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Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 
 

 
 

 

 

 

 

 

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 2019 

 

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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
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RESEARCH ARTICLE 

 

A DEPICTION OF REHABILITATION PATIENTS 65 YEARS AND YOUNGER WITH 
DYSVASCULAR LOWER EXTREMITY AMPUTATION 

 
Mayo A.L.1,2 *, Cimino S.R.3, Hitzig S.L.3,4,5  
 

1 
St. John’s Rehab, Sunnybrook Health Sciences Centre, Toronto, Canada. 

2 
Faculty of Medicine, University of Toronto, Toronto, Canada. 

3 St. John’s Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada. 
4 Rehabilitation Sciences Institute, Faculty of Medicine, University of Toronto, Toronto, Canada. 
5 

Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada. 

 

 

 

ABSTRACT 

BACKGROUND: The majority of lower limb amputations (LLA) in Canada are 

dysvascular due to complications of diabetes and/or vascular disease. 

Traditionally dysvascular amputations have occurred in the elderly. With younger 

onset of adult diabetes, amputations are now occurring in non-geriatric 

populations. An understanding of younger patients with dysvascular LLA is 

needed to determine their risk factors, and unique health and psychosocial 

challenges. 

OBJECTIVES: To obtain a depiction of the key demographic and impairment 

characteristics of adults 65 years and younger with dysvascular LLA undergoing 

inpatient rehabilitation. 

METHODOLOGY: A retrospective chart review was completed on inpatient adult 

amputation rehabilitation patients over a five year period. Data extracted included 

socio-demographics, Functional Independence Measure (FIM) scores, co-

morbidities, and discharge outcomes. 

FINDINGS: One hundred and forty-three patients who were 65 years and younger 

were included, which represented almost a quarter of all admissions. Most 

patients were male (79%) with an average age of 55 years old (SD=8). The 

majority (72%) were unemployed. The mean number of co-morbidities was  

5.2 (SD=8.2). Individuals discharged home (n=122) had higher (p<0.05) FIM 

scores than those readmitted to acute care or discharged to long-term care 

(n=20). 

CONCLUSIONS: Similar to the literature on older dysvascular LLA patients, our 

study found high rates of disability and co-morbidities in younger patients with 

dysvascular LLA, which might impact their ability to work. Given these challenges, 

better amputation prevention strategies and targeted rehabilitation programming 

for this population are needed. 

CITATION 

Mayo A.L, Cimino S.R, Hitzig 

S.L. A depiction of 

rehabilitation patients 65 years 

and younger with dysvascular 

lower extremity amputation. 

Canadian Prosthetics & 

Orthotics Journal. 2019; 

Volume2, Issue1, No.1. 

https://doi.org/10.33137/cpoj.v

2i1.31950 

 KEYWORDS 

Dysvascular, Limb loss, 

Amputation, outcomes, 

lower extremity, socio-

demographics, inpatient 

rehabilitation. 

*CORRESPONDING AUTHOR 

Amanda L. Mayo, MD, MHSc, FRCPC 

1) Physiatrist: St. John’s Rehab, 285 Cummer Avenue, Toronto, ON, Canada M2M 2G1; 2) Assistant Professor, Faculty of Medicine, University of 

Toronto, Toronto, Canada. 

Tel: 416.226.6780  

Email: amanda.mayo@sunnybrook.ca    

DOI: https://doi.org/10.33137/cpoj.v2i1.31950 

ARTICLE INFO 

Received: December 2, 2018 

Accepted: February 21, 2019 

Published: February 27, 2019 

 

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https://doi.org/10.33137/cpoj.v2i1.31950


 

 

Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
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INTRODUCTION 

