of
64% stated to enjoy life as before, 80% would like to have the sample, 48% of participants were over 60 years of age,
psychological counseling, 36% experienced stress about and 34% had a finger amputation.
responding to the care of loved person, and 38% experi- In terms of information, all participants self-reported to
enced uncertainty about future. have received oral instructions from time of surgery until
the day of hospital discharge. However, the main enquiry of
Description of Trait and State Anxiety Scores of the present study was not to evaluate the current state in
hospital settings regarding association between provision of
Patients and Caregivers verbal information and anxiety but to find patients’ needs
From Table 6, concerning the trait anxiety of patients and about information before return to normal life as the ulti-
caregivers, it is observed that at least 50% of the patients mate goal is to plan effective and specific projects in health
and caregivers scored below 50 and 47, respectively services concerning amputation. More significant, 62% of
(median), 25% scored lower than 40 and 39, respectively, amputees wished to receive written information after hospi-
and the remaining 25% scored over 69 and 55, tal discharge before returning home, 60% of patients
respectively. believed their family to be “very” informed about their
In terms of state anxiety, at least 50% of patients and health, and 52% of caregivers declared to be “very well”
caregivers scored below 56 and 50.5, respectively (median), informed about the health of their loved person. Provision
25% scored below 42, and the remaining 25% scored above of verbal information only at the time of discharge may con-
73 and 62, respectively. tribute to patients’ disempowerment and passivity as they
These values indicate moderate to high levels of the are unable to refer to information or may not remember
impact of amputation on the trait and state anxiety of what they have been told. Contrariwise, providing written
patients and their caregivers. These results are also graphi- material in the form of information booklets or summary
cally displayed as a boxplot (Figure 1). letters may increase patients’ knowledge and reduce confu-
Stratified analysis based on the level of amputation sion. Accurate and simple written information along with
showed that patients with limp amputation had a little assessment of patients’ beliefs, concerns, and expectations
higher levels of anxiety than patients with finger amputa- may be a successful step to reduce anxiety and misunder-
tion, whereas caregivers of patients with finger amputation standings. Providing effective information to patients is a
had slightly higher anxiety than caregivers of patients with key element of quality care and a fundamental right of all
limp amputation. patients being discharged.11,12
Tsoulou et al 7

Figure 1.  Boxplot of state and trait anxiety of patients and their caregivers. Box-Whisker plot presents data as mean ± 1 SD.

Table 7.  Association Between State and Trait Anxiety of Patients and Caregivers.

Patients Caregivers

State Anxiety, Trait Anxiety, State Anxiety, Trait Anxiety,

  Spearman’s ρ (P) Spearman’s ρ (P) Spearman’s ρ, (P) Spearman’s ρ, (P)
Patients State anxiety —  
Trait anxiety 0.915 (<.001) —  
Caregivers State anxiety 0.239 (.039) −0.048 (.742) —  
Trait anxiety −0.061 (.674) 0.322 (.030) 0.920 (<.001) —
Level of amputation: upper/lower limp (N = 33)
Patients State anxiety —  
Trait anxiety 0.893 (<.001) —  
Caregivers State anxiety 0.271 (.028) 0.062 (.731) —  
Trait anxiety 0.211 (.238) 0.023 (.898) 0.926 (<.001) —
Level of amputation: finger (N = 17)
Patients State anxiety —  
  Trait anxiety 0.870 (<.001) —  
Caregivers State anxiety 0.515 (.034) −0.189 (.066) —  
  Trait anxiety −0.113 (.059) 0.534 (.027) 0.954 (<.001) —

P values determined using Spearman’s rho correlation coefficient. Significant values are in bold.

