This Article


Creative Commons License
Except where otherwise noted, this work is licensed under Creative Commons Attribution-NonCommercial 4.0 International License.
This article, by Trauma Monthly , is licensed under a Creative Commons Attribution License .

Pain and Health-Related Quality of Life in War Veterans with Bilateral Lower Limb Amputations

1 Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, IR Iran
2 Department of Community and Preventive Medicine, Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran
3 Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran
4 Department of Public Health and Epidemiology, Mental Health Research Group, Health Metrics Research Centre, Iranian Institute for Health Sciences Research, Tehran, IR Iran
*Corresponding author: Batool Mousavi, Department of Community and Preventive Medicine, Janbazan Medical and Engineering Research Center (JMERC), Tehran, IR Iran. Tel.: +98-22415367, Fax: +98-22415367, E-mail: mousavi.b@
Trauma Monthly. 2012 July; 17(2): 282-286. , DOI: 10.5812/traumamon.5135
Article Type: Research Article; Received: Apr 10, 2012; Revised: May 30, 2012; Accepted: Jun 27, 2012; epub: Jul 31, 2012; ppub: Jul 2012
Running Title: Pain and Health Related Quality of Life in War Related BLLA


1. Background: Amputation and pain may have considerable impact on health-related quality of life.

2. Objectives: The purpose of this study was to assess the impact of pain on health-related quality of life in a population of war related bilateral lower limb amputees.

3. Materials and Methods: The Veterans and Martyrs Affairs Foundation (VMAF) database documented 578 patients with bilateral lower limb amputation; 335 consented to the study (response rate = 58%). The majority of participants in the sample were males (96.7%). Types of pain were investigated using a questionnaire. Health-related quality of life (HRQOL) was investigated using the sf-36 questionnaire.

4. Results: About two third of amputees reported phantom pain 66.7% (n = 223) and vertebral column pain 60.9% (n = 204). The most common type of pain was lumbosacral pain 52.8 % (n = 177) followed by neck 18.2 % (n = 61) and thoracic pain 9.6% (n = 32). Back pain affected on vitality, social function, mental health and mental component scale in our cases (P < 0.05). Neck pain affected all components of health-related quality of life (P < 0.05). Thoracic pain affected quality of life significantly (P < 0.05). The results obtained from logistic regression analysis indicated that none of the three spinal column pains including neck, thoracic and lumbosacral pain resulted in poor physical or mental component scales.

5. Discussion: This study revealed that bilateral lower limb amputees suffer from different types of pain and poor health-related quality of life. Therefore, the assessment and management of all types of pain are necessary to improve quality of life in veterans.

Keywords: Pain; Quality of Life; Lower Extremity; Amputation; Veterans

1. Background

Lower limb amputation is correlated to considerable morbidity, mortality and disability (1, 2). Research so far has shown that pain is a major risk factor of distress in a variety of cases. Many amputees experience significant amputation associated pain, which can affect their health-related quality of life (HRQOL) (3, 4), health, return to work (2), sleep and daily activities (5), and participation in social activities (6). Individuals with lower limb amputations often develop gait patterns to accommodate a prosthesis that may put them at risk for other types of pain such as hip and back pain and pain of the unaffected leg (7). Many studies have reported prevalence of pain types especially stump pain, phantom pain, phantom sensations (8, 9), and back pain after lower limb amputation (10-12).

Although the importance of prevention and health promotion in patients with lower limb amputation is well established (13), however, HRQOL in bilateral lower limb amputees has not been widely investigated (14). Additionally, information regarding the relationship between pain and quality of life in patients with loss of both lower limbs are more restricted (3). HRQOL in Iranian veterans with lower limb amputation has been previously evaluated and it has been shown that the war related bilateral lower amputees suffer from poor health related quality of life (15). However, there is no applicable evidence on the specific effect of pain on health-related quality of life in this group of veterans.

2. Objectives

The objective of this study was to assess the relationship between potential pain determinants and health-related quality of life in veterans with bilateral lower limb amputation.

3. Materials and Methods

3.1. Design and Data Collection

In a cross-sectional study, 578 veterans with bilateral lower limb amputation (either civilians or veterans) supported by the Veterans and Martyrs Affairs Foundation (VMAF) (16) were selected by census sampling. The inclusion criteria were: Being a war survivor, no underlying severe physical or mental condition, and willing to participate.