Major lower limb amputation (LLA) is a life-altering 

event that can negatively affect an individual’s 

physical function, emotional well-being and quality of 

life.1 In North America, most LLA are dysvascular in 

etiology, resulting from the complications of diabetes 

mellitus, and/or vascular disease.2-4 A study on the 

total number of amputations done in Canada 

reported there were 5,342 persons (mean age  

67 (SD=13) years) who underwent LLA between 

2006 and 2009, with over 80% of the LLA being 

dysvascular in nature.3 Imam and colleagues2 also 

examined incidence of minor and major lower 

extremity amputation in Canada between 2006 and 

2012 and found 44,430 amputations were done in 

mostly male (69%) diabetic (65%) patients with a 

mean age of 65.7 (SD=16.6) years. The most 

common level of amputation was transtibial. Imam et 

al. also reported the incidence of Canadian diabetic 

LLA increased by 13% from 2006-2012.2  

Secondary complications associated with diabetes, 

such as renal failure, visual impairment, neuropathy, 

and cardiovascular disease can impact functional 

outcomes after amputation,5-8 as can depression, 

anxiety, and pain.9 Common health conditions 

impacting function of older adults include respiratory 

disease10 (e.g., Chronic Obstructive Pulmonary 

Disease),11,12 end-stage renal failure,13 stroke12 and 

cognitive impairment due to dementia.11 It has been 

reported that older adults with dysvascular LLA can 

have on average 6.5 co-morbidities.14 The 

dysvascular LLA population has a poor survival rate, 

with a 2-year mortality rate of 16%-56%,15 and a  

5-year survival rate of 23%-45%.14 These patterns of 

mortality have not changed in 40 years.16 

The worldwide incidence of diabetes is increasing, 

and is closely linked to the rising rates of adult 

obesity, sedentary lifestyle, and poor dietary habits.17 

Traditionally, dysvascular amputation has been 

associated with older age (over 65 years old).23 In 

Canada, an increased incidence of diabetes has 

been found to be the most significant in adults aged 

less than 50.18 Maturity onset diabetes of the young 

(MODY) has been associated with a more 

aggressive disease course and higher risk of end 

stage complications.19 A recent study by Geiss and 

colleagues20 found an increase in the rates of total, 

major, and minor amputations in the United States, 

which were most pronounced in young (age 18–44 

years) and middle-aged (age 45–64 years) adults.  

They also found that men also contributed to this 

increase in amputations due to diabetes while the 

rates for women and older adults have plateaued 

after having decreased in recent years.20  Adults who 

are younger than 65 years old with dysvascular 

amputations present unique challenges to 

healthcare and rehabilitation teams as these patients 

are in their employment years and may have 

complex family stressors.21,22 

To date, the majority of dysvascular LLA research 

has focused on older adults, and there is no existing 

Canadian data on LLA in younger adults. As a 

population of younger dysvascular LLA patients 

emerges, a better understanding of their 

characteristics is needed. Doing so will provide 

insight on whether their health can be modified to 

prevent amputation or promote better LLA long-term 

outcomes (e.g., prevention of a second amputation; 

decreasing early mortality, return to work, etc.). 

During the rehabilitation process, a large focus on 

the physical health of the patients is often taken and 

may not adequately address or acknowledge their 

psychosocial functioning.23 There is evidence that 

addressing mental and social issues within the LLA 

rehabilitation process can improve outcomes.24 

To help address gaps in knowledge of the younger 

adult dysvascular LLA patient population (65 years 

old and younger), the purpose of this study was to 

describe the key demographic and impairment 

characteristics of this understudied population. This 

data will help advance clinical knowledge to help 

identify younger dysvascular patients at risk of 

amputation and foster better approaches to 

rehabilitation and secondary prevention care. 

METHODOLOGY 

A retrospective chart review was conducted on 

patients who received inpatient amputation 

rehabilitation at an urban rehabilitation hospital, 

Sunnybrook Health Sciences Centre’s St. John’s 

Rehab (SJR), for a major dysvascular LLA. SJR 

provides extensive assessment, treatment and 

resources for health promotion to patients recovering 

from amputation. The large interprofessional team 

consists of physiatrists, hospitalist physician, 

prosthetists, psychiatrists, physiotherapists, 

occupational therapists, a social worker, a speech 

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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
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language pathologist and a dietician. SJR has 

approximately 125 new inpatient amputation 

admissions per year, and has a large outpatient 

services department to provide ongoing rehabilita-

tion and support post-discharge from inpatient 

rehabilitation. 

