







































All articles are permanently available online to the public without restrictions or subscription 

fees. All articles are free to be used, cited, and distributed, on condition that appropriate 

acknowledgment is included. Authors are the copyright holders of their original 

contributions and grant the Canadian Prosthetics & Orthotics Journal (CPOJ) a license to 

publish the article and identify itself as the original publisher. CPOJ articles are licensed 

under the Creative Commons Attribution 4.0 International License.   

 

CPOJ Website: https://jps.library.utoronto.ca/index.php/cpoj/index 

Editorial Office: cpoj@online-publication.com    

ISSN: 2561-987X 

CPOJ is a member of, and subscribes to the principles of, the Committee on Publication 

Ethics (COPE).   

 

 

VOLUME 3, ISSUE 1 

 2020 

 

 

RESEARCH ARTICLE 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 

Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1. https://doi.org/10.33137/cpoj.v3i1.33916 

http://creativecommons.org/licenses/by/4.0/
https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
https://publicationethics.org/about/our-organisation
https://publicationethics.org/about/our-organisation
https://doi.org/10.33137/cpoj.v3i1.33916


 

1 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

 

 

 
RESEARCH ARTICLE 

 

COMORBIDITY AND NON-PROSTHETIC INPATIENT REHABILITATION OUTCOMES AFTER 
DYSVASCULAR LOWER EXTREMITY AMPUTATION   

 
Marquez M.G1, Kowgier M2, Journeay W.S3,4,*         
 

1 Department of Anatomy and Cell Biology, McGill University, Montreal, Canada. 
2 Dalla Lana School of Public Health, University of Toronto, Toronto, Canada. 
3 Providence Healthcare – Unity Health Toronto, Toronto, ON, Canada. 
4 Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Canada. 

 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

The primary risk factors for lower extremity amputation 

(LEA) are diabetes and peripheral arterial disease along 

with associated dysvascular complications.1-4 When 

combined, peripheral arterial disease and diabetes are 

associated with greater than 80% of LEA in Canada 4,5 and 

recent population-based research by Hussain et al.,6 

demonstrated that diabetes-related amputations are on the 

rise. Moreover, patients with dysvascular limb loss often 

carry a burden of comorbidity including cognitive 

impairment and heart failure among others which can 

potentially further impact recovery and function in 

hospitalized patients after amputation.7,8 

After a LEA, patients may be discharged to inpatient 

rehabilitation, specialized nursing facilities, or directly home, 

 
OPEN  ACCESS Volume 3, Issue 1, Article No.1. 2020 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

BACKGROUND: Dysvascular amputations arising from peripheral vascular disease and/or diabetes are 

common. Patients who undergo amputation often have additional comorbidities that may impact their 

recovery after surgery. Many individuals undergo post-operative inpatient rehabilitation to improve their 

non-prosthetic functional independence. Thus far, our characterization of comorbidity in this population 

and how it is associated with non-prosthetic inpatient functional recovery remains relatively unexplored. 

OBJECTIVE: The objective of this study was to describe comorbidities, using the Charlson Comorbidity 

Index (CCI), and to examine associations between comorbidity and functional outcomes in a cohort of 

patients with dysvascular limb loss  undergoing non-prosthetic inpatient rehabilitation.  

METHODOLOGY: A retrospective cohort design was used to analyze a group of 143 patients with 

unilateral, dysvascular limb loss who were admitted to inpatient rehabilitation.  Age, sex, amputation 

level, amputation side, length of stay (LOS), time since surgery, Functional Independence Measure (FIM) 

scores (Total and Motor at admission and discharge), and CCI scores were collected.  

FINDINGS:  The data showed that neither total or specific comorbidities were associated with functional 

outcomes or LOS in this cohort and rehabilitation model. Multivariate analysis demonstrated an inverse 

relationship with age and FIM scores, where increased age was associated with lower Total and Motor 

FIM at admission and discharge. Comorbidities were not associated with functional outcomes. Dementia 

was negatively associated with FIM scores, however this requires more study given the low number of 

patients with dementia in this cohort.  