In order to collect data, interviews were conducted by 3 trained assessors. Each amputee was interviewed separately, face-to-face, for about 15-20 minutes. The amputees responded to demographic questions and were also asked about their amputation including the cause of the injury, amputation level and prosthesis usage. Information regarding history of neck, thoracic and lumbosacral pain. The participants were asked about bothersome and chronic pain in the three parts of the spinal column (cervical, thoracic and lumbosacral) in the past 6 months. The participants were also asked about phantom pain, its intensity and duration. Phantom pain intensity was rated as severe or not severe in one or both limbs (17). The data regarding duration of phantom pain was observed as always, usually, sometimes and rarely. The majority of participants in the sample were male (96.7%). All participants were informed about the purpose of the study and their participation was voluntary.

3.2. Quality of Life

Quality of life was measured using the 36-item Short Form Health Survey (SF-36). The SF-36 is a generic questionnaire that can be used for the general population and in different patient groups. The questionnaire consists of 36 questions that measure 8 health-related concepts. The SF-36 contains 8 domains; physical function (PF), physical role (PR), general health (GH), bodily pain (BP), vitality (VI), social functioning (SF), emotional role (RE), and mental health (MH). It also provides two summary scales: Physical Component Summary (PCS) and Mental Component Summary (MCS). Scores on each of the subscales range from 0 to 100, with 0 representing the worst health-related quality of life and 100 representing the best (18,19).

3.3. Statistical Analysis

In addition to descriptive statistics and independent t-test, we performed regression analysis to determine variables that mostly contributed to physical and mental health-related quality of life in patients with bilateral lower limb amputation. We consider a study power of 95% confidence interval and P- value less than 0.05 was significant. Data were analyzed by SPSS 16.0 statistical software.

3.4. Ethics

The ethics committee of Janbazan medical and engineering research center (JMERC), Tehran, I.R. Iran approved the study. All patients gave informed consent.

4. Results

Amputees ranged in age from 21 to 71 years (mean 42.05 yrs SD = 6.32 yrs). The average age of the amputees was 42.6 years (SD = 6.32). The average age at the time of injury was 22.6 years (SD = 4.3). The most common cause of amputation was related to blast injury due to grenades 56% (n=191) which was followed by land mine explosion 33% (n = 111) and bombing 4.7% (n = 16), respectively. Level of amputation in 37.9% (n = 124) of the cases was bilateral below knee, in 22.3% (n = 73) bilateral above knee, and in 34.3% (n = 112) of amputees level of amputation was a combination of above and below knee. Most of the cases used their prosthetics 80.3% (n = 269).

About two thirds of amputees 66.7% (n = 223) reported phantom pain. Of these 37.6% (n = 84) reported their pain to be severe, and 21% (n = 46) said that they always or usually suffered from phantom pain. There was a significant relationship between severity of phantom pain and three SF-36 domains including physical functioning, general health, and physical component scale (P < 0.05) Findings also showed a significant relationship between duration of phantom pain and physical functioning, bodily pain, mental health, and physical component scale (P < 0.05, Table 1).

Table 1
Comparison of the SF-36 Scores in Bilateral Lower Limb Amputees According to Phantom Pain Intensity and Duration

About two thirds of the amputees 60.9% (n = 204) reported vertebral column pain. The most common type of pain was lumbosacral pain 52.8 % (n = 177) followed by neck 18.2 % (n = 61) and thoracic pain 9.6% (n = 32). Existence of vertebral pain was significantly associated with lower scores in bodily pain (BP) (P < 0.009), vitality (VI) (P < 0.001), social functioning (SF) (P < 0.01), mental health (MH) (P < 0.003), physical component scale (P < 0.02) and mental component scale (P < 0.002).

Neck pain affected on all the components of health related quality of life except physical and emotional components. The subject who suffered from thoracic pain had significantly lower scores in physical function (PF), general health (GH), vitality, social function, mental health, physical component scale and mental component scale. Having back pain was also significantly associated with lower scores in bodily pain, vitality, social function, men tal health and mental component scale (Table 2).

Table 2
Comparison of the SF-36 Scores in Bilateral Lower Limb Amputees for Vertebral Pain

5. Discussion

This study assessed impact of pain on HRQOL in Iranian survivors of the Iraq-Iran war with bilateral lower limb amputation. Poor QOL was the most important finding of this study. In this regard a study by Dajpratham et al (2011) showed that Thai people with unilateral LLA reported primarily fair HRQOL and the number of people with LLA who had fair QOL were more than eighty six percent (20). Also our study indicates that amputees who reported to have vertebral column or phantom pain had a considerable poorer HRQOL comparing with their counterparts.

Pain has a considerable impact on HRQOL (3). Individuals with lower limb amputations often develop gait patterns to accommodate a prosthesis that may put them at risk for other types of pain such as back pain (10). Frequency of back pain among lower limb amputees varies from 47.7 to 94.7% in different studies (10-12), in our study more than half of the participants reported back pain. In the study by Hammarlund et al. (2011) there was a high prevalence of back pain after amputation (21), which is consistent with the findings of our study.