The results also showed that 82% of patients believed extent on understanding and help of family. Family mem-
their family would support them while 54% of caregivers bers usually try to protect the injured young individuals
declared that they would support their loved person. (aged 16 to 24 years old) and facilitate their transition back
Effective treatment of an amputation depends up to an to independence.13 The more the family is involved in the
8 The International Journal of Lower Extremity Wounds 00(0)
rehabilitative care, the lower the mental burden of these
individuals.14 Family as a source of support is linked with
improved health outcomes after amputation.15
Another finding of this study concerned disfigurement,
with 68.8% of amputees declaring a change in body image
and 58% of caregivers declaring they would help amputees
to restore their body image. Amputees may perceive them-
selves as no longer complete persons either due to the loss
of physical functionality or the loss of future hopes and
expectations. Amputation causes triple loss, that is, loss of
function, sensation, and body image. The path to accept the
new body is long and complex as the person is asked to
pass through 5 stages: denial, anger, negotiation, depres-
sion, and acceptance. These stages lead patients to over-
come the initial shock, reconcile with their new body
image, and move from a state of mourning to accept
changes though understanding the loss and regaining con-
trol over the new reality.8,16,17 Timely participation in ear-
lier activities ensures that prior roles are retained, which in
turn positively affects self-esteem and facilitates successful
adaptation.18,19 It is worth noting that 1997 was a signifi-
cant year for the association between body image and
amputation because Breakey introduced the Amputee
Body-Image Scale (ABIS) scale.20
With regard to social interactions, 60% of amputees
believed they faced many difficulties with social environ-
ment (very and enough) and 54% stated they would limit
their social contacts (very and enough), whereas only 6% of
caregivers reported they would restrict their social contacts.
Society is influenced by preconceived notions and preju-
dice and there is a reluctance to treat them as physiologi-
cally healthy individuals. Interestingly, amputation is a
visible remainder of disability and it is only after hospital
discharge that amputees understand the tremendous changes
in lifestyle, career prospects, and entertainment options.
Meanwhile, at this time family, friendship, and social ties
are tested.17 Low levels of social integration are associated
with negative health outcomes. Raising awareness about
social support is a challenge to minimize the devastating
consequences of amputations, especially those involving
disability, thus weakening social bias or stereotypes for
these vulnerable groups.21
A discouraging finding of the present study is that 79.2%
of amputees believed that they will experience a change in
their quality of life. Several explanations may account for
the diminished quality of life such as the changes in their
physical capabilities, reduced mobility, pain, and loss of
physical integrity.17
Results also showed that 78% of amputees and 80% of
caregivers wished to have access to psychological counsel-
ing after hospital discharge. Moreover, 36% of caregivers
experienced stress about their ability to respond to the care
of the amputee. After hospital discharge, counseling is facil-
itating adjustment to amputation and the therapeutic bond
among amputees, caregivers, and health care professionals,
thus improving health outcomes. According to Bennett,22
patients often report lack of empathy and effective commu-
nication from health care providers, which along with
absence of postoperative follow-up are triggering anxiety in
individuals with limb amputation and their caregivers.
Counseling is influenced by the availability of services and
related structures. For example, health professionals can
monitor the patient in the community, with prescheduled
home visits. Early counseling significantly contributes in
handling practical issues and reducing emotional distress
that may emerge 2 to 24 months after surgery.23 One other
aspect is the development of a more patient-centered sys-
tem that facilitates adjustment through telephone consulta-
tions and support for persons with amputation. Rehabilitation
approaches will be most effective when tailored to patients’
profiles. Individuals satisfied with rehabilitation services
and accepted by society experience less anxiety.6
Moreover, 66% of caregivers reported to have finan-
cial worries (very and enough). One more important goal
of rehabilitation is to facilitate return to work, which is
influenced by the following factors: (1) demographic
(age, sex, and educational level), (2) clinical (amputation
level, time from the event to amputation and mobility
restrictions), and (3) other (salary and social support).
However, physically demanding occupations or those
requiring external appearance are difficult to combine
with amputation. In these cases, individuals feel their pro-
fessional ambitions break down due to disability, thus
experiencing increased anxiety about their future profes-
sional goals. A literature review showed 66% return-to-
work rate after limb amputation.24
The results indicated moderate to high levels of the
impact of amputation on the STAI of patients and their care-
givers. STAI is a psychological inventory that measures 2
types of anxiety: (1) state anxiety, or anxiety about an event,
and (2) trait anxiety, or anxiety level as a personal charac-
teristic. It is important to measure these 2 different types of
anxiety at the time of hospital discharge and before transit
home. First, it will help health professionals to recognize
individuals at high risk of experiencing anxiety after hospi-
tal discharge. Second, it will distinguish anxiety that was
triggered by amputation and anxiety as a type of personal-
ity, thus needing different treatment approaches. Third, this
information is a valuable resource when planning health
care services and implementing psychological intervention
to alleviate emotional burden. Additionally, results showed
that as the patients’ anxiety (either state or trait) increased
the caregivers’ anxiety also increased and vice versa.
Individuals who underwent amputation experience anxi-
ety because of the following concerns: (1) change in appear-
ance and mobility; (2) ability to participate in activities and
dependency on the environment; and (3) ability to respond
to prior social, family, and professional role.24-28 In the
Tsoulou et al 9
literature, there are studies indicating high prevalence of
anxiety and depression in posttraumatic amputees but data
on levels of anxiety and depression beyond 2 years of fol-
low-up are sparse.29 Williams et al30 showed that nearly one
third of 106 adult hand-injured patients (40 women and 66
men) met diagnostic criteria for posttraumatic disorder and
depression.
On the other end of the spectrum, caregivers frequently
put other’s needs before their own, sacrifice their leisure
time, try to manage daily needs of the loved person includ-
ing tasks such as bathing, eating, taking medicine, or arrang-
ing activities, and finally take financial decisions.
Unplanned accidental amputation often meets caregivers
not prepared for this new phase in life, which may lead to
physical and emotional strain.31
Conclusively, it is necessary to have documented knowl-
edge of the short-term and long-term effects of amputation
on the psychological state. Assessing the psychosocial
impact of amputations is a matter of priority for rehabilita-
tion and social care services. Understanding all amputation-
related aspects may help health professionals to provide
holistic care.
Limitations of the Study
Convenience sampling is one of the principal limitations of
this study. First, this method is not representative of all pop-
ulations with traumatic amputation living in Greece, thus
limiting the generalizability of results. Second, the study
design was cross-sectional and not longitudinal, thus not
permitting investigation for causal relation between state-
trait anxiety and patients’ or caregivers’ characteristics.
Finally, there was no other assessment that would allow
evaluation of possible changes in anxiety levels of both
patients and caregivers through time.
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) received no financial support for the research,
authorship, and/or publication of this article.
Ethical Approval
All procedures performed in the studies involving human partici-
pants were in accordance with the ethical standards of the institu-
tional and/or national research committee and with the 1964
Helsinki Declaration and its later amendments or comparable ethi-
cal standards.
Informed Consent
Informed consent was obtained from all individual participants
included in the study.
ORCID iD
Georgios Vasilopoulos https://orcid.org/0000-0001-7753-1553
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