CONCLUSION: These data suggest that regardless of burden of comorbidity or specific comorbidities 

that patients with dysvascular limb loss may derive similar functional benefit from post-operative non-

prosthetic inpatient rehabilitation. 

ARTICLE INFO 

Received: March 29, 2020 

Accepted: May 8, 2020 

Published: May 16, 2020 

CITATION 

Marquez M.G, Kowgier M, 

Journeay W.S. Comorbidity 

and non-prosthetic inpatient 

rehabilitation outcomes after 

dysvascular lower extremity 

amputation. Canadian 

Prosthetics & Orthotics 

Journal. 2020;Volume3, 

Issue1, No.1. 

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

v3i1.33916 

KEYWORDS 

Amputation, Comorbidity, 

Dysvascular, Inpatient 

Rehabilitation, Charlson 

Comorbidity Index, 

Functional Independence 

Measure, Diabetes, Limb 

Loss, Rehabilitation, 

Amputee. 

 

* CORRESPONDING AUTHOR: 
Dr. W. Shane Journeay, PhD, MD, MPH, FRCPC, BC-Occ Med  
Providence Healthcare – Unity Health Toronto,  
3276 St Clair Avenue East, Toronto ON M1L 1W1 
E-mail: shane.journeay@utoronto.ca 
ORCID: https://orcid.org/0000-0001-6075-3176 
 

https://doi.org/10.33137/cpoj.v3i1.33916
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v3i1.33916
https://doi.org/10.33137/cpoj.v3i1.33916
https://orcid.org/0000-0001-6075-3176


 

2 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
with the destination contingent on factors such as the 

patient’s age, level of amputation, and family support9-12 as 

well as the location and availability of rehabilitation facilities. 

Inpatient rehabilitation is particularly beneficial as it 

correlates to fewer additional amputations, reduced 

mortality, a greater probability of receiving a prosthesis, and 

improved medical stability.10,13 Regardless of one’s 

prosthetic candidacy, patients undergoing amputation have 

a number of post-operative rehabilitation needs including 

transfer training, wheelchair skills and contracture 

prevention. A patient’s stay in inpatient rehabilitation and 

medical status after surgery may be impacted not only by 

the amputation, but also by other comorbidities they may 

have.12 To date, few studies have examined comorbidity in 

patients with dysvascular limb loss  and/ its association with 

functional outcomes and length of stay in the non-prosthetic 

inpatient rehabilitation setting. 

A measure that can be used to quantify comorbidity is the 

Charlson Comorbidity Index (CCI).14,15 In the classical chart 

review version of the CCI, it is split into individual conditions, 

each assigned a weighted score of either 1, 2, 3, or 6. A 

higher total score indicates a greater burden of 

comorbidities and a higher risk of mortality in hospitalized 

patients. The Functional Independence Measure (FIM) is a 

standardized indicator of functional progress in the inpatient 

rehabilitation setting and such data can be readily obtained 

from rehabilitation hospital data reporting systems.16,17 

Given its common use in inpatient rehabilitation settings, the 

FIM can be used as a clinical marker to reflect progression 

in self care, transfers and wheelchair independence needed 

before non-prosthetic discharge. 

The majority of prior studies have catalogued common 

comorbidities without using an established index or they 

employed various measures of functional outcome outside 

of the inpatient non-prosthetic setting. For example, 

Melchiorre et al.8 have investigated the relationship between 

comorbidities and rehabilitation for patients with LEA. 

However, their work focused on amputations of etiology that 

were both traumatic and vascular. They used a modified 

CCI in order to reflect their study sample, and looked at 

correlations with length of stay (LOS) and FIM scores. 

