Back to Work
November 2014 Issue
A meta-analysis was recently conducted on many of the major outcomes that occur following trauma-related lower-limb amputations; the study authors culled data from a comparatively high number of subjects extracted from numerous, previously published studies.1 Employment was among the outcomes considered. Drawing from 17 prior studies that addressed the issue, the authors were able to report on the employment rates observed among 1,222 individuals with traumatic lower-limb amputations, inclusive of 689 transtibial, 327 transfemoral, and 159 bilateral amputations, along with 47 knee disarticulations. As might be expected, employment rates were highest among those with transtibial amputations (74 percent) and lowest amongst those with transfemoral amputations (64 percent), with employment rates of 70 percent observed at the two remaining amputation levels.1 While the employment rates were encouragingly high across the various levels, additional questions arise: Are these individuals generally satisfied with their employment? Are similar trends observed in individuals with upper-limb amputations? Do people return to their pre-amputation vocations? If so, how many require workplace adaptations? How common is workplace discrimination and where is it more likely to occur?
This article examines the various considerations associated with return to work following amputation.
While employment rates for individuals with traumatic lower-limb amputations hover near 70 percent across the breadth of published research, there is considerable variation in the percentages identified by individual studies. In their summary on this topic, West et al. cite studies with return to work rates as high as 79 to 89 percent.2 In summarizing the literature on positive correlates to optimal vocational outcomes, the authors recognize the following potential contributors:
- Participation in a work-hardening program (i.e., job-specific rehabilitation activities).
- Vocational rehabilitation.
- Higher educational level.
- Extensive social network.
- Lower level of amputation.
- Extroverted personality.
- Prompt prosthesis fitting.
- Workplace accommodations.
- Transfer to a less physically demanding job.
- Time restructuring.
- Expectation of a return to work.
- Psychological acceptance of limb loss.
- Acceptance and use of a prosthesis.
However, in the same summary, they also cited studies with return to work rates as low as 43.5 to 58 percent.2 Correlates to less favorable return to work outcomes include the following:
- Lower educational level.
- Higher level of amputation.
- Advancing age.
- Intensity of residual limb pain or phantom limb pain.
- Prolonged depression or psychological distress.
- Comorbidities, such as diabetes.
Surveys of the available literature on this topic suggest tremendous variability on return to work rates and whether or not certain characteristics affect vocational outcomes. Therefore the aforementioned generalities should be considered cautiously and not overgeneralized.
Many individuals define themselves, in part, by their careers. Thus it is not surprising that those who are satisfied with and actively participate in their jobs have an improved perceived sense of well-being. A catastrophic injury such as amputation presents inherent compromises to this paradigm. Lost work time, a decreased possibility of promotion, and unemployment all pose threats to this important component of an individual's quality of life. Given these challenges, to what extent are individuals with lower-limb amputations able to experience satisfaction within their employment?
One of the studies included in the meta-analysis took a closer look at the concept of job satisfaction.3 The researchers began with an elaborate method of subject recruitment. After identifying 413 employed subjects with lower-limb amputations, they had each subject recommend an able-bodied colleague at work who was about the same age, the same gender, and performing the same kind of job. While this further reduced the sample size, this recruitment design resulted in an experimental cohort of 144 subjects with lower-limb amputations and a second control cohort of 144 able-bodied subjects matched by job type, age, and gender.
A questionnaire was administered to both cohorts, examining a number of vocational considerations. There were no substantial differences in the number of hours worked each week or the general employment history of the cohorts. Unsurprisingly, the experimental cohort reported a worse physical health experience than their able-bodied peers. However, general job satisfaction was reported by 70 percent of those employees with lower-limb amputations. By contrast, the same level of job satisfaction was reported by only 54 percent of the control cohort.3 While this finding may appear paradoxical, it is consistent with trends observed among individuals with chronic disabilities: Despite their physical limitations, individuals with disabilities tend to view the opportunity to work more favorably than healthy people do.
