Man Is by Nature a Social Animal: Social Integration Following Lower-limb Amputation
October 2018 Issue
Aristotle asserted long ago that "man is by nature a social animal" and that one who does not partake of society is "either a beast or a god." Socialization is an important component of the human experience, an experience that continues even after a traumatic interruption such as an amputation.
This article reviews recent literature related to the value of social support among those who have experienced a lower-limb amputation as it relates to physical function and quality of life; the participation, satisfaction, and value of socialization in the first year after lower-limb amputation; and quality and characterization of relationships with primary caregivers following lower-limb amputation.
In the first article under consideration, Hawkins et al. based their investigation upon the premise that the construct of social support can be reasonably broken down into the contributing sub-constructs of social integration and systemic or structural social support. The former relates to "the number of contacts and interactions between persons and their wider social networks," and varies considerably from individual to individual in otherwise similar settings. The latter is "the support provided by a society to patients with impairment and handicap," and includes both local and federal policy (i.e., the Americans with Disabilities Act), as well as the attitudes of the local society toward individuals with disabilities. To better understand the impact of these two sub-constructs on the function and quality of life of people with lower-limb amputations, cohorts from two dramatically different structural social support environments, the United States and Tanzania, were recruited and examined.1
The functional outcome of interest for the cross-sectional trial was performance on the six-minute walk test (6MWT). For the purposes of comparison, individuals were categorized as either unable to walk, slow walkers, or fast walkers, with the latter two groups populated by those subjects whose 6MWT times fell above or below the median 6MWT after excluding people who were unable to walk from consideration.1
Quality of life
Quality of life was assessed using the EuroQol-5D, a brief, reliable self-report instrument. Social integration was assessed using the Short Form Craig Handicap Assessment and Reporting Technique. Within this scale of 0 to 100, higher scores indicate higher levels of social integration. Because the instrument has a known ceiling effect, participants with a score of 100 were categorized as high, while those with scores below 100 but above the median score were classified as medium and those with scores below the median were classified as low.1
The expected relationships between function and social integration were observed among the 63 subjects recruited from the greater Boston area. Among the 31 fast walkers, nearly three-quarters had identified with a high level of social integration, while only 10 percent had identified with a low level of social integration.1 Among the slow walkers, the majority (59 percent) also identified with a high level of social integration.1 Only among the non-ambulatory subjects was reduced social interaction predominantly identified, with nine of the ten non-ambulatory subjects self-reporting low or medium social integration.1
Following multivariate regression adjusting for the potential confounders of age and gender, patients who identified with a high social integration were nearly 14 times more likely to be slow walkers and nearly 45 times more likely to be fast walkers than their peers who identified with low social integration scores.1 By comparison, when considered by age, those under the age of 65 were only 3.5 and 7 times more likely to attain slow and fast walking status compared with those over the age of 65.1
Quality of life scores followed a similar pattern, with increasing social integration scores associated with increasing quality of life scores.1
These relationships beg the question of which populations may be at elevated risk of compromised social integration. Several general trends were observable in the reported data. For example, those with low social integration tended to be older (mean age = 68.5 years) than those with medium or high social integration (reported at 60.0 and 53.5 years old respectively).1
Comorbid health conditions were also more prominent, with ten of the 13 subjects with low social integration presenting with diabetes (77 percent) and 12 presenting with dysvascular amputations (92 percent). However, it must be stressed that such comorbidities should not be over generalized as discrete markers of compromised social integration. For example, there were more subjects with comorbid diabetes who identified with high social integration (14) than low social integration (10).1 Similarly, there were more people with dysvascular amputations who identified with high social integration (16) than those who identified with a low social integration (12).1
Notably, none of those who identified with low social integration were working, describing themselves as unemployed (3), retired (5), or on disability (5). By contrast, of the 11 individuals who were employed, all but one identified themselves as having high social integration.1 However, since this only accounted for 27 percent of the high cohort, employment does not appear to be prerequisite to high social integration.
Insurance type was also notable in that only one of the 13 individuals with low social integration was privately insured, while 38 percent and 46 percent of those with medium and high social integration reported having private insurance coverage.1
Considered collectively, the aggregated demographic variables are unable to provide clear direction as to which patients might be at an elevated risk for decreased social integration with the associated risks of decreased function and quality of life. Rather, this unfortunate attribute was ultimately observed across a range of ages, races, comorbid health conditions, and amputation levels.1
As for the remaining component of social support, that of systemic or structural support, the responses of the 63 Boston-area patients were compared against those of 39 patients from Moshi, Tanzania. This area was characterized by the authors as "an East African country that has recently undertaken a greater commitment to rights of the disabled but has yet to demonstrate a meaningful change in the lives of people with disabilities," which "lacks both the access and resources of the United States healthcare system as well as legal protection."1
However, what the Tanzanians lacked in structured social support may have been made up for in their increased general health, reduced incidence of comorbid health conditions, and high prevalence of traumatic amputations. Keeping these cohort differences in mind, despite the lack of structural social supports, the Tanzanian cohort demonstrated a non-significant improvement in 6MWT scores and a higher quality of life.1
Social Participation, Satisfaction, and Values
Recognizing the apparent value of social integration and its effects on quality of life and physical function, the next study under consideration examined the social participation and satisfaction with social participation among a cohort of 68 individuals one year after their dysvascular lower-limb amputations. Importantly, at the time of the evaluation, only 38 (56 percent) of the subjects had been fitted with a prosthesis.2 The subjects were provided a series of tasks and asked who usually performed them: the individual, the individual with someone else, or simply someone else.
