Running head: VULNERABLE POPULATION: VETERANS WITH AMPUTATIONS
Vulnerable Population: Veterans with Amputations
Whitney Y. Hugie
Southern Utah University
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VULNERABLE POPULATION: VETERANS WITH AMPUTATIONS
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Vulnerable Population: Veterans with Amputations
Introduction
The United States of America has been engaged in the Iraq and Afghanistan Wars for over 10
years. These wars are recognized as Operation Iraqi Freedom, Operation New Dawn, and Operation
Enduring Freedom. The use of improvised explosive devices has risen during these operations resulting
in a dramatic rise in traumatic limb amputations. Advances in immediate care after the injury, long-term
medical care, and prosthetic technology has created a growing population of veterans who have suffered
traumatic limb amputations. Due this increasing population, the long-term consequences of limb
amputation needs to be addressed.
Population
On March 19, 2003, President George W. Bush launched an invasion of Iraq which would later
become known as Operation Iraqi Freedom (OIF). On August 31, 2010, President Barrack Obama
declared that the combat mission in Iraq had ended. A transitional force remained in Iraq until December
15, 2011 which came to be known as Operation New Dawn (OND). Operation Enduring Freedom (OEF)
began on October 7, 2001 in Afghanistan as a response to the September 11, 2001 terrorist attacks.
Currently the war is still ongoing with several thousand American troops stationed in Afghanistan and
surrounding countries. Throughout these operations, the use of improvised explosive devices (IEDs) has
become more common. The U.S. Department of Defense defines IEDs as “devices placed or fabricated in
an improvised manner incorporating destructive, lethal, noxious, pyrotechnic or incendiary chemicals,
designed to destroy [and] disfigure…IEDs have become the most common mechanism of death and injury
involving US soldiers” (Benfield et al., 2012, p. 1753-1754). These devices have led to a dramatic
increase in battle-related limb amputations. The Department of Veterans Affairs Office of Inspector
General (2012) define amputations as major or minor based on where a limb is severed. A major
amputation includes a leg at or above the ankle or an arm at or above the wrist while minor amputation
involves all or part of a hand or foot. As of December 3, 2012, 1,715 service members who have served
in OIF, OND, and OEF suffered battle-related amputations with 1,493 of those being a major limb and
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222 of those being a minor (Fischer, 2013). Historically, injuries that have resulted in limb amputation
have largely ended in death either by the initial trauma, blood loss, or by the onset of infection later.
Short-term mortality following a traumatic limb amputation has dramatically decreased with the
development of improved hemostatic resuscitation, sterile technique and tools, and proper
decontamination of wounds (Benfield et al., 2012). Long-term prognosis for amputees has improved with
the development of advanced medical and prosthetic technology. This has led to amputees being able to
live longer, which has created a need to determine the long-term consequences of limb amputation.
During an inspection of prosthetic limb care in VA facilities, it was found that of a population of nearly
500,000 veterans, “most (99.1 percent) [of] veterans with traumatic amputations transitioned to VA care
within 5 years after separation from active duty, and the amputees had more co-morbidities than their
non-amputees counterpart” (Department of Veterans Affairs Office of Inspector General, 2012, p. iv).
Three of the major identified health issues facing these veterans include pain, an increased risk of
cardiovascular disease, and prosthetic rehabilitation.
Top Three Health Issues
Pain
Both acute and chronic pain are associated with traumatic limb amputation. Many factors
influence the perception and type of pain that may develop. DeAth, Perkins, Sharp and Tai (2011) define
four different types of pain that most commonly affect amputees: phantom limb pain, residual limb pain,
back pain, and contralateral joint pain.
Phantom limb pain is a sensation of neuropathic pain that radiates down the limb which has been
removed. Amputees often describe it as pain that takes form of the missing limb so that it feels as if the
limb is still there. Although the pathogenesis behind phantom limb pain is unknown, the pain is a real
factor in the quality of life for veterans with amputations and occurs in 50-80% of amputees (Perkins et
al., 2011).
Residual limb pain is the most common pain reported initially following an amputation. It differs
from phantom limb pain because it often resolves a few months after surgery. Veterans are at a high risk
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of experiencing persistent residual limb pain because IEDs typically result in highly contaminated
amputations which increases the risk of poorly fitting prostheses, symptomatic neurmoas, stump
infections, bone pathologies (including bone spurs and sharp bone ends), and soft tissue pathologies
(including failure of muscle reconstruction and wound breakdown) (Perkins et al., 2011).
Back pain “occurs in 52-81% of traumatic amputees, a considerably higher prevalence than the
general population” (Perkins et al., 2011, p. 78). Although research has not found a definitive cause of
back pain related to amputations, it is believed that a combination of poor prosthetic fit and alignment,
abnormal posture, amputation level, general condition, and leg-length discrepancy may contribute to the
development of chronic back pain in amputees (Gailey, Allen, Castles, Kucharik, & Roeder, 2008).