Lower limb amputation commonly leads to asymmetrical weight-bearing, even after rehabilitation treatment and in particular leads to additional weight gain which causes back and extremity pain. This is detrimental to the amputees’ long-term HRQOL (22). Some risk factors for back pain such as work-related factors, educational level, exercise and individual factors, directly or indirectly affect SF-36 scores in individuals and need consideration in the evaluation and interpretation of the HRQOL (23). Study of Asano et al. (2008) revealed some other significant factors as predictors of subjects’ perceived QOL in lower limb amputation including: depression, perceived prosthetic mobility, social support, co-morbidity, prosthesis problems and social activity participation. Several modifiable characteristics influence QOL after lower limb amputation including depression and participation in daily living. These findings suggest the importance of addressing individuals’ perception status to regain or maintain QOL (24).

Prevalence of lumbosacral pain was higher than other pains in the amputees. Similar results have been shown by Taghipour et al. (2009) study, in which poor physical HRQOL was positively associated with transfemoral amputation, phantom movement and back pain (25). The results of this study showed that neck pain compared to other types of pain was more accompanied with lower scores on SF-36 domains especially on physical function, general health, bodily pain, vitality, social function and mental health in our subjects.

The prevalence of phantom pain was also high in our study population. This result is consistent with the study of Wartan et al. (26) and is somewhat lower than the prevalence reported by Sherman et al. (5), and Dijkstra et al. (8). Our study also showed that amputees with phantom pain suffered more from poor HRQOL compared to their counterparts. This finding is consistent with the findings of Van der Schans et al. (2002) (3) and Lerner et al. (27). Because of the high reported prevalence and the impact of phantom pain on medical care and quality of life, identification of risk factors associated for phantom pain may be important (8).

As shown in Table 2 amputees with severe phantom pain had poorer quality of life in physical health subscales more than mental health subscales. Similar results were found by Mousavi et al. (2009) that victims scored better on mental health related subscales than physical health (16). Moreover, amputees who reported that their phantom pain is usually or always severe, had lower scores in both physical and mental component subscales of SF-36. Back Pain and other types of pain are common after limb loss (22, 23, 25). In this survey we did not study intensity, quality and duration of spinal pain. Further research is recommended to focus on these topics. According to results of this study, it can be concluded that pain in BLLA was accompanied by poor health-related quality of life. This situation remarks an indication that patients need more support from the healthcare system. The recognition of risk factors contributing to pain and healthrelated quality of life may result in the development of interventions aimed at the prevention or treatment and improvement of HRQOL in war veterans.


None declared.


Implication for health policy/practice/research/medical education: Ensight into the factors causing pain affecting health-related quality of life in BLLA may help in the development of interventions directed towards the prevention or treatment of pain and improving HRQOL in veterans.
Please cite this paper as: Rahimi A, Mousavi B, Soroush M, Masumi M, Montazeri A. Pain and Health-Related Quality of Life in War Veterans with Bilateral Lower Limb Amputations. Trauma Mon. 2012;17(2):282-6.
Financial Disclosure: This article was financially supported by Janbazan Medical and Engineering Research Center (JMERC).
Funding/Support: None declared.