There were only two activities that at least half of the queried subjects reported performing, either on their own or with someone else. These were planning social engagements and looking after personal finances.2 By contrast, at least two-thirds of the subjects reported that someone else did everyday housework, took care of vehicles, and did home repairs.2
The subjects also reported how often they participated across a number of activities with available answers of five or more times per month, one to four times per month, or never. Those in which the greatest number of subjects participated at least once a month were shopping outside of the home (81 percent) and visiting with friends and relatives (82 percent). An additional construct was observed in 85 percent of respondents that reported having a best friend to confide in.2
The baseline characteristics that correlated with greater levels of social participation were physical and cognitive factors, including better premorbid mobility, better general mental status, and a more distal amputation level.2
To assess the related construct of satisfaction with social participation, individuals were asked whether they would like to be doing more or less of a given activity than they are currently doing across a range of tasks.2 This exercise was enhanced by the authors' decision to have the respondents also rate the relative importance they associated with each activity.2
The three activities that were valued the greatest were looking after personal finances, having a best friend to confide in, and visiting with friends and relatives.2 Consistent with the data reported thus far, the relative satisfaction with the first two items, personal finances and having a best friend, exceeded 80 percent. Unfortunately, only 50 percent of the queried subjects reported satisfaction with the third item of visiting with friends and family.2 As indicated earlier, visiting with friends and family was a frequent activity for this population, with 40 percent reporting five or more visits per month and 49 percent reporting one to four visits per month.2 However, satisfaction data suggests that for many respondents this was not enough.
By contrast, satisfaction rates were much higher for a number of other activities that were less frequently participated in and less valued. Meal preparation and grocery shopping were two activities that were performed by other people for 60 percent of respondents, yet roughly two-thirds of the queried sample were satisfied with their current participation in these activities.2
In contrast to actual social participation levels that correlated with physical and cognitive factors, the only baseline factor that correlated with an individual's satisfaction with his or her social participation was the reported level of social support at the time of amputation.2
Collectively, this data underscores the complex interplay between what individuals are able to do, their satisfaction with that ability, and the relative value placed on those activities. The relatively high prevalence of social interactions with family and friends among this group, coupled with high rates of dissatisfaction with these levels, and a desire for more such visits seems to highlight the craving for socialization following amputation.
Relationships With Caregivers
The final article under consideration examines the role of the primary caregiver, distinct from the broader construct of general social support. The article reports on 137 veterans with dysvascular lower-limb amputations. While many tend to associate the role of primary caregiver with a spouse or partner, of the queried individuals, all of whom identified a primary caregiver, only 60 percent were married. Further, a spouse/partner was only identified as a primary caregiver by 48 percent of respondents.3 Other caregivers included a son or daughter (11 percent), another family member (15 percent), a friend (12 percent), and paid care providers (11 percent).3 Further, while primary caregivers frequently lived with the participant, this was not necessarily the case, with 30 percent of caregivers living separately.3
In examining the impact of this individual relationship, participants were asked to grade on both support and conflict. Support was assessed with three items: 1) Could you turn to this person for advice about problems? 2) Could you count on this person for help with a problem? and 3) Can you count on this person to listen to you when you are very angry at someone else?3
Conflict was similarly assessed through responses to three questions: 1) Do you need to work hard to avoid conflict with this person? 2) How upset does this person make you feel? and 3) How angry does this person make you feel? Across all six questions, response options ranged from one (not at all) to four (very much).3
With both support and conflict scores established for each participant, the researchers targeted the psychosocial outcomes of satisfaction with life and depressive symptoms. However, before these relationships could be examined, other variables had to be considered and controlled for. Older age, better mobility, and better self-reported health were all found to be correlated with higher satisfaction with life scores. As such, these variables had to be statistically controlled for, along with global social support, to determine the impact of caregiver support on satisfaction with life.3
Ultimately, the anticipated relationships were confirmed. Those individuals citing higher levels of support from their primary caregivers reported higher satisfaction with life, while those individuals citing elevated conflict levels with their primary caregivers reported lower satisfaction with life.3 While these correlations reached statistical significance, it should be noted that the correlations between caregiver support and conflict and satisfaction with life were lower than those observed between satisfaction with life and mobility, age, and self-reported health.
By contrast, while there was a very robust correlation between caregiver conflict and depressive symptoms, the correlation between support and decreased depressive symptoms fell shy of statistical significance.3
As the O&P profession continues to hold itself accountable for the outcomes obtained within the amputee community, the variables that impact the core outcomes of mobility, quality of life, social participation, and satisfaction with life need to be understood. While socialization is largely outside of the direct influence of a clinical prosthetist, an appreciation of its potential impacts can ultimately inform clinical decision making.
Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City. He can be contacted at firstname.lastname@example.org.
1. Hawkins, A. T., A. J. Pallangyo, and A. M. Herman, et al. 2016. The effects of social integration on outcomes after major lower extremity amputation. Journal of Vascular Surgery 63:154-63.
2. Roepke, A. M., R. M. Williams, and A. P. Turner, et al. 2017. A longitudinal study of social participation after dysvascular lower extremity amputation. American Journal of Physical Medicine and Rehabilitation 96(10):741-7.
3. Brier, M. J., R. M. Williams, and A. P. Turner, et al. 2018. Quality of relationships with caregivers, depression, and life satisfaction after dysvascular lower extremity amputation. Archives of Physical Medicine and Rehabilitation 99(3):452-458.