Chopra et al.18 also studied the relationship between 

comorbidities and functional outcomes in patients with lower 

extremity amputation. Their study did not focus on inpatient 

rehabilitation, as most of their cohort were discharged to 

skilled nursing facilities. They measured function by 

observing patient independence with activities of daily living 

(ADL) and ambulation. They did not use the CCI, but tallied 

several specific comorbidities. Vogel et al.,7 looked at the 

impact of amputation and comorbidities using the CCI in 

nursing home residents with LEA. Due to the elderly cohort 

and their disposition in a nursing home, the treatment 

provided was more residential rather than focused 

predominantly on post-operative, non-prosthetic 

rehabilitation. They also measured function with 

performance of ADLs. Cheng et al. found no association of 

comorbidity with unplanned discharge or functional gains 

however they utilized specific medical predictors rather than 

an index such as the CCI.19 The role of comorbidity is 

increasingly an important area of study as even in patients 

with dyvascular limb loss  under the age of 65 years old 

there exists a high burden of comorbidity.20  

While there has been previous work concerning the role of 

comorbidity on prosthetic rehabilitation outcomes, there has 

not been a more comprehensive look into the distinct 

components of the CCI and its association with inpatient 

non-prosthetic rehabilitation outcomes including the FIM 

and LOS. Thus, with increasing rates of amputation related 

to diabetes6 and a greater number of patients needing 

rehabilitation,12 this remains a relevant topic to explore. 

Therefore, the purpose of this study was to describe 

comorbidities, using the CCI, and to examine associations 

between comorbidity, functional outcomes and LOS in a 

cohort of patients with dysvascular lower limb loss 

undergoing non-prosthetic inpatient rehabilitation. 

METHODOLOGY 

This was a retrospective cohort study and was approved by 

the Research Ethics Board of Providence Healthcare and 

closed by the Unity Health Toronto Research Ethics Board. 

All patients with a LEA that were discharged from our 

rehabilitation hospital between January 1, 2014 and March 

30, 2018 were identified and their medical records were 

reviewed. Inclusion criteria for the study consisted of those 

with a recent unilateral, transfemoral (TF) or transtibial (TT) 

amputation. Only those amputations with a dysvascular or 

diabetic cause were included, and those due to trauma, 

cancer or other reasons were excluded. Those receiving 

hemodialysis were also excluded from this study as data 

from this group was used in a separate comparative study. 

Inclusion and exclusion criteria were developed to establish 

a uniform data set of the most common reason for 

admission to post-amputation rehabilitation (dyvascular 

amputation). Patients who met inclusion criteria but had an 

incomplete data set were excluded.  

All data retrieved from medical records came from both 

physical charts and electronic files utilized by Health 

Information Management at the hospital. The rehabilitation 

model at this institution involved post-operative 

interdisciplinary rehabilitation including physiotherapy, 

occupational therapy, nursing, wound care and physiatry 

consultation. The focus of rehabilitation for these patients 

was non-prosthetic rehabilitation only which includes but is 

not limited to; wound care, standing tolerance, contracture 

prevention, transfers and wheelchair skills. Patients were 

discharged home after non-prosthetic rehabilitation and 

then revisited regarding prosthetic candidacy and gait 

training at a later date. Data that was extracted from the 

medical records included age, sex, amputation level, 

https://doi.org/10.33137/cpoj.v3i1.33916


 

3 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
amputation side, surgery date, LOS in inpatient 

rehabilitation, FIM scores at admission and discharge,16,17 

and CCI scores.14,15 The authors are aware that the CCI was 

initially used as an epidemiological tool to predict mortality 

in patients admitted to hospital. However, we have selected 

it as a standardized method in which to catalogue 

comorbidities.  

Each patient was reviewed using the CCI  and assigned 

points for the individual conditions, then given a total score. 

These scores were based on information present upon their 

admission and any past medical history that was 

documented in the chart. The time since surgery was also 

recorded by calculating the number of days between the 

surgery date and the admission date to inpatient 

rehabilitation. LOS in rehabilitation was calculated from 

admission date to discharge date. Total FIM, and total motor 

FIM information was retrieved from admission and 

discharge data. We included motor FIM because in the non-

prosthetic phase of rehabilitation, the motor FIM scores 

would  reflect acquisition of independence with transfers 

and wheelchair mobility as this study did not examine 

prosthetic gait outcomes.   