  • 1. Spichler ER, Spichler D, Lessa I, Costa e Forti A, Franco LJ, LaPorte RE. Capture-recapture method to estimate lower extremity amputation rates in Rio de Janeiro, Brazil. Rev Panam Salud Publica. 2001;10(5):334-40.
  • 2. Hanley MA, Ehde DM, Jensen M, Czerniecki J, Smith DG, Robinson LR . Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil. 2009;88(9):742-51 quiz 52, 79..
  • 3. van der Schans CP, Geertzen JH, Schoppen T, Dijkstra PU. Phantom pain and health-related quality of life in lower limb amputees. J Pain Symptom Manage. 2002;24(4):429-36. [DOI]
  • 4. Demet K, Martinet N, Guillemin F, Paysant J, Andre JM. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil. 2003;25(9):480-6. [DOI]
  • 5. Sherman RA. In: Sherman RA, Devor M, Heermann-Do K, editor(s). Phantom Pain. New York: Plenum Press; 1997.
  • 6. Gallagher P, Desmond D, MacLachlan M . In: Gallagher P, Desmond D, MacLachlan M, editor(s). Psychoprosthetics. London: Springer; 2007.
  • 7. Ehde DM, Czerniecki JM, Smith DG, Campbell KM, Edwards WT, Jensen MP, et al. Chronic phantom sensations, phantom pain, residual limb pain, and other regional pain after lower limb amputation. Arch Phys Med Rehabil. 2000;81(8):1039-44. [DOI]
  • 8. Dijkstra PU, Geertzen JH, Stewart R, van der Schans CP. Phantom pain and risk factors: a multivariate analysis. J Pain Symptom Manage. 2002;24(6):578-85. [DOI]
  • 9. Bosmans JC, Suurmeijer TP, Hulsink M, van der Schans CP, Geertzen JH, Dijkstra PU. Amputation, phantom pain and subjective well-being: a qualitative study. Int J Rehabil Res. 2007;30(1):1-8. [DOI]
  • 10. Smith E, Comiskey C, Ryall N. Prevalence and patterns of back pain and residual limb pain in lower limb amputees at the National Rehabilitation Hospital. Ir J Med Sci. 2008;177(1):53-7. [DOI]
  • 11. Hagberg K, Branemark R. Consequences of non-vascular transfemoral amputation: a survey of quality of life, prosthetic use and problems. Prosthet Orthot Int. 2001;25(3):186-94. [DOI]
  • 12. Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil. 2005;86(10):1910-9. [DOI]
  • 13. Robinson-Whelen S, Bodenheimer C. Health practices of veterans with unilateral lower-limb loss: Identifying correlates. J Rehabil Res Dev. 2004;41(3B):453-60. [DOI]
  • 14. Smith DG, Horn P, Malchow D, Boone DA, Reiber GE, Hansen ST, Jr. Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J Trauma. 1995;38(1):44-7. [DOI]
  • 15. Mousavi B, Mirsalim F, Soroush MR, Masoumi M, Montazeri A. Quality of life in war related bilateral lower limb amputee: Results of a national project from Iran. Payesh. 2009;8(3):303-10.
  • 16. Mousavi B, Soroush MR, Montazeri A. Quality of life in chemical warfare survivors with ophthalmologic injuries: the first results form Iran Chemical Warfare Victims Health Assessment Study. Health Qual Life Outcomes. 2009;7:2. [DOI]
  • 17. Su CJ, Liu K, Wang YM. Midazolam as an effective drug for severe phantom limb pain in a patient after undergoing spinal anesthesia for two consecutive surgeries in the contralateral lower limb. Acta Anaesthesiol Taiwan. 2009;47(1):32-5. [DOI]
  • 18. Ware JE, Jr., Kosinski M, Gandek B, Aaronson NK, Apolone G, Bech P, et al. The factor structure of the SF-36 Health Survey in 10 countries: results from the IQOLA Project. International Quality of Life Assessment. J Clin Epidemiol. 1998;51(11):1159-65. [DOI]
  • 19. Montazeri A, Goshtasebi A, Vahdaninia M, Gandek B. The Short Form Health Survey (SF-36): translation and validation study of the Iranian version. Qual Life Res. 2005;14(3):875-82. [DOI]
  • 20. Dajpratham P, Tantiniramai S, Lukkanapichonchut P. Health related quality of life among the Thai people with unilateral lower limb amputation. J Med Assoc Thai. 2011;94(2):250-5.
  • 21. Hammarlund CS, Carlstrom M, Melchior R, Persson BM. Prevalence of back pain, its effect on functional ability and health-related quality of life in lower limb amputees secondary to trauma or tumour: a comparison across three levels of amputation. Prosthet Orthot Int. 2011;35(1):97-105. [DOI]
  • 22. Duclos C, Roll R, Kavounoudias A, Mongeau JP, Roll JP, Forget R. Postural changes after sustained neck muscle contraction in persons with a lower leg amputation. J Electromyogr Kinesiol. 2009;19(4):e214-22.
  • 23. Kwon MA, Shim WS, Kim MH, Gwak MS, Hahm TS, Kim GS, et al. A correlation between low back pain and associated factors: a study involving 772 patients who had undergone general physical examination. J Korean Med Sci. 2006;21(6):1086-91.
  • 24. Asano M, Rushton P, Miller WC, Deathe BA. Predictors of quality of life among individuals who have a lower limb amputation. Prosthet Orthot Int. 2008;32(2):231-43.
  • 25. Taghipour H, Moharamzad Y, Mafi AR, Amini A, Naghizadeh MM, Soroush MR, et al. Quality of life among veterans with war-related unilateral lower extremity amputation: a long-term survey in a prosthesis center in Iran. J Orthop Trauma. 2009;23(7):525-30.
  • 26. Wartan SW, Hamann W, Wedley JR, McColl I. Phantom pain and sensation among British veteran amputees. Br J Anaesth. 1997;78(6):652-9.
  • 27. Lerner RK, Esterhai JL, Jr., Polomano RC, Cheatle MD, Heppenstall RB . Quality of life assessment of patients with posttraumatic fracture nonunion, chronic refractory osteomyelitis, and lowerextremity amputation. Clin Orthop Relat Res. 1993;(295):28-36.