These potential causations of back pain should be addressed as soon as possible to try to prevent further
damage from occurring and to keep the veteran as active as possible.
Contralateral joint pain is pain which develops in the non-amputated limb. 50-63% of
transfemoral amputees developed contralateral joint pain while 36-41% developed it after a transtibial
amputation (Perkins et al., 2011). Gailey et al. (2008) found that osteoarthritis in the non-amputated leg
is increasing in prevalence and related it to the improper use and fit of prosthetic devices.
Current interventions for treating and preventing pain include the administration of opiate or
ketamine analgesia as soon as possible after the initial injury, pre-emptive analgesia to prevent the
development of pain memories, and ensuring proper prosthetic size and fit (Perkins et. al., 2011).
Pharmacological pain relief is often emphasized, however the source of the pain and non-pharmacological
pain relief should also be addressed.
Increased Risk of Cardiovascular Disease
Research has indicated that veterans with lower limb amputations have an increased risk of
cardiovascular disease (CVD). Naschitz and Lenger (2008) cited an epidemiological study conducted by
Hrubec and Ryder who found that that “the relative risk for death by cardiac causes was 1.58 times as
great in unilateral above-knee amputees and 3.5 times as great in bilateral above-knee amputees in
comparison with disfigured veterans” (Naschitz & Lenger, 2008, p. 252). The pathophysiology behind
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this increased risk is not completely understood. Some of the suspected contributing factors include
concurrent traumatic brain injury, PTSD, increased insulin resistance, deviant behaviors, and
compromised arterial flow. Although the cause has not been isolated, there is definitive evidence of an
increase in cardiac pathology in the amputee population when compared to their non-amputee
counterparts. The most common cardiovascular diseases that affect the amputee population include
ischemic heart disease, abdominal aortic aneurysm, stroke, pulmonary embolism, and hypertension
(Perkins et al., 2011). As the veteran ages, education about the increased risk of CVD is essential.
Initially after an amputation, many medical aspects take priority. After that phase in which the veteran is
able to achieve some normalcy in life, it is important to educate them about some of the long-term
implications as well as the short-term.
Prosthetic Rehabilitation
After a service member suffers a traumatic amputation, healing the wound is only the beginning.
Proper prosthetic rehabilitation is essential in determining the long-term quality of life for an amputee. A
prosthetic device is an “artificial extension that replaces a missing body part such as an upper or lower
body extremity” (McGimpsey & Bradford, 2010, p. 3). In order to determine the right type of prosthesis
for an amputee the size, location of amputation, baseline health, other medical conditions, and activity
level are only a few of the considerations taken into account. If a prosthesis is not fitted correctly it may
result in increased chronic pain leading to a decrease in physical activity resulting in other health
problems including cardiovascular disease. Due to the fact that prosthetic use is significantly
interconnected with the overall health of an amputee it is important to address the associated social and
financial implications.
Social Implications
After a limb amputation there is a physical and emotional adaptation that must occur. Questions
of how an amputee will live, work, and love are raised. Prosthetic rehabilitation is the first step in the
journey in which an amputee will rediscover their personal identity. Advancements in prosthetic
technology have provided a wide range of devices in order to provide each amputee with a prosthesis that
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is right for him or her. Devices may be as simple as an upper-extremity that serves as a cosmetic hand to
a computer-assisted C-Leg prostheses which allows an amputee to walk naturally (McGimpsey &
Bradford, 2010). The VA is one of the leading organizations in the research and development of
prosthetic devices for wounded veterans. One of the aims of VA research is to develop more lifelike
artificial limbs. “The integration of body, mind, and machine is a major guiding principle as VA
specialists design and build artificial limbs that look, feel, and respond like natural arms and legs”
(Veterans Health Administration Research and Development [VA R&D], 2009, p. 3). Eventually, the
ultimate goal of prosthetic research is to not only replace the limb itself, but its functionality as well.
Financial Implications
An amputation places not only a physical and emotional strain on a veteran but a financial burden
as well. There are a wide variety of prosthetic devices available to amputees. However, the more
complex and realistic the prosthetic, the more expensive it is as well. McGimpsey and Bradford (2010)
outlined the basic financial costs related to different prosthetic devices.
For $5,000 to $7,000 patient can get a…below-the knee prosthesis that allows the user to stand
and walk on level ground…a $10,000 device will allow the person to become a “community
walker”, able to go up and down stairs and traverse even terrain… $12,000 to $15,000 will
facilitate running and functioning at a level nearly indistinguishable from someone with two
legs…$15,000 or more contain polycentric mechanical knees, swing-phase control, stance
control, and other advanced mechanical or hydraulic systems… Computer-assisted devices start
in the $20,000 to $30,000 [and] adjust for degree and speed of swing…Upper-extremity amputees
can buy a nonfunctional cosmetic hand for $3,000 to $5,000 that “just fills a sleeve”… $10,000
will buy a transradial prosthesis that is a functional “split hook”…costmetically realistic
myoelectric hands that open and close may cost $20,000 to $30,000 or more…A neuroprosthetic
arm may cost as much as $100,000 (McGimpsey & Bradford, 2010, p. 10-11).