Statistical Methods 

Continuous variables were summarized by observed means 

with standard deviation (SD) and categorical variables were 

summarized by frequency counts (percentages). Univariate 

and multivariate linear regression analyses were used to 

investigate the effect of comorbidities on each of the 

outcomes of Total and Motor FIM at both admission and 

discharge as well as LOS. Multiple regression analysis 

adjusted for clinically relevant variables including age and 

sex as well as any comorbidities showing statistical 

association (p < 0.05) in univariate analysis. Data was 

analyzed using the R statistical software (version 3.5.1). 

RESULTS 

All patients admitted with a diagnosis of LEA from January 

1, 2014 to March 30, 2018 were identified by our medical 

records team for a total of 382 charts.  Three patients were 

excluded due to death prior to discharge. Four patients were 

excluded due to incomplete admission to discharge data 

sets. Twenty-five patients were excluded due to 

hemodialysis. Two hundred and seven charts were 

excluded by not meeting inclusion criteria such as: etiology 

of amputation (i.e. not dysvascular), had bilateral 

amputations, or were not TT or TF level amputations (i.e. 

only forefoot or toe amputation), or were not admitted post-

operatively but rather for other reasons such as gait training 

or other medical conditions. There was a total of 143 

patients who met inclusion criteria and were analyzed 

(Table 1).  

The majority of the cohort was male (66%) and the mean 

age was 68 years old. Most of the cohort had a TT level 

amputation (59%). Ninety-five percent of the cohort had 

peripheral vascular disease (PVD), 68% had diabetes 

mellitus (DM), 87% had hypertension (HBP), and 42% had 

a skin ulcer. Table 1 presents further descriptive data, along 

with the distribution of the rest of the individual comorbidity 

scores. 

Table 1:  Cohort characteristics and Charlson Comorbidity Index.  

  
  

Cohort 
n = 143 (%) 

Age (years) 67.7 (SD 11.1) 

Sex 
 M 95 (66) 

 F 48 (34) 

Amputation 
Level 

Transfemoral 59 (41) 

Transtibial 84 (59) 

Amputation 
Side 

Left 69 (48) 

Right 74 (52) 

Length of stay in rehabilitation (LOS) 33.9 (SD 18.6) 

Time since surgery to admission  (days) 15.2 (SD 13.8) 

    

FIM scores 

Overall Total Admission 72.6 (SD 14.4) 

Overall Total Discharge 97.5 (SD 14.3) 

Motor Total Admission 42.7 (SD 12.0) 

Motor Total Discharge 66.9 (SD 11.4) 

Efficiency 0.9 (SD 0.5) 

    

Charlson Total 4.7 (SD 1.7) 

Charlson 
Comorbidity 
Index items 

 Peripheral Vascular Disease 136 (95) 

 High Blood Pressure 124 (87) 

 Diabetes Mellitus 78 (55) 

 Skin Ulcer 60 (42) 

Chronic Obstructive Pulmonary 
Disease 

31 (22) 

Myocardial Infarction 27 (19) 

Cerebrovascular Accident 19 (13) 

Diabetes Mellitus - End Organ 19 (13) 

 Congestive Heart Failure 16 (11) 

 Depression 13 (9) 

Cancer / Malignancy 9 (6) 

 Warfarin 9 (6) 

 Peptic Ulcer Disease 6 (4) 

 Dementia 6 (4) 

Rheumatic Disease 4 (3) 

  Renal Disease 3 (2) 

  Mild Liver Disease 1 (1) 

  Mod-Sev Liver Disease 2 (1) 

  Metastatic cancer 1 (1) 

Human Immunodeficiency 
Virus 

0 (0) 

Hemiplegia 0 (0) 

 

https://doi.org/10.33137/cpoj.v3i1.33916


 

4 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

    

F
IM

 T
o

ta
l 

A
d

m
is

s
io

n
 

F
IM

 T
o

ta
l 

D
is

c
h

a
rg

e
 

F
IM

 M
o

to
r 

A
d

m
is

s
io

n
 

F
IM

 M
o

to
r 

D
is

c
h

a
rg

e
 

L
e

n
g

th
 o

f 
S

ta
y
 (

L
O

S
) 

