Psychosocial Factors
Clinicians should screen all patients with high energy lower extremity trauma for psychosocial risk factors (e.g. depression, PTSD, anxiety, low self-efficacy, poor social support) affecting patient outcomes.
Limb Salvage or Early Amputation
This guideline was produced in collaboration with METRC, with funding provided by the US Department of Defense. Endorsed by: AOFAS, OTA

Rationale

RATIONALE:

STRENGTH OF EVIDENCE: Moderate

O’toole (JBJS-AM; 2008) determined that the presence of anxiety or depression at 2 years after injury decreased patient satisfaction. MacKenzie (JBJSn-AM; 2005) found that patients with low self-efficacy had worse Sickness Impact Profile (SIP) scores. Melcer (JOT; 2013) showed that lower extremity trauma amputees had greater odds of mood disorders. Furthermore, PTSD risk was lower in amputees versus non-amputees. Bosse (N Engl J Med; 2002) concluded that amputees and non-amputees had higher SIP scores if they had poor self-efficacy and a poor social support network.

BENEFITS & HARMS:

Screening and treatment of psychosocial risk factors can increase patient satisfaction after amputation or limb salvage. Failure to address these risk factors have been shown to result in poor SIP scores, functional outcome, and patient satisfaction.

OUTCOME IMPORTANCE:

Identification and proper referral for psychosocial risk factors can help improve outcomes in all lower extremity trauma patients regardless of whether they receive amputation or limb salvage.

COST EFFECTIVENESS/RESOURCE UTILIZATION:

Bhatnagar (J Rehabil Res Dev; 2015) demonstrated presence of PTSD resulted in higher prosthetic costs as well as cost associated with psychiatric treatment in amputees.

ACCEPTABILITY:
This recommendation is acceptable to all civilian and military lower extremity trauma patients undergoing amputation or limb salvage

FEASIBILITY:

This recommendation is feasible in trauma centers with proper referral services. The application of these services to provide psychosocial support will not affect surgical decision making and operative treatment.

FUTURE RESEARCH:

Current literature has shown that negative psychosocial factors results in poorer outcomes and satisfaction in both amputation and limb salvage. Long term studies are necessary to determine which factors are most important to address and what specific interventions are most effective.

 

* Strength of recommendation upgraded. Evidence from two or more “High” quality studies with consistent findings for recommending for or against the intervention. Also requires no reasons to downgrade from the EtD framework.
 


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