Data from charts from discharged inpatients over a 

five-year period (between October 31, 2012 and 

October 31, 2017) were extracted for review via the 

hospital’s decision support information management 

team. The information obtained included: socio-

demographics, impairment characteristics; 

admission and discharge Functional Independence 

Measure [FIM] score,25 co-morbidities and 

rehabilitation and/or discharge outcomes. All the 

data utilized for analysis is information typically 

collected from patients who participate in the 

rehabilitation program at SJR. Study approval was 

obtained by the research ethics board at the 

Sunnybrook Health Sciences Centre.  

Socio-demographic variables were comprised of 

sex, age at admission, and location of residence 

(urban or rural) as coded by Canada Post.26 

Amputation and impairment characteristics 

consisted of date of amputation, acute care setting 

location, dysvascular cause of amputation and 

characteristics of amputation (e.g. unilateral or 

bilateral and level of major LLA). A list of common co-

morbidities and secondary health conditions typically 

seen in the dysvascular LLA population (e.g. 

diabetes, hypertension, dyslipidemia, smoking, 

previous amputation, etc.) were recorded at 

discharge from rehabilitation and prevalence of each 

co-morbidity/condition was determined. A total 

number of co-morbidities and secondary health 

conditions score was created by summing each co-

morbidity/condition. In order to determine pain and 

pain management, the presence or absence of pain 

was recorded as were pain severity on admission 

and discharge. The pain severity score is a 

subjective patient reported rating used at SJR.  It is 

a pain scale that ranges from 0 to 3 (0=no pain; 

1=mild pain; 2=moderate pain; and 3=severe pain). 

The FIM is a basic indicator of patient disability. It is 

used to assess the changes in the functional ability 

of a patient during an episode of hospital 

rehabilitation care along two dimensions: motor (13 

items) and cognitive (5 items).27 FIM scores range 

from 18 to 126, with higher scores indicating higher 

levels of function.  The FIM was designed to be used 

across various disability groups and has been used 

in the LLA population.28-30 A study examining the 

psychometric properties of the FIM across 20 

impairment categories (including LLA) found the FIM 

sub-scales exceeded minimum criteria for item 

internal consistency in 96.9% of tests and item 

discriminant validity in 100% of tests.31 Further, the 

reliability coefficients ranged between 0.86 to 0.97 

across each impairment group for both subscales.31 

An improvement of 8 points on the FIM has been 

deemed to be clinically meaningful for patients 

undergoing specialized rehabilitation for LLA.32 For 

the present study, the FIM was collected upon 

admission to rehabilitation as well as on discharge. 

Outcomes related to rehabilitation and discharge 

included the date the patient was ready for 

rehabilitation, date of inpatient admission, date of 

inpatient discharge, time to rehabilitation and active 

length of stay (LOS). Employment status was 

collected prior to admission as well as on discharge. 

It was separated into two categories employed  

(full-time, part-time, adjusted/modified, unpaid 

employment or student) and unemployed (retired, 

unemployed, on disability). Living situation prior to 

admission and discharge destination was also 

determined. Discharge destination included return to 

home, retirement home, hospital transfer (to acute 

care for medical instability), residential care facility, 

or long-term care home. 

Participants 

Adult patients from age 18 to 65 admitted to SJR for 

inpatient amputation rehabilitation following a major 

dysvascular LLA (transfemoral, knee disarticulation, 

transtibial, or ankle disarticulation level) between 

October 31, 2012 and October 31, 2017 were eligible 

for inclusion. Patients with non-dysvascular 

amputations from trauma, cancer, burns, or non-

diabetic related infection were excluded. Minor 

amputations (partial feet and toe amputations) were 

excluded as were patients who underwent an upper 

extremity amputation. 