B
e

ta
 

C
I 

P
-

v
a

lu
e

 
B

e
ta

 
C

I 
P

-
v
a

lu
e

 
B

e
ta

 
C

I 
P

-
v
a

lu
e

 
B

e
ta

 
C

I 
P

-
v
a

lu
e

 
B

e
ta

 
C

I 
P

-
v
a

lu
e

 

S
e

x
 (

 F
e

m
a

le
 v

s
 M

a
le

) 
-3

.5
1
 

[(
-8

.4
9
) 

- 
(1

.4
7
)]

 
0

.1
7

0
 

-3
.0

6
 

[(
-8

.0
1
) 

- 
(1

.9
0
)]

 
0

.2
2

9
 

-4
.3

6
 

[(
-8

.4
6
) 

- 
(-

0
.2

5
)]

 
0

.0
4

0
* 

-3
.8

6
 

[(
-7

.7
7
) 

- 
(0

.0
5
)]

 
0

.0
5

5
 

-1
.0

4
 

[(
-7

.5
3
) 

- 
(5

.4
4
)]

 
0

.7
5

3
 

A
m

p
 S

id
e

 (
 L

e
ft

 v
s
 R

ig
h

t)
 

-1
.4

7
 

[(
-6

.2
0
) 

- 
(3

.2
7
)]

 
0

.5
4

5
 

-1
.8

9
 

[(
-6

.5
8
) 

- 
(2

.8
1
)]

 
0

.4
3

3
 

-0
.1

3
 

[(
-4

.0
7
) 

- 
(3

.8
1
)]

 
0

.9
4

8
 

-1
.2

5
 

[(
-4

.9
9
) 

- 
(2

.4
9
)]

 
0

.5
1

3
 

3
.6

0
 

[(
-2

.5
0
) 

- 
(9

.7
0
)]

 
0

.2
4

9
 

A
m

p
 L

e
v
e

l 
( 

T
F

 v
s
 T

T
) 

-3
.0

6
 

[(
-7

.8
4
) 

- 
(1

.7
3
)]

 
0

.2
1

3
 

-1
.9

2
 

[(
-6

.6
9
) 

- 
(2

.8
5
)]

 
0

.4
3

1
 

-3
.0

5
 

[(
-7

.0
2
) 

- 
(0

.9
2
)]

 
0

.1
3

4
 

-2
.7

8
 

[(
-6

.5
5
) 

- 
(0

.9
9
)]

 
0

.1
5

1
 

-2
.1

9
 

[(
-8

.3
9
) 

- 
(4

.0
2
)]

 
0

.4
9

1
 

 A
g

e
 

-0
.5

8
 

[(
-0

.7
8
) 

- 
(-

0
.3

9
)]

 
0

* 
-0

.4
7
 

[(
-0

.6
7
) 

- 
(-

0
.2

8
)]

 
0

* 
-0

.4
5
 

[(
-0

.6
1
) 

- 
(-

0
.2

9
)]

 
0

* 
-0

.3
3
 

[(
-0

.4
9
) 

- 
(-

0
.1

7
)]

 
0

* 
0

.2
4
 

[(
-0

.0
4
) 

- 
(0

.5
1
)]

 
0

.0
9

2
 

  
  

  
  

  
  

 
 

 
 

 
 

 
 

 
 

C
h

a
rl

s
o
n

 T
o

ta
l 
S

c
o

re
 

-1
.2

8
 

[(
-2

.6
6
) 

- 
(0

.0
9
)]

 
0

.0
7

0
 

-1
.0

8
 

[(
-2

.4
5
) 

- 
(0

.3
0
)]

 
0

.1
2

6
 

-1
.1

3
 

[(
-2

.2
8
) 

- 
(0

.0
1
)]

 
0

.0
5

4
 

-0
.9

3
 

[(
-2

.0
2
) 