Table 1

Comparison of the SF-36 Scores in Bilateral Lower Limb Amputees According to Phantom Pain Intensity and Duration

Phantom Pain Intensity a Phantom Pain Duration b
HRQOL Subscales Mean (SD) P Duration Mean (SD) P
Physical Function 0.027 0.015
No 56.2 (22.6) Usually 45.13 (20.49)
Yes 48.7 (23.8) Sometimes 54.51(23.46)
Role-Physical NS c NS
No 50.3 (24.9) Usually 43.63 (21.75)
Yes 45.8 (25.1) Sometimes 49.36 (25.26)
Bodily Pain NS 0.025
No 47.1(22.2) Usually 38.03 (20.21)
Yes 41.4(20.8) Sometimes 46.39 (22.66)
General Health 0.017 NS
No 55.3 (26.5) Usually 45.38 (23.30)
Yes 48.1 (26.2) Sometimes 53.89 (26.75)
Vitality NS NS
No 63.1 (24.2) Usually 56.42 (23.35)
Yes 58.9 (23.2) Sometimes 62.36 (23.95)
Social Function NS NS
No 63.2 (26.1) Usually 62.89 (28.64)
Yes 65.9 (28.4) Sometimes 64.11 (26.23)
Role-Emotional NS NS
No 65.2 (26.6) Usually 55.43 (24.27)
Yes 59.7 (26.3) Sometimes 63.63 (26.76)
Mental Health NS 0.016
No 63.1 (26.5) Usually 51.96 (23.95)
Yes 55.7 (24.5) Sometimes 62.31 (25.97)
Physical Component Scale 0.019 (n=117) 0.028
No 47.4 (21.1) Usually 38.07 (17.09)
Yes 40.2 (20.7) Sometimes 45.7 (21.5)
Mental Component Scale NS NS
No 58.3 (25.8) Usually 51.03 (22.44)
Yes 54.1 (24.5) Sometimes 57.57 (25.52)
a Severe (Yes) (n = 84) Not severe (No) (n = 139)
b Usually (n = 46) Sometimes (n = 117)
c Abbreviation: NS: Not Significant

Table 2

Comparison of the SF-36 Scores in Bilateral Lower Limb Amputees for Vertebral Pain

Neck Pain Mean (SD) Thoracic Pain Mean (SD) Lumbosacral Pain Mean (SD)
HRQOL Subscales Yes (n = 61) No (n = 274) P Yes (n = 28) No (n = 307) P Yes (n = 117) No (n = 158) P
Physical function 48.0 (23.4) 56 (24.5) 0.02 41 (24.9) 55.7 (24.1) 0.002 53 (24.9) 56.2 (24) NS
Role physical 45.6 (22.3) 51(25.6) NSa 44 ( 21) 50.6 (25.3) NS 48.7 (24.7) 51.6 (25.5) NS
Bodily pain 41.2 (22.7) 49.5 (24.1) 0.01 41.9 (19.8) 48.5 (24.3) NS 45.4 (24) 50.9 (23.8) 0.03
General health 45.6 (26.9) 57.4 (263) 0.002 41.6 (24.9) 56.6 (26.6) 0.004 54.3 (26) 56.5 (27.6) NS
Vitality 57 (23.1) 64.9 (23.6) 0.01 52 (21.1) 64.5 (23.7) 0.007 59.4 (24) 68 (23.2) 0.001
Social function 60.4 (26.4) 68.1 (26.7) 0.04 51.5 (30) 68.1 (26.1) 0.002 63.5 (27.2) 70.2 (25.8) 0.02
Role emotional 59.3(24.8) 64 (27.2) NS 56.3(24.3) 63.8(27) NS 60.8(26.2) 65.7(27.2) NS
Mental health 53.6 (25) 64.5 (25.1) 0.002 46.6 (25) 64 (25) 0.001 59 (25.3) 66.5 (24.9) 0.006
Physical component scale 37.9 (21.6) 48.7 (22.3) 0.001 31.8 (18.7) 48.1 (22.4) 0.001 44.9 (22) 48.9 (23.1) NS
Mental component scale 51.1 (23.5) 60.3 (25.4) 0.01 44.8 (23.4) 59.9 (25.1) 0.002 54.9 (24.5) 63 (25.6) 0.003
a Abbreviation: NS: Not Significant