Data Analysis 

Frequencies and descriptive statistics were 

calculated for the data. To compare within group 

differences (e.g., rural vs. urban LLA patients) on 

certain outcomes (e.g., FIM change score; pain 

intensity), chi-square (or Fisher’s exact test) and 

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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
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paired t-tests were utilized. As well, correlations were 

used to examine relationships between variables. 

RESULTS  

From October 31, 2012 to October 31, 2017; a total 

of 643 patients with LLA were admitted to SJR for 

inpatient amputation rehabilitation. Of those, four-

hundred and ninety-six did not meet the inclusion 

criteria due to either being older than 65 years of age 

or because they had a non-dysvascular etiology 

(e.g., trauma), an upper-extremity amputation or 

minor LLA. Hence, one-hundred and forty-three 

patients were included for study chart review (22%). 

It should be noted that four patients were re-admitted 

for inpatient rehabilitation during this time period but 

there was no change in their level of amputation 

across both hospital admissions. 

The sociodemographic and impairment characte-

ristics are presented in TABLE 1. The average age at 

amputation was 55 (SD=8) years, with an age range 

of 21 to 65 years old. Twenty percent of patients were 

younger than 50, 47% were aged 50 to 59 years, and 

the remaining 33% were aged 60 to 65 years. The 

vast majority of patient amputations (n=138, 96%) 

were due to chronic complications of diabetes and/or 

vascular disease including infections, ulcers, chronic 

ischemia and gangrene.  Only five patients had acute 

vascular events leading to amputation. Four of the 

five acute patients had acute emboli/thrombosis 

leading to LLA. The other acute patient was in their 

thirties and had a LLA resulting from dissection of a 

vascular aneurysm. Eighteen patients had a previous 

amputation. Of those with a previous amputation, the 

majority (n=12, 67%) were between the ages of 50 

and 59. No details were available if the previous 

amputations were minor or major in nature. 

FIGURE 1 highlights the top ten most common  

co-morbidities/secondary health conditions found in 

our cohort. On average, patients had five co-

morbidities/secondary health conditions (SD=2.4), 

with 27.2% having at least 7 co-morbidities/ 

conditions (see FIGURE 2). Other co-morbidities 

included obesity (n=21), and respiratory disease 

(n=15). Fourteen patients had documented 

psychiatric conditions, such as bipolar disorder 

(n=4), schizophrenia (n=1), adjustment disorder 

(n=2) and drug addiction (n=7). 8.4% of patients had 

a clinical diagnosis of depression and 2.8% were 

diagnosed with an anxiety disorder. When examining 

relationships between key demographic and 

impairment characteristics with co-morbidities/ 

secondary health conditions, patients 50 years of 

age and older (n=115) were more likely to have 

atherosclerosis (47%; p<0.05) than those who were 

younger than 50 years of age (n=28), with only 21% 

having the condition. As well, patients 50 years of 

age and older were more likely to have heart disease 

(30%; p<0.05) than those who were less than 50 

years of age (7%). Conversely, patients younger 

than 50 years of age were more likely to have 

osteomyelitis leading to amputation (14%; p<0.01) 

than the older cohort (1%). Notably, the proportion of 

those from rural settings (n=11) were more likely to 

have a pressure ulcer (55%; p<0.05) than those from 

urban settings (n=132; 28%).  

 

TABLE1: Sample demographic and impairment characteristics  

(n=147). 

