Health-related quality of life and the ability to perform activities of daily living: a cross-sectional study on 1079 war veterans with ankle-foot disorders

Background:The ankle-foot injuries are among the war-related injuries that cause many serious secondary problems for a lifetime.This nationwide study aimed to assess health-related quality of life and the ability to perform activities of daily living in veterans with ankle-foot injuries due to the Iran-Iraq war.Methods:A total of 1079 veterans with ankle-foot injuries were enrolled in a cross-sectional study from 2014 to 2016.Demographic characteristics,including age,gender,marital status,disability percent,educational level,employment and additional injuries,were collected.The ability to perform daily activities was assessed using the Barthel activities of daily living(ADL)and Lawton instrumental activities of daily living(IADL)Indexes.Physical and mental health-related quality of life(HRQOL)data were measured via the SF-36 subscales.The data were compared with those of bilateral lower limb amputees(BLLAs)and of the general Iranian population.Statistical analyses,including Pearson’s correlation coefficient,one-sample t-test and analysis of variance(ANOVA),were performed using SPSS16.0.A multiple linear regression model was used to determine the contribution of independent variables to the Physical Component Summary(PCS)and Mental Component Summary(MCS).Results:The highest and lowest scores were observed for mental health(48.93±20.69)and bodily pain(28.16±21.74),respectively.The mean scores of veterans with ankle-foot injuries on the SF-36 were significantly lower on all eight measures than those of the general Iranian male population and of the bilateral lower limb amputees(P<0.001).The mean scores of ADLs and IADLs were 83.9±16.3 and 5.3±2.0,respectively.The higher dependency in ADLs(P<0.001)and IADLs(P<0.001),the higher disability rate(P<0.001)and additional injury(P<0.001)were significant determinants of the PCS.ADL(P<0.001)and IADL(P<0.001)limitations,additional injury(P<0.001),history of hospitalization in the year preceding the study(P=0.007)and employment(P=0.001)were reported as determinants of the MCS.Conclusion:The results strongly suggest that veterans with ankle-foot injuries suffer from critically poor healthrelated quality of life.The main predicting factors of HRQOL were the disability to perform ADLs/IADLs,suffering two or more injuries,a history of hospitalization in the year preceding the study and unemployment.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees

Background: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation.Methods: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees(206 amputations) from the IranIraq war were evaluated, and a detailed questionnaire was also administered.Results: The most common level of amputation was the finger or wrist level(108, 52.4%). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis(65, 31.6%), rotator cuff injury(24, 11.7%), bicipital tendonitis(69, 33.5%), shoulder drop(42, 20.4%) and muscle atrophy(19, 9.2%). Peripheral nerve disorders included carpal tunnel syndrome in 13(6.3%) and unilateral brachial plexus injury in 1(1%). Fifty-three(51.5%) were diagnosed with facet joint syndrome at the level of the cervical spine(the most frequent site). Using a prosthesis was reported by 65(63.1%), both left and right sides. The back was the most common site of pain(71.8%).Conclusion: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Chronic traumatic ankle and foot osteomyelitis: a nationwide case-control study

Background: Osteomyelitis(OM) is an atypical consequence of ankle-foot trauma which is associated with long-term mental and physical morbidity and persistent pain. This study aimed to assess the health status of OM patients with war-related ankle-foot injuries.Methods: A total of 1129 veterans with ankle-foot injuries participated in a case-control study(2014–2016). Thirty patients with chronic OM of the ankle-foot were compared with 90 non-OM participants as the control group. Quality of life(QOL), life satisfaction and the ability to perform basic and instrumental activities of daily living were measured using the following questionnaires: short-form health survey(SF-36), satisfaction with life scale(SWLS), activity of daily living(ADL) and instrumental activity of daily living(IADL), respectively. OM patients were categorized according to their risk factors as A, B and C hosts using a modified version of the Cierny and Mader classification system. The one sample t-test, 2-independent sample t-test, ANOVA, Pearson correlation coefficient and multiple linear regression analyses were applied to analyze the data.Results: Ankle-foot pain leading to surgery(P <0.001) and orthosis usage(P =0.039) were more common in OM patients. There was no significant difference between the two groups in the prevalence of pulmonary and cardiovascular diseases or kidney failure and other related diseases. OM patients showed a significantly lower level of mental health compared to non-OM respondents(P=0.025). Approximately, 70.0% of ankle-foot injured veterans were dissatisfied with their life, and there was no difference between the two groups(P>0.05). Mobility was significantly lower in the OM patients than in the control group(P=0.023). Life satisfaction(P=0.001) and the ability to perform daily activities were the determinants for poor physical(P=0.018) and mental health-related quality of life(P=0.012). According to the Cierny and Mader classification system, they were all included in the type C host classification, with one major and/or three or more minor risk factors.Conclusion: A low level of quality and satisfaction of life and ability to perform activities of daily living were observed in OM patients with war-related ankle-foot injuries. Surgeries of the ankle and foot due to pain were much more common in OM patients than in non-OM participants. Since all the participants were classified as the C-host, health policy planning seems to be necessary.