- 
(0

.1
6
)]

 
0

.0
9

6
 

0
.7

6
 

[(
-1

.0
4
) 

- 
(2

.5
6
)]

 
0

.4
1

0
 

C
h

a
rl

s
o
n

 (
 >

=
 6

 v
s
 <

6
) 

-3
.6

4
 

[(
-8

.8
1
) 

- 
(1

.5
3
)]

 
0

.1
6

9
 

-2
.7

2
 

[(
-7

.8
7
) 

- 
(2

.4
3
)]

 
0

.3
0

2
 

-3
.8

0
 

[(
-8

.0
8
) 

- 
(0

.4
8
)]

 
0

.0
8

4
 

-3
.1

1
 

[(
-7

.1
9
) 

- 
(0

.9
6
)]

 
0

.1
3

6
 

0
.3

3
 

[(
-6

.3
9
) 

- 
(7

.0
6
)]

 
0

.9
2

3
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

 
 

Charlson items 

M
y
o

c
a

rd
ia

l 
in

fa
rc

ti
o

n
 

0
.5

8
 

[(
-5

.4
8
) 

- 
(6

.6
3
)]

 
0

.8
5

2
 

1
.9

3
 

[(
-4

.0
7
) 

- 
(7

.9
4
)]

 
0

.5
2

9
 

-0
.0

9
 

[(
-5

.1
3
) 

- 
(4

.9
4
)]

 
0

.9
7

1
 

1
.2

2
 

[(
-3

.5
5
) 

- 
(5

.9
9
)]

 
0

.6
1

8
 

-0
.1

9
 

[(
-8

.0
2
) 

- 
(7

.6
3
)]

 
0

.9
6

2
 

C
o
n

g
e

s
ti
v
e

 H
e

a
rt

 
F

a
ilu

re
 

-2
.9

8
 

[(
-1

0
.4

8
) 

- 
(4

.5
2

)]
 

0
.4

3
8
 

-1
.9

4
 

[(
-9

.3
9
) 

- 
(5

.5
2
)]

 
0

.6
1

2
 

-4
.7

4
 

[(
-1

0
.9

3
) 

- 
(1

.4
6

)]
 

0
.1

3
6
 

-3
.8

7
 

[(
-9

.7
7
) 

- 
(2

.0
3
)]

 
0

.2
0

1
 

5
.2

2
 

[(
-4

.4
5
) 

- 
(1

4
.9

0
)]

 
0

.2
9

2
 

P
e

ri
p
h

e
ra

l 
v
a

s
c
u

la
r 

 
d

is
e
a

s
e
 

-3
.5

3
 

[(
-1

4
.4

9
) 

- 
(7

.4
4

)]
 

0
.5

2
9
 

-4
.1

6
 

[(
-1

5
.0

5
) 

- 
(6

.7
2

)]
 

0
.4

5
4
 

0
.4

4
 

[(
-8

.6
8
) 

- 
(9

.5
7
)]

 
0

.9
2

4
 

-0
.6

7
 

[(
-9

.3
3
) 

- 
(8

.0
0
)]

 
0

.8
8

0
 

3
.0

1
 

[(
-1

1
.1

7
) 

- 
(1

7
.1

9
)]

 
0

.6
7

8
 

C
e
re

b
ro

v
a

s
c
u

la
r 

a
c
c
id

e
n

t 
-8

.0
9
 

[(
-1

4
.9

4
) 

- 
(-

1
.2

4
)]

 
0

.0
2

2
* 

-7
.8

2
 

[(
-1

4
.6

3
) 

- 
(-

1
.0

1
)]

 
0

.0
2

6
* 

-5
.2

5
 

[(
-1

0
.9

8
) 

- 
(0

.4
9

)]
 

0
.0

7
5
 

-4
.6

6
 

[(
-1

0
.1

2
) 

- 
(0

.7
9

)]
 

0
.0

9
6
 

5
.0

8
 

[(
-3

.9
0
) 

- 
(1

4
.0

6
)]