 

 

Variable Frequency (%) 

Sex  

 
• Male 113 (79.0%) 

• Female 30 (21.0%) 

Language  

 
• English speaking 140 (97.9%) 

• Non-English speaking 3 (2.1%) 

Level of amputation  

 

• Above knee 30 (21.0%) 

• Below knee 109 (76.2%) 

• Bilateral above knee 1 (0.7%) 

• Bilateral below knee  2 (1.4%) 

• Bilateral (one leg AK; one leg BK) 1 (0.7%) 

Pre-rehab admission living situation  

 • Home 143 (100%) 

Rehab discharge living situationa  

 

• Home 122 (85.3%) 

• Acute care 15 (10.5%) 

• Long-term care 5 (3.5%) 

Geographic region  

 
• Urban 132 (92.3%) 

• Rural 11 (7.7%) 

Employment statusa  

 

• Employed at time of rehab 
admission 

  40 (28.0%) 

• Unemployed at time of rehab 
admission 

102 (72.1%) 

• Employed at time of rehab 
dischargeb 

16 (11.2%) 

• Unemployed at time of rehab 
discharge 

109 (76.2%) 

a Data missing for one participant;  

b Data missing for 18 participants; 

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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
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FIGURE 1: Top 10 most common co-morbidities/secondary health 

conditions.  

 

FIGURE 2: Total number of co-morbidities. Note: Maximum 

number of co-morbidities was 13.  

In regards to pain, 122 persons had completed pain 

rating scores at both admission and discharge, with 

86.1% having pain on admission to rehabilitation and 

64.8% had pain still present on discharge. Further, 

for those with both a pain admission and pain 

discharge severity score (n=122), patients with mild 

pain had similar pain scores, but the pain intensity 

scores decreased for the moderate and severe 

groups (FIGURE 3). 

 

FIGURE 3: Frequency of pain severity ratings at admission and 

discharge. (N=122 patients) 

In terms of LOS, the sample was admitted to 

inpatient rehabilitation on for average 35.9 (SD=15)  

days, with a mean FIM admission score of  

86.9 (SD=11.1) and FIM discharge score of 107.6 

(SD=8.5). FIM discharge scores were not completed 

for 13 persons. When examining various socio-

demographic factors on outcomes, the proportion of 

women (n=3) who had undergone a bilateral 

amputation was higher than the proportion of men 

(n=1; p<0.05). There were no differences in FIM 

scores between men and women. Men were 

significantly older (M=56.0; SD=7.5; t[141]=2.3,  

p<0.05) than women (M=52.2; SD=10.0).  Older age 

was associated with a lower FIM discharge score 

(r=-0.21, p<0.05).  

Having more co-morbidities/secondary health 

conditions was associated with a lower FIM 

admission score (r=-0.20, p<0.05), and lower FIM 

discharge score (r=-0.24, p<0.01). Similarly, having 

more co-morbidities/conditions was associated with 

a longer LOS (r=-0.19, p<0.05). Those who were 

discharged to home (n=122) had higher FIM 

admission scores (M=87.9; SD=10.3) than those 

who were discharged to an acute care or long-term 

care setting (n=20; M=80.8; SD=14.0; t[22.5]=2.2,  

p<0.05). 

DISCUSSION  

The present study is the first Canadian study, to our 

knowledge, to examine the specific characteristics of 

a younger cohort of adult patients with a dysvascular 

LLA. Almost a quarter (22%) of our LLA admissions 

over a five year period were 65 years old and 

younger, which might be representative of the 

dropping age of onset of adult diabetes in Canada.12 

It may also reflect the more aggressive nature of 

mature onset diabetes in the younger population as 

well as premature atherosclerosis.18,19,33 Our findings, 

along with those of Geiss et al.20 who also found an 

increasing rate of younger adults with diabetes 

undergoing amputation, illustrates a disturbing trend.  