However, these higher levels of job satisfaction were not ubiquitous. The remaining 30 percent of the experimental cohort reported some level of compromise in their job satisfaction. A host of potentially influencing variables was examined. Neither education level, amputation level, the presence of residual limb pain, nor job type appeared to affect reported job satisfaction. Rather, the presence of an additional comorbidity and comparatively compromised mobility appeared to play a role. Additional insights were gained in the realm of workplace modifications. These were more commonly reported by those employees describing insufficient job satisfaction (35 percent) than among the satisfied employees (25 percent). However, nearly one-third of the less satisfied experimental cohort expressed a desire for additional workplace modifications.3 Thus it appears that those individuals with compromised job satisfaction have additional physical limitations beyond their amputations and may require or benefit from additional workplace modifications.
Upper versus Lower Limb
An investigation by Van der Sluis et al. considered some of the observations cited previously, along with input from a group of employed individuals with upper-limb amputations.4 The cohort of individuals with upper-limb amputations (n=28) was much smaller than the comparison cohorts (n=144 each). However, several trends were still observed. In contrast to the cohort of individuals with lower-limb amputations, in which 61 percent described their work as white collar and 39 percent described their work as blue collar, the cohort of individuals with upperlimb amputations reported a reversed ratio of 61 percent employed in blue-collar work. This phenomenon is only partially explained by the amputation etiologies, since trauma was the most common cause of amputation in both cohorts (upper limb, 79 percent; lower limb, 66 percent). While prosthetic use at work was not reported among the individuals with lower-limb amputations, it was encouraging to observe that three-quarters of individuals with upper-limb amputations wore their prostheses at work.4
While infrequent, workplace accommodations were more common among workers with upper-limb amputations (38 percent) than among those with lower-limb amputations (28 percent). The most common types of adjustments included accommodative hours, getting help from colleagues, and furniture adaptations.4
Vocational rehabilitation was also infrequent, occurring for only one quarter of the cohort of individuals with upper-limb amputations and less than 10 percent among the employees with lower-limb amputations.4 Whether this reflected a lack of available vocational rehabilitation resources or a reduced need for these services could not be determined from the study findings.
Collectively, this admittedly small cohort study encouragingly suggests that following upper-limb amputations, individuals are generally able to return to their often blue-collar work environments with a modest rate of workplace accommodations and frequent use of their prostheses.
Predictors of Return and Workplace Disability Days
Returning to trends observed strictly in individuals with lower-limb amputations, the Workers' Compensation Board of Alberta, Canada, published its findings of predictors for those individuals who will return to their employment following lower-limb amputations.5 Drawing upon a five-year window of claims for which there was at least two years of follow-up data, the investigators assembled a cohort of 88 claims involving lowerlimb amputations. The average age of the overwhelmingly male cohort was 34 years, and the following amputation levels were reported: toes (48 percent); transtibial (23 percent); transfemoral (14 percent); partial foot (14 percent); and hip disarticulation (2 percent).5 Consistent with the trends observed in the meta-analysis, 58 percent (n=51) of the individuals who had workers' compensation cases returned to work, with an additional 19 percent (n=17) deemed "fit for work." Only 23 percent (n=20) did not return to work.5 Of those with a documented return to work, 68 percent returned to the same occupation. In contrast to the results reported by Van der Sluis et al., in these workers' compensation cases, half of the individuals underwent vocational rehabilitation, and over one-third had a workplace assessment performed.5
A number of variables were examined as potential predictors of return to work. Factors such as age, job category, and the number of surgical procedures failed to demonstrate a significant relationship. The strongest predictor within this cohort was amputation level, with individuals who had proximal amputation levels being less likely to return to work.5 However, the authors were cautious about the potential effects of the disproportionately high prevalence of toe amputations within the cohort on this finding. Further, they cited earlier studies that suggest that the relationship between amputation level and return to work has proven somewhat inconsistent.
In addition to return to work, the authors were able to provide data on the length of workplace disability, which ranged from zero to 1,664 days, with a mean disability period of slightly more than one year. The average number of workplace disability days were lowest among those with toe amputations (about four months) and partial foot amputations (just less than one year), and considerably higher among those with more proximal levels of amputation (transtibial, transfemoral, or hip disarticulation), which lasted, on average, just less than two years.5 Additional factors such as the occurrence of vocational rehabilitation, age, and the number of surgical procedures also appeared to affect this variable. For example, an increase of one year in age resulted in an average increase of seven days of disability. An increase of one surgical procedure resulted in 52 extra days of disability. Interestingly, each additional day in acute care resulted in an average decrease of ten days of disability.5
The unfortunate realities of major limb amputation include physical limitations that may lead to workplace discrimination (WPD). Data culled from the U.S. Equal Employment Opportunity Commission provides some insight into which demographic populations may be at elevated risks for WPD, the nature of the discrimination that may occur, which employers are more likely to discriminate, and the resolution characteristics encountered within the community of individuals with amputations.
