the large range of potential outcomes of interest, outcomes were not included in the search strategy. Rather, the above three search strings were used to capture all potentially relevant papers on older limbless veterans, with key outcomes highlighted during the initial phase of searching. Citation scanning was conducted for all papers included at the final stage. A special issue in the Journal of Rehabilitation Research and Development – in which one of the searched-for articles was published – was searched, and the authors also searched their personal collections of articles. Selection of studies, data extraction, quality assessment and synthesis of results For screening, article titles and abstracts were scanned for relevance by one reviewer and checked against the inclusion criteria by five members of the review team and discrepancies resolved by discussion. All relevant articles were subsequently read by three reviewers and a standardized data extraction form used to record key findings from each study. This form was also used to capture details on the type of study, location, and sample characteristics including age, gender, type/cause of amputation, and (where relevant) conflict in which limb trauma originated. Previous review studies (Bunn et al. 2008; Cattan et al. 2005; Wilson et al. 2016) as well as recognized assessment tools (CASP 2013; EPHPP 2010) were used to guide processes of quality assessment. For qualitative studies, judgments were based on the suitability of the research design and recruitment processes for addressing the study’s aims, the rigour of data collection and analysis processes, and whether there was a clear statement of the study’s findings (CASP 2013). For the quantitative studies, quality was determined by an overall assessment of the appropriateness of the study design and methods in relation to the study’s aims and objectives (Cattan et al. 2005). Studies were judged accordingly – by the same three reviewers who completed data extraction – as strong, moderate, or weak according to their methodological quality, and any discrepancies were resolved by discussion.
Sandinistas under the ‘Organization of Disabled Revolutionaries’ (ORD) sought to distance themselves from ‘other’ disabled people, preferring to emphasize their privileged status as ‘war heroes’. Their amputations were symbols of valor setting them apart from other disabled groups and protecting them from ‘stigmatized’ disabled identities. Sandinista veterans thereby adopted an ambiguous relationship to other disabled people: choosing to set themselves apart yet occasionally being compelled to identify with wider disability movements in order to gain access to benefits and resources. Meyers’ findings showed that the political and military context in which veterans were injured was an important feature of their long-term adjustment to ‘disability’ and negotiations around personal and social identity. By highlighting matters of social identity, Meyers also situated the study of older veteran amputees within the wider literature on critical disability studies (e.g., Meekosha and Shuttleworth 2009), which the literature on older veterans has otherwise yet to engage with. Indeed, one insight from Meyers’ paper – mirroring the perspective of disability scholars more broadly (Meekosha and Shuttleworth 2009) – was that disabled and amputee veterans were not a homogenous group in terms of their social identities and experiences of disability, and that various ‘intersecting’ identities (particularly in relation to age, gender, race, and combat-era) were important in understanding their lives. Estimating the long-term cost of prosthetic provision for limbless veterans In line with the aims of this systematic review to evaluate the long-term impact of limb-loss, three papers considered the long-term financial burden of prosthetic device provision required to meet veterans’ mobility needs (Blough et al. 2010; Edwards et al. 2015; Stewart and Jain 1999). Using Markov model analysis, Blough et al. (2010) projected the cost of prosthetic device provision for US veterans over 5 year, 10 year, 20 year and lifetime periods. Using the Survey for Prosthetic Use sample (see above), the authors contrasted the estimated the
None of the cost-estimate studies were, however, able to account for variations in the cost of care provision through chronic disease, age-related changes (e.g., in mobility), and comorbidities such as mental health problems that limbless veterans are likely to encounter ‘downstream’ (Geiling et al. 2012). As Geiling et al. (2012), in their commentary on the ‘medical costs of war in 2035’ put it, there was a need to consider the “secondary and tertiary consequences in middle age [which] might include decreased mobility, weight gain, coronary artery disease, and diabetes mellitus” (p. 1237). Accordingly, Geiling et al. emphasised the need for early interventions – including prevention and treatment measures – to help mitigate the likely additional costs to society. Indeed, as Edwards et al. (2015) also cautioned, their estimates should be considered merely as “the start of a challenge to develop sustained rehabilitation and recovery funding