Younger dysvascular LLA patients may have 

different psychosocial challenges, such as 

employment and childcare responsibilities, than 

geriatric patients.21 To maximize return of function 

and community reintegration post-amputation, 

rehabilitation programs must address the unique 

needs of younger dysvascular patients. Adding to the 

complexity is that our younger cohort still had high 

rates of medical co-morbidities similar to the rates 

3

14

30

22
20

15

19

8
6

4

0

8

15

23

30

38

1 2 3 4 5 6 7 8 9 10 +

N
u
m

b
e
r 

o
f 
p
a
ti
e

n
ts

Number of co-morbidities

30

45

3031 32

16

0

13

25

38

50

Mild Moderate Severe

N
u
m

b
e
r 

o
f 

p
a
ti
e
n
ts

Admission Discharge

85

82

72

60

46

36

35

31

26

24

0 23 45 68 90

Diabetes

Hypertension

Anaemia

Arthersclerosis

Phantom Limb Pain

Other heart disease

Hypercholesterolemia

Pressure ulcer

Renal

Bowel and bladder problems

Number of Patients 

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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

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described in the geriatric dysvascular LLA 

population.34,35 Long-term outcomes, including 

mortality, of the younger dysvascular patient has yet 

to be studied. 

Although rates of depression and anxiety (11%) were 

relatively low in our cohort, another 10% of our 

patients had a chronic mental health diagnosis 

(schizophrenia, bipolar disorder, adjustment 

disorder, addiction), with four of them having co-

morbid depression and/or anxiety. Thus, over a fifth 

of the patients had documented significant mental 

health issues.  Mental health issues are important to 

monitor in patients with limb loss since sequelae of 

mood issues post-amputation include low self-worth, 

impaired body image36 and high rates of suicidal 

ideation.37 Previous studies have shown that the 

rates of depression post-amputation can be as high 

as 60%.38 Depression post-LLA is associated with 

lower prosthetic use, higher perceived vulnerability, 

and lower self-rated overall health.39 The lower rates 

of depression and anxiety in our inpatient 

rehabilitation population may be supportive of 

previous evidence highlighting that depression and 

anxiety is exacerbated upon discharge to the 

community.40 Future studies should track the long-

term psychosocial outcomes of this cohort since 

depression and anxiety can negatively influence 

outcomes in a number of domains. 

Despite being in the typical Canadian working age 

range (18-65 years), our cohort had high rates of 

unemployment (72%) at time of rehab admission, 

and that increased slightly at discharge (76%). This 

is consistent with previous findings that diabetic foot 

ulcers and amputations are associated with high 

rates of disability and unemployment.41-43 In a recent 

study of patients with diabetic foot ulcers, only 12% 

had full-time employment.43 Often mobility is limited 

months prior to dysvascular amputation due to 

wounds, pain, restricted weight-bearing, and/or 

offloading casts.44 It is possible that the individuals 

described in this study may have returned to work 

after a certain recovery period but there several 

issues that makes this process challenging. Most 

notably is that return to work after amputation is often 

limited by lack of accommodations and inaccessible 

workplaces.42 As well, our cohort had on average five 

co-morbidities, and a high number of co-morbidities 

has been shown to be a negative prognosis for 

employment.42,43 The rates of unemployment in this 

population is concerning as employment is 

associated with higher health related quality of life.42 

Vocational retraining and/or work modifications may 

be needed for LLA patients with labour intensive 

occupations while those with office jobs or sedentary 

occupations typically have higher rates of return to 

work after LLA.45 Overall, there is a need to ensure 

better employment opportunities and/or financial 

supports for the dysvascular LLA population. 

There were significant differences found between 

male and female LLA patients, with men being on 

average four years older than women, and women 

being more likely to have bilateral amputations. 

Despite the women in the study being younger, both 

sexes reached the same average FIM score by 

rehabilitation discharge. Our findings suggest that 

females with diabetes and/or vascular disease have 

younger onset amputation risk, but further work is 

needed to explore this given the small number of 

women (n=30) in our cohort.  Overall, there is a 

paucity of literature comparing dysvascular LLA 

between males and females, and there is a need for 

more research to examine in detail sex and gender 

differences.  

In keeping with previous studies, most patients were 

able to return home post inpatient rehabilitation.45 

Patients with higher number of co-morbidities had 

longer rehabilitation stays and were more likely to be 

discharged back to acute care for medical instability. 