Data from amputation-related discrimination events was compared against data from a much larger cohort of individuals with nonparalytic orthopedic impairments, including injuries of the back and limbs. The rationale for this decision was that this control group would experience comparable loss of ability to move or use parts of the body. All of the cited observations concerning WPD experienced by individuals with amputations are relative to the WPD experienced by those with orthopedic injuries.
Among individuals with limb loss, the age groups at greatest risk for WPD are those below the age of 29 and over the age of 65. WPD was proportionately more common among white and Native American workers and less common among African American workers.2 Discrimination events were more frequently reported against smaller employers (15-200 workers) located in the southern United States. By contrast, WPD was proportionately less common among medium and large employers (201-500 workers, and more than 500 workers, respectively) located in the Midwestern or northern states. The industries with proportionately elevated rates of WPD were identified as construction, transportation, and manufacturing. By contrast, proportionately lower rates of WPD were observed in the wholesale, finance, and retail sectors.2
The areas of greatest WPD within the community of individuals with limb loss occurred in the processes of hiring, promotion, and training. Therefore, individuals within this community may do well to learn of their employment rights with respect to issues of employment acquisition and advancement. By contrast, proportionately lower rates of WPD were observed in the areas of accommodation, insurance benefits, employment discharge, and other benefits. These findings suggest that employees with major limb amputations are generally treated fairly once established in their jobs and unlawful discharge is comparatively rare among individuals with amputations.2
One of the more striking findings of these authors is the relatively high resolution rates of WPD allegations. The resolution category of "no cause," in which full investigation fails to support the alleged violation, was rarely encountered in cases involving individuals with limb loss. Further, successful resolutions of alleged discrimination were more commonly observed than in the control group with orthopedic injuries.2 Taken collectively, this would suggest that the allegations brought forth by those with limb loss are generally legitimate and often resolved.
The actual employment rate among individuals with limb loss is difficult to identify but appears to rest just below 75 percent. While there are several variables that appear to affect this rate in some studies, the results are inconsistent, and the risk of overgeneralization should be appreciated. Once employed, members of the amputee community appear to be more satisfied with their employment than their able-bodied colleagues, and they experience less WPD than those with orthopedic injuries. When it does occur, WPD appears to affect employment acquisition and advancement and occurs among smaller employers in blue-collar industries. However, it is less common in less industrial sectors and among larger employers.
Taken collectively, patients may find encouragement from the generalities drawn from these studies. Following their amputations, patients should be made aware that returning to work is possible, generally very satisfying, and more common than unemployment.
Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City, Utah. He can be reached at
- Penn-Barwell, J. 2011. Outcomes in lower limb amputation following trauma: A systematic review and meta-analysis. Injury 42:1474-9.
- West, S. L., B. T. McMahon, E. Monasterio, L. Belongia, and K. Kramer. 2005. Workplace discrimination and missing limbs: The national EEOC ADA research project. Work 25 (1):27-35.
- Schoppen, T., A. Boonstra, J. W. Groothoff, J. de Vries, L. Göeken, and W. Eisma. 2002. Job satisfaction and health experience of people with a lower-limb amputation in comparison with healthy colleagues. Archives of Physical Medicine and Rehabilitation 83 (5):628-34.
- Van der Sluis, C. K., P. P. Jartman, T. Shoppen, and P. U. Dijkstra. 2009. Job adjustments, job satisfaction and health experience in upper and lower limb amputees. Prosthetics and Orthotics International 33 (1):41-51.
- Herbert, J. S., and N. L. Ashworth. 2006. Predictors of return to work following traumatic work-related lower extremity amputation. Disability Rehabilitation 28 (10):613-18.