 
0

.2
7

0
 

C
O

P
D

 
0

.0
8
 

[(
-5

.6
6
) 

- 
(5

.8
3
)]

 
0

.9
7

7
 

2
.3

7
 

[(
-3

.3
3
) 

- 
(8

.0
6
)]

 
0

.4
1

7
 

-1
.3

1
 

[(
-6

.0
9
) 

- 
(3

.4
6
)]

 
0

.5
9

1
 

1
.2

7
 

[(
-3

.2
6
) 

- 
(5

.8
1
)]

 
0

.5
8

2
 

3
.3

1
 

[(
-4

.1
0
) 

- 
(1

0
.7

2
)]

 
0

.3
8

3
 

D
ia

b
e

te
s
 -

 e
n

d
 

o
rg

a
n
 

3
.3

2
 

[(
-3

.6
3
) 

- 
(1

0
.2

8
)]

 
0

.3
5

1
 

-0
.2

4
 

[(
-7

.1
7
) 

- 
(6

.6
9
)]

 
0

.9
4

7
 

1
.9

8
 

[(
-3

.8
2
) 

- 
(7

.7
7
)]

 
0

.5
0

5
 

-0
.7

8
 

[(
-6

.2
8
) 

- 
(4

.7
3
)]

 
0

.7
8

3
 

1
.1

9
 

[(
-7

.8
3
) 

- 
(1

0
.2

1
)]

 
0

.7
9

6
 

S
k
in

 U
lc

e
r 

-3
.8

0
 

[(
-1

5
.6

0
) 

- 
(8

.0
0

)]
 

0
.5

2
9
 

1
.0

8
 

[(
-1

0
.6

6
) 

- 
(1

2
.8

1
)]

 
0

.8
5

8
 

-6
.1

3
 

[(
-1

5
.9

0
) 

- 
(3

.6
4

)]
 

0
.2

2
1
 

-0
.4

6
 

[(
-9

.7
8
) 

- 
(8

.8
7
)]

 
0

.9
2

4
 

5
.1

9
 

[(
-1

0
.0

6
) 

- 
(2

0
.4

4
)]

 
0

.5
0

6
 

M
e

ta
s
ta

ti
c
 C

a
n

c
e

r 
-0

.3
3
 

[(
-1

0
.0

9
) 

- 
(9

.4
2

)]
 

0
.9

4
7
 

4
.4

8
 

[(
-5

.1
8
) 

- 
(1

4
.1

4
)]

 
0

.3
6

5
 

0
.9

1
 

[(
-7

.2
0
) 

- 
(9

.0
1
)]

 
0

.8
2

7
 

3
.6

2
 

[(
-4

.0
5
) 

- 
(1

1
.3

0
)]

 
0

.3
5

6
 

-1
.7

5
 

[(
-1

4
.3

5
) 

- 
(1

0
.8

6
)]

 
0

.7
8

6
 

D
e
m

e
n

ti
a
 

-2
3

.4
6
 

[(
-3

4
.6

3
) 

- 
(-

1
2

.3
0

)]
 

0
* 

-2
8

.8
5
 

[(
-3

9
.5

7
) 

- 
(-

1
8

.1
2

)]
 

0
* 

-1
6

.3
9
 

[(
-2

5
.8

4
) 

- 
(-

6
.9

5
)]

 
0

.0
0

1
* 

-1
9

.4
2
 

[(
-2

8
.1

8
) 

- 
(-

1
0

.6
6

)]
 

0
* 

-3
.5

1
 

[(
-1

8
.7

7
) 

- 
(-

1
1

.7
5

)]
 

0
.6

5
3
 

R
h
e

u
m

a
ti
c
 d

is
e
a

s
 

-5
.0

3
 

[(
-1

9
.3

8
) 

- 
(9

.3
1

)]
 

0
.4

9
3
 

2
.3

5
 

[(
-1

1
.9

1
) 

- 
(1

6
.6

1
)]

 
0

.7
4

8
 

-8
.4

4
 

[(
-2

0
.3

0
) 

