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In addition to the physical retraining that often accompanies an acquired disability, there are a number of emotional adjustments and adaptations that need to occur as well. In many instances, the goals and aspirations that preceded the injury or traumatic event are no longer physically possible and may need to be restructured.

In the world of prosthetic rehabilitation, lower-limb amputation is typically an acquired event, frequently occurring during adulthood when goals and expectations are well established. In the face of this new disability and its associated limitations, patients with lower-limb amputations are suddenly forced to reconsider their goals and restructure their expectations of themselves. It’s a process that some patients navigate more easily than others. This article investigates some of the qualities that appear to facilitate successful long-term adjustment to life after amputation. The reviewed materials also provide insight into the goals that many of our patients appear to value and how these goals may change over time.

Goals

Most of the material for this article is taken from the observations that doctoral student Laura Coffey published in a recent Clinical Rehabilitation ¹ journal article and in her comprehensive doctoral dissertation.² Coffey introduces the concept of “self-regulation theory,” the notion that our behaviors are largely governed by our pursuit of individual goals. Some of these goals are valued more than others, with higher-level goals being rather broad and conceptual in nature. Our pursuit of these goals provides structure and purpose to our lives and can greatly influence our emotional well-being.¹

In the presence of an acquired disability such as lower-limb amputation, the ability of an individual to reasonably pursue and attain some of his or her goals can be fundamentally disrupted. This may ultimately lead to psychological distress and a reduced quality of life. In such instances, it can be beneficial for individuals to abandon goals that are no longer realistic and select more appropriate, attainable goals. Studies from other populations with disabilities have suggested that the ability to disengage from difficult goals and re-engage in alternative goals can result in fewer depressive symptoms and emotional distress.¹ To this end, Coffey set out to identify the higher-order goals among a cohort of individuals with new lower-limb amputations and monitor their longitudinal progression over the six months following amputation. She also measured the subjects’ willingness to abandon difficult goals and compared this with eventual measures of depression and general adjustment.¹

Goal Importance

Coffey’s research initially identified 98 participants who agreed to respond to a number of goal-related questionnaires upon their admission to inpatient rehabilitation following lower-limb amputation. These questionnaires were repeated at six weeks and six months post-admission, with each iteration experiencing an expected attrition of subjects. Ultimately, the responses of 64 subjects were tracked across a six-month observation period.¹

The first task that subjects were asked to engage in was assigning importance rankings to a series of higher-order life goals taken from the Goal Facilitation Inventory.³ The inventory began with this introduction: “The following is a list of things that people may find important in their everyday lives. To what extent is each of the following things important to you in your everyday life?”

Subjects then used a Likert scale ranging from “not at all important” (1) to “very important” (5). The 26 inventory items included such things as:

• Feeling relaxed.
• Having fun.
• Discovering new things.
• Coming up with new ideas.
• Keeping up my self-confidence.
• Making my own decisions in life.
• Doing things better than others.
• Receiving support from others.
• Fulfilling my duties to others.
• Treating others fairly.

Subjects tended to rate these statements as being rather important, with an average ranking value of 3.9 across all subjects and all items. The highest ratings were found with the following goals:

1. Being healthy (4.65).
2. Keeping up my self-confidence (4.50).
3. Treating others fairly (4.47).¹

By contrast, the following goals received the lowest ratings:

1. Doing things better than others (3.11).
2. Feeling unique (3).
3. Obtaining more money or possessions (2.84).²

With one exception that will be discussed later in this article, these importance rankings changed little over time.

Goal Hindrance

Across this spectrum of higher-order goals, it is reasonable to assume that the pursuit of some goals might be interrupted to a greater extent than the pursuit of others. Thus, the subjects were presented the same list of goals and asked, “To what extent are you currently hindered in achieving each of the following things due to your amputation?” These assessments were also made using a Likert scale, and ranged in this instance from “not at all hindered” (1) to “completely hindered” (5).¹ Interestingly, in spite of the substantial physical impediments that accompany a recent lower-limb amputation, the higher-order nature of these goals was such that, among the original 98 subjects, the mean hindrance value of 21 of the 26 goals was below 2 (or “hardly hindered”).² At the time of admission to inpatient rehabilitation, the highest hindrance values were observed for “Fulfilling my duties to others,” and “Having daily activities run smoothly,” both tied at a Likert rating of 2.08.² Unlike the importance ratings cited earlier, longitudinal changes in this area were perceived as being more hindered by an amputation. These will also be discussed later in the article.

Goal Disturbance

It is logical to infer that the relative disturbance created by a lower-limb amputation to the pursuit of a given goal is a product of its perceived importance to that individual and his or her perception as to how much the amputation hinders the pursuit of that goal. Thus, a “goal disturbance value” was calculated for each goal (the product of its importance and hindrance scores). It is noteworthy that there was very little overlap between those goals deemed most important to individuals with a recent amputation and those goals perceived as being the most hindered by the amputation.¹ When examining the data collected upon admission for the 64 subjects that would persist through the sixmonth observation period, there were only two goals that could be found within the top ten of both “importance” and “hindrance” values. These goals were “Ensuring my safety,” and “Being healthy,” with disturbance values of 9.39 and 9.31 respectively. These were distantly followed by such goals as “Having my daily activities run smoothly” (8.58) and “Keeping up my self-confidence” (8.56).² This data provides some insight into the goals that may resonate most with patients in the earliest days following their amputations. Efforts directed toward ensuring their safety and promoting a healthy lifestyle appear to address areas that are perceived as both important and, to some extent, threatened following lower-limb amputation.