and provision” (p. 2854), and that ongoing assessment of injured soldiers and their care would be required as the population ages. Quality of the literature on ageing and limb-loss in veterans The literature as a whole is over-reliant on the self-report survey method (17/21 studies). Whilst many of these were large, well designed surveys which included comparison groups, there are limitations associated with this dependence on survey methodology. For instance, 11 studies discussed the potential representativeness of their samples, including questions over the presence of selection bias and differences between respondents and non-respondents. In particular, evidence that some veterans self-medicated with alcohol to deal with phantom pain (Sherman et al. 1983) and avoided contact with clinicians when treatments were deemed ineffective (Machin and Williams 1998), could indicate that non-respondents had potentially more severe problems with mental health or alcohol use. It could also be argued that the use of a single 5-point scale to assess quality of life within the VA survey for prosthetic use (2010) was an overly simplistic measure for a complex, multi-faceted construct. Whilst 11
Vietnam and OIF/OEF conflicts. Journal of Rehabilitation Research and Development, 47, 4, 299-316. Meekosha, H., and Shuttleworth, R. 2009. What’s so ‘critical’ about critical disability studies? Australian Journal of Human Rights, 15, 1, 47-76. Meyers, S. 2014. The social model of disability under the shadow of the revolution: negotiating identity in Nicaragua. Qualitative Sociology, 37, 4, 403-424. Messinger, S. 2010. Getting past the accident: Explosive devices, limb and refashioning a life in a military medical center. Medical Anthropology Quarterly, 24, 3, 281-303. Ministry of Defence. 2011 [Online]. The Forces Covenant. Available at: . [Accessed 02/03/17]. Mosher, D., Liberati, A., Tetzlaff, J., and Altman, D. 2009. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med, 6, 7: e1000097. Murray, C. 2005. The social meanings of prosthesis use. Journal of Health Psychology, 10, 3, 425-441. Murrison, A. 2011. A better deal for military amputees. Available at: [Accessed 02/03/17]. Norvell, D., Czerniecki, J., Reiber, G., Maynard, C., Pecoraro, J., and N. 2005. The prevalence of knee pain and symptomatic knee osteoarthritis among veteran traumatic amputees and nonamputees. Archives of Physical and Medical Rehabilitation, 86, 3, 487-93. Phoenix, C., Smith, B., and Sparkes, A. 2010. Narrative analysis in aging studies: A typology for consideration. Journal of Aging Studies, 24, 1, 1-11. Reiber, G., McFarland, L., Hubbard, S., Maynard, C., Blough, D., Gambel, J., and Smith, D. 2010. Servicemembers and veterans with major traumatic limb loss from Vietnam war
Key: AK = above knee; BK = below knee; CTD = Cumulative trauma disorder; OIF = Operating Iraqi Freedom (Iraq); OEF = Operation Enduring Freedom (Afghanistan); QoL = Quality of life. Table 1b: Summary of remaining studies included in systematic review Author, year and location of study Design and focus of study Participants: age (M(age)), sex, etiology of and time since limb loss (M(time)) Key findings 2 Desmond and MacLachlan (2006) UK Cross-sectional. Coping strategies and long-term psycho-social adaptation to lower limb-loss. N = 796 members of BLESMA with lower (96% male, M(age) = 74 yrs, M(time) = 42.6 yrs). 82.8% of amputations reported as traumatic etiology. Problem solving, seeking social support, and increasing time since amputation positively associated with adjustment to amputation. 3 Desmond (2007) UK Cross-sectional. Coping strategies and long-term psycho-social adaptation to upper limb-loss. N = 138 members of BLESMA with combat-related traumatic upper limb-loss (100% male, M(age) = 75 yrs, M(time) = 50 yrs). Avoidant coping strategies associated with psychological distress and poorer adjustment. 4 Dougherty (1999) USA Survey. Long-term outcomes for bilateral AK amputees from Vietnam War. 1. N = 23 Vietnam veterans with combat-related traumatic bilateral AK amputations (100% male, M(age) = 48 yrs, M(time) = 28 yrs). 2. N = 145 age and sex-matched controls Decreased physical functioning among Vietnam amputees. Majority had been employed since injury, yet few were current prosthetic users. 5 Dougherty (2001) USA Survey. Long-term outcomes for unilateral BK amputees from Vietnam War. 1. N = 28 Vietnam veterans with combat-related unilateral BK amputations 2. N = 44 Vietnam veterans with combat-related unilateral BK amputation plus ≥ 1 other major injury (1 and 2; 100% male, M(age) = 48 yrs, M(time) = 28 yrs) Veterans with additional (secondary) injuries had worse health outcomes and made more use of psychological support services.
Table 2: Prevalence of pain among older limbless veterans Type of pain Average % pain prevalence identified in reviewed studies No. of papers reporting prevalence statistics Phantom limb pain 17 – 90.8 14 Residual limb pain 32 – 92.2 10 Chronic back pain 8 – 76.6 9 Pain in contra-lateral knee amputees) 38 – 79.4 4 Prosthetic-related pain 33 – 51 3 Hip pain on ipsilateral (amputated) side in amputees 14.8 1 Knee pain on ipsilateral (amputated) side in BK amputees 13 1