This outlines only the basic cost for the prosthetic limb and does not take into account the cost in
order to fit and size the limb appropriately. “Prices remain high because prostheses cannot be mass-
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produced…prosthetics are produced in relatively small numbers and made of custom materials with a
variety of componentry” (McGimpsey & Bradford, 2010, p. 12). Just as no two people are exactly the
same, there is no one prosthetic that will work for every person with a lower leg amputation. Along with
the initial cost of a prosthetic, limbs must be replaced on average every 3-5 years, more frequently if the
person is physically active. Private insurance companies place a cap on reimbursement for devices and
services typically at around $500 to $3,000 a year and have lifetime restrictions from $10,000 to one
prosthetic device for a person’s lifetime (McGimpsey & Bradford, 2010). Due to the major restrictions in
prosthetic services under third party insurers, many veterans turn to Medicaid, Medicare, and the VA in
order to afford quality prosthetic devices. The Department of Veterans Affairs found that as of
September 30, 2011, “93.2 percent of amputees had used VA prosthetic care” (Department of Veterans
Affairs Office of Inspector General, 2012, p. 32). Although a prosthesis is an expensive investment, it is
a critical aspect into the overall activity and quality following an amputation in a veteran’s life.
Evidence-Based Intervention Plan for Veterans with Amputations
The goal of the intervention plan is to decrease the risk of cardiovascular disease, minimize pain,
and increase activity in veterans with amputations by having properly fitted and serviced prosthetic
devices. The Transtheoretical Model of health promotion is “based on the assumption that behavior
change takes place over time, progressing through a sequence of stages” (Nies & McEwen, 2011, p. 55).
The stages include precontemplation, contemplation, preparation, action, and maintenance.
Precontemplation is a stage in which an individual is not preparing or planning on making a
change in behavior. Veterans who are in this stage may believe that pain associated with their amputation
is normal or that the financial burden and pain are worse than the need to exercise. At this point, it is
important to teach veterans about the increased risk of cardiovascular disease in amputees. It is also
important to teach them about the different types of pain associated with an amputation. While phantom
and residual limb pain cannot be cured with a properly fitted prosthetic devices, back and contralateral
limb pain may.
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Veterans would then move into the contemplation stage in which they would weigh the pros and
cons of obtaining a new prosthesis and becoming more active. Some considerations would include the
financial aspect of obtaining a new prosthetic, the motivation to begin a new exercise regimen, the
potential reduction in pain, and the long-term consequences of this action. A healthcare professional must
be prepared to answer questions and assist in evaluating the short and long term consequences of action
and inaction.
The preparation stage follows in which the veteran takes the steps in order to make the change.
Health care professionals should have resources available to help educate the veteran on the options
available for handling the financial burden of obtaining a new prosthetic. This may include information
on the VA, Medicare, Medicaid, and private insurance. Referrals to orthotic and prosthetic specialists and
physical therapy are required. These referrals are necessary in order to ensure that the prosthetic received
is properly fitted, customized, and that it will be used correctly by the veteran.
The next stage is the action phase in which the veteran would follow through with the
measurements, fittings, and rehabilitation of their new prosthetic device. This stage requires emotional
and physical support as the adjustment is made. Healthcare professionals must be ready to address
problems and answer questions that may arise. The veteran will also contemplate and create a plan in
order to reach a goal and maintain a certain level of activity.
Finally, the maintenance stage is reached when the veteran has maintained their expected activity
level for over six months. The goal at this point is to continue to maintain that level of activity and
prevent a relapse. Critical interventions include ensuring proper service to the prosthetic device,
replacing devices when needed, and follow up appointments addressing unresolved problems.
The expected outcomes for this intervention plan is that with the properly fitted prosthetic device,
veterans will continue to stay physically active with minimal pain. By remaining active, this will
ultimately decrease the risk of cardiovascular disease resulting in a better long-term quality of life.
Conclusion
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The increasing trend IED use in OIF, OND, and OEF has developed a population of veterans who
have suffered traumatic limb amputations. This is a diverse population with many short and long term
needs. These veterans are often plagued by chronic pain and have an increased incidence of
cardiovascular disease. A thorough rehabilitation with correctly fitted prosthetic devices is essential in
assisting a veteran to remain physically active and transition back to civilian life. This may ultimately
lead to a decrease risk of cardiovascular disease, decrease pain, and improve quality of life in these
honored heroes.
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