Assessment of orthotic needs in Iranian veterans with ankle and foot disorders

Background: War-related traumas can lead to orthopedic and neurological disorders in victims. However, the scope of such disorders may expand months or even years after the trauma. Orthotic treatment as a rehabilitation process aims to enable people with disabilities to reach and maintain their optimal physical, sensory, intellectual, psychological, and social functional levels. This study aimed to investigate the rate of using orthoses among Iranian veterans with neuromuscular and skeletal disorders of the ankle and foot. Furthermore, the priorities of orthotic treatment in those veterans were explored.Methods: This qualitative study was a national health needs assessment conducted in 11 provinces of Iran during 2011–2016. A stakeholder research group was established to survey the veterans in respect to their demographic variables, activities of daily living, current health conditions, and rate of using orthoses.Results: Overall, 907 of the 1124 veteran participants completed the survey(response rate: 80.7%). Most of the veterans were men(97.7%), and their age and disability rate were 52.07±8.13 years and 31.92%±14.93%, respectively. Nearly 42% of the veterans had experience in using orthoses on a daily and weekly basis. As physical ambulation was the main problematic activity in veterans, most of them were using medical shoes and foot orthoses. Nearly 37% of veterans were in need of some type of lower limb orthoses on the contralateral side to compensate for their hip inequality. In sequential order, the most in need orthoses for veterans were foot orthoses(n=538), medical shoes(n=447), lower limb orthoses on the contralateral side(n=320), spinal orthoses(n=273), and upper limb orthoses(n=86).Conclusion: In spite of the high demands for orthoses among Iranian veterans with ankle and foot disorders, the use of orthoses is insufficient. Hence, there is a discrepancy between the current rate of orthoses use and its ideal situation, and more resources should be provided for service providers to be able to serve veterans. Moreover, veterans should be educated regarding orthoses, their use, and their impacts on the user's health status. The findings of a needs assessment of orthoses can be used in strategic planning and decision making to improve health care services for Iranian veterans.

Mental health disorders in child and adolescent survivors of post-war landmine explosions

Background: To describe the mental health status of 78 child and adolescent survivors of post-war landmine explosions.Methods: Child and adolescent survivors of landmine explosions who were younger than 18 years old at the time of the study were identified and enrolled in this study. The mental health status of the participants was assessed by general health assessment and psychiatric examinations. Psychiatric assessment and diagnosis were undertaken using the Diagnostic and Statistical Manual for mental disorders(DSM-IV) criteria. A psychiatrist visited and interviewed each survivor and identified psychiatric disorders.Results: Seventy-eight child and adolescent survivors with a mean age of 16.11±2 years old were identified and agreed to participate in the study. The mean age of the victims at the time of injury was 8.2±3.12 years old(range 2–15). Thirty-seven(47.4%) of the adolescent survivors suffered from at least one psychiatric disorder. Twenty-nine survivors(37.1%) were newly diagnosed and needed to start medication and psychiatric treatment. The most common findings were anxiety disorders(34.6%), including posttraumatic stress disorder(PTSD) in 20(25.6%), and generalized anxiety disorder(GAD) in 7(9%) subjects. Mild-Moderate depression was found in 5(6.4%) subjects. No personality disorders were observed, and two patients suffered from mental retardation. The study results revealed a significant association between age of casualty, duration of injury and limb amputation, and types of psychological disorders.Conclusion: Child and adolescent survivors of landmine explosions had a high prevalence of psychiatric disorders.

Assistive technologies for pain management in people with amputation: a literature review

The prevalence of limb amputation is increasing globally as a devastating experience that can physically and psychologically affect the lifestyle of a person. The residual limb pain and phantom limb pain are common disabling sequelae after amputation surgery. Assistive devices/technologies can be used to relieve pain in people with amputation. The existing assistive devices/technologies for pain management in people with amputation include electrical nerve block devices/technologies, TENS units, elastomeric pumps and catheters, residual limb covers, laser systems, myoelectric prostheses and virtual reality systems, etc. There is a great potential to design, fabricate, and manufacture some portable, wireless, smart, and thin devices/technologies to stimulate the spinal cord or peripheral nerves by electrical, thermal, mechanical, and pharmaceutical stimulus. Although some preliminary efforts have been done, more attention must be paid by researchers, clinicians, designers, engineers, and manufacturers to the post amputation pain and its treatment methods.

Health concerns of veterans with high-level lower extremity amputations

Background: To identify health concerns of veterans with high-level lower extremity amputations.Methods: Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists,physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire(SF-36) that assessed their ability to perform activities of daily living(ADL), instrumental activities of daily living(IADL) and life satisfaction(SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs.Results: The means of the Physical Component Summary(PCS), Mental Component Summary(MCS), SWLS, ADL and IADL were 48.58±29.6, 33.33±22.0, 19.30±7.7, 48.10±10.5 and 5.08±1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders;among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma(49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study.The Canadian-type of prosthesis was uncomfortable and not useful(27%) and excessively heavy(10%) according to the amputees.Conclusions: Understanding veterans’ characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.

What priorities should be considered for Iranian veterans with ankle-foot injuries？ A health needs assessment study, 25 years post-conflict

Despite the passage of time,a large number of veterans are still affected by injuries acquired during Iran-Iraq war.In addition to their primary injuries,the majority of veterans also experience difficulty with long-term,secondary effects.Studies have shown that the most common of these include a range of disabilities,pain,and dramatic decline in mental health and quality of life.Improving living conditions and providing rehabilitation services to veterans has always been a main priority of authorities.The goal of this study was to explain the methods and materials with which these priorities were explored.