Changes Over Time

It is difficult to draw conclusions with respect to changes in goal ranking over time because of the attrition that occurred throughout the study period. However, where notable changes were observed, some discussion is warranted. As suggested earlier, the relative importance assigned to the various higher-order goals was generally constant across the six-month observation period. Indeed, the six goals with the highest importance ranking at the time of admission remained the top six goals six months later. The only goal that appeared to be affected over time was “Ensuring my safety.” Originally assigned the fifth highest importance score, the average importance rating for this goal increased over time until it ultimately received the highest average importance score.² It would appear that the experiences during the first six months postamputation may increase the relative importance subjects placed on their safety.

Similarly, movement was observed in the relative hindrance rankings of certain goals. Two goals that failed to rank in the top ten at the time of admission were ultimately ranked with the highest hindrance scores. These were “Obtaining more money or possessions” (2.42) and “Doing things better than others” (2.37).² Given that these latter rankings were obtained six months post-admission, at a time when subjects might have been attempting to re-enter the work force or re-engage with more activities of daily living (ADLs), it seems reasonable to assume that patients became progressively more cognizant of the hindrance their amputations would have upon these particular goals.

However, while these two goals received high hindrance rankings, their corresponding importance rankings represented the two lowest importance scores.² Thus, despite their high hindrance scores, their disturbance scores were low, 7.11 and 7.98 respectively. By contrast, because of the coupling of its high importance score and moderately high hindrance scores, “Ensuring my safety” retained the highest goal disturbance score.²

Additional Insights

To this point, Coffey’s observations give us some insight into the types of goals that would appear to resonate more deeply to patients during the first six months following amputation— considerations of safety, general health, accomplishing daily activities, and maintaining self-confidence. However, in addition to the questionnaires described to this point, study subjects were also asked to complete the Goal Adjustment Scale, the standardized Beck Depression Inventory, and the Trinity Amputation and Prosthesis Experience Scales, a self-report assessment of a subject’s adjustment to amputation and prosthesis use.¹ These survey instruments allowed a deeper view into the roles that goals may play in adapting to amputation.

For example, Coffey observed that the subjects who provided higher goal importance scores tended to have fewer symptoms of depression and were better adjusted to their transitions postamputation than those with lower goal importance scores.²

By contrast, the subjects with higher goal disturbance scores, implying an increased perception that the amputation will hinder them from the pursuit of higher-level goals, tended to have lower scores on adjustment outcomes.¹ Restated, those subjects who assign a higher importance to these broad goals shortly after their surgeries tend to better adapt to life after amputation. Alternatively, those who anticipate that amputation will be a greater hindrance to engaging in these same goals have a more difficult time adjusting to this new challenge.

Charting a New Course

The Goal Adjustment Scale is a ten-question survey instrument that assesses how subjects react when they need to abandon an important goal in their lives and seek out something more attainable.⁴ Among the survey questions, four seek to assess a subject’s willingness to disengage from a goal. They include the following:

• It’s easy for me to reduce my effort toward the goal.
• I find it difficult to stop trying to achieve the goal.
• I stay committed to the goal for a long time; I can’t let it go.
• It’s easy for me to stop thinking about the goal and let it go.

When these scores were compared against subject scores on the Beck Depression Inventory, it was noted that those subjects who indicated a greater willingness to disengage from prior goals tended to have fewer depressive symptoms.¹

Adding It All Up

Lower-limb amputation constitutes a major, life-altering event. The goals and ambitions that defined an individual’s life prior to the surgery may or may not be attainable in its wake. While the value of goals in defining the structure and purpose of an individual’s life is generally understood, in the presence of a dramatic acquired disability such as amputation, the ability to abandon some personal goals in favor of more attainable goals appears to be predictive of emotional well-being and adjustment to life with a prosthesis. From the standpoint of rehabilitation, there are certain goals that appear to be more important to patients than others. Similarly, there are certain goals that patients perceive as being more hindered by an amputation than others. In the first six months after amputation, these “disrupted” goals include considerations of safety and general health, the ability to smoothly accomplish ADLs, and the ability to retain a sense of self-confidence. An understanding of the importance of these goals following amputation may help the rehabilitation community target their interventions toward those things that appear to matter most to their patients.

Phil Stevens, MEd, CPO, FAAOP, is in clinical practice with Hanger Clinic, Salt Lake City, Utah. He can be reached at

References

1. Coffey, L., P. Gallagher, and D. Desmond. 2013. A prospective study of the importance of life goal characteristics and goal adjustment capacities in longer term psychosocial adjustment to lower limb amputation. Clinical Rehabilitation (published online before print).
2. Coffey, L. 2012. Goals, adaptive self-regulation, and psychosocial adjustment to lower limb amputation: A longitudinal study. PhD diss., Dublin City University, accessed September 13, 2013, doras.dcu.ie/17443/1/Laura_Coffey_ thesis_final_version_hard_copy_submitted.pdf
3. Maes, S., L. Ter Doest, and W. Gebhardt. 2002. The goal facilitation inventory: Factor structure and psychometric properties. Leiden University, Clinical and Health Psychology Section.
4. Wrosch, C, M. F. Scheire, G. E. Miller, et al. 2003. Adaptive self-regulation of unattainable goals: Goal disengagement, goal re-engagement, and subjective well-being. Personality and Social Psychology Bulletin 29 (12):1494–1508.