Discharge to long-term care was also associated 

with higher number of co-morbidities. Co-morbidities 

of chronic heart failure and renal failure/dialysis have 

poor prognosis for independent living, morbidity and 

mortality in the dysvascular LLA population.46 

Rehabilitation teams must take into consideration the 

number of co-morbidities when planning 

rehabilitation intensity, LOS, community care needs 

and discharge destination planning. 

There are several limitations with the data that 

should be acknowledged. The data from the charts 

were extracted via a trained healthcare data analyst 

from the hospital system. As a result, there are likely 

some additional data from the charts that would have 

provided a richer clinical description of the sample, 

such as details regarding those who had undergone 

a previous amputation. There were also some 

instances of missing data, which may have affected 

some of the results (e.g., missing discharge 

destination, missing discharge FIM scores, etc.). 

Given the noted high rates of mortality in the overall 

https://doi.org/10.33137/cpoj.v2i1.31950
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Mayo A.L, Cimino S.R, Hitzig S.L. A depiction of rehabilitation patients 65 years and younger with dysvascular lower extremity 

amputation. Canadian Prosthetics & Orthotics Journal. 2019; Volume2, Issue1, No.1. https://doi.org/10.33137/cpoj.v2i1.31950 
7 

 
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DYSVASCULAR LOWER EXTREMITY AMPUTATION 

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dysvascular LLA population (including those over 65 

years old),15 it would have been informative if we 

were able to collect mortality data. Future studies 

should examine this issue to determine if younger 

dysvascular LLA have the same high rates of 

mortality as those over age 65. More importantly, 

future studies should directly examine differences 

between younger (65 years and younger) and older 

adults (over 65 years old) across a variety of 

functional, health and psychosocial domains to better 

understand their rehabilitation needs.  Despite the 

limitations of this dataset, the findings from this study 

provide some considerations for planning future 

research and highlight clinical issues for advancing 

knowledge and care for this population. 

CONCLUSION 

This study demonstrated that approximately one 

quarter of individuals with dysvascular LLA admitted 

to inpatient rehabilitation are 65 years and younger. 

This younger proportion of the LLA population will 

continue to increase if the age of diabetes onset 

continues to decrease. A higher number of co-

morbidities in dysvascular LLA is associated with 

longer rehabilitation LOS, lower FIM scores, and 

higher care needs on discharge from rehabilitation. 

Rates of unemployment were high in our young 

dysvascular LLA patient cohort. More resources 

(e.g., education) are needed to prevent LLA in this 

population given the functional, psychological, 

financial impacts of amputation, and high rates of 

mortality. Rehabilitation programs for LLA may need 

to evolve to incorporate appropriate programming for 

younger dysvascular patients including return to 

employment.   

ACKNOWLEDGEMENTS 

We would like to thank Grace Liu, NRS Coordinator 

in Clinical Informatics at St. John’s Rehab and Marie 

Disotto-Monastero, Manager in Clinical Informatics 

at St. John’s Rehab, for their time in extracting the 

data. We would also like to thank Jorge Rios, Lab 

Manager at St. John's Rehab Research Program, for 

his support in preparing the manuscript. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors have no conflicts of interest to declare. 

 

SOURCES OF SUPPORT 

Funding for this study was provided by the St. John’s 

Rehab Research Program, Sunnybrook Research 

Institute. 

ETHICAL APPROVAL 

Study approval was obtained by the research ethics 

board at the Sunnybrook Health Sciences Centre. 

AUTHOR CONTRIBUTION 

• Amanda L. Mayo,  

conceived the idea for the project, supported the 

data analysis, and led the writing of the manuscript. 

• Stephanie R. Cimino, 

managed the data files, supported the writing of the 

manuscript, and provided insights into the 

interpretation of the data. 

• Sander L. Hitzig, 

conducted the statistical analyses, and supported 

the writing of the manuscript. 

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