- 
(3

.4
2

)]
 

0
.1

6
5
 

-1
.2

2
 

[(
-1

2
.5

6
) 

- 
(1

0
.1

2
)]

 
0

.8
3

3
 

5
.5

4
 

[(
-1

3
.0

0
) 

- 
(2

4
.0

9
)]

 
0

.5
5

9
 

H
ig

h
 b

lo
o

d
 

p
re

s
s
s
u

re
 

-9
.4

6
 

[(
-1

6
.2

6
) 

- 
(-

2
.6

5
)]

 
0

.0
0

7
* 

-7
.7

8
 

[(
-1

4
.5

9
) 

- 
(-

0
.9

6
)]

 
0

.0
2

7
* 

-6
.4

1
 

[(
-1

2
.1

1
) 

- 
(-

0
.7

0
)]

 
0

.0
2

9
* 

-4
.0

8
 

[(
-9

.5
5
) 

- 
(1

.3
9
)]

 
0

.1
4

6
 

8
.4

0
 

[(
-0

.5
2
) 

- 
(1

7
.3

1
)]

 
0

.0
6

7
 

S
k
in

 U
lc

e
r 

-3
.0

6
 

[(
-7

.8
4
) 

- 
(1

.7
1
)]

 
0

.2
1

1
 

-2
.6

4
 

[(
-7

.3
9
) 

- 
(2

.1
0
)]

 
0

.2
7

7
 

-3
.2

6
 

[(
-7

.2
1
) 

- 
(0

.7
0
)]

 
0

.1
0

9
 

-2
.8

8
 

[(
-6

.6
4
) 

- 
(0

.8
8
)]

 
0

.1
3

6
 

2
.7

4
 

[(
-3

.4
5
) 

- 
(8

.9
3
)]

 
0

.3
8

7
 

D
e
p

re
s
s
io

n
 

1
.6

6
 

[(
-6

.5
8
) 

- 
(9

.9
0
)]

 
0

.6
9

3
 

3
.5

5
 

[(
-4

.6
2
) 

- 
(1

1
.7

1
)]

 
0

.3
9

6
 

0
.5

8
 

[(
-6

.2
7
) 

- 
(7

.4
3
)]

 
0

.8
6

9
 

2
.1

0
 

[(
-4

.4
0
) 

- 
(8

.6
0
)]

 
0

.5
2

7
 

-1
.9

6
 

[(
-1

2
.6

1
) 

- 
(8

.6
8

)]
 

0
.7

1
9
 

W
a

rf
a

ri
n
  

-0
.9

2
 

[(
-1

0
.6

8
) 

- 
(8

.8
3

)]
 

0
.8

5
3
 

-1
.4

5
 

[(
-1

1
.1

3
) 

- 
(8

.2
4

)]
 

0
.7

7
0
 

1
.3

8
 

[(
-6

.7
3
) 

- 
(9

.4
9
)]

 
0

.7
3

9
 

-0
.5

3
 

[(
-8

.2
3
) 

- 
(7

.1
7
)]

 
0

.8
9

4
 

-7
.0

8
 

[(
-1

9
.6

4
) 

- 
(5

.4
7

)]
 

0
.2

7
1
 

 

T
a
b

le
 2

: 
U

n
iv

a
ri
a

te
 a

n
a
ly

s
is

, 
F

IM
 T

o
ta

l,
 F

IM
 M

o
to

r 
a
n
d
 L

O
S

. 
*P

<
0
.0

5
 

  
F

IM
 T

o
ta

l 
A

d
m

is
s

io
n

 
F

IM
 T

o
ta

l 
D

is
c
h

a
rg

e
 

F
IM

 M
o

to
r 

A
d

m
is

s
io

n
 

F
IM

 M
o

to
r 

D
is

c
h

a
rg

e
 

L
e

n
g

th
 o

f 
S

ta
y
 (

L
O

S
) 

  
E

s
ti
m

a
te

 (
S

E
) 

t 
v
a

lu
e
 

P
-v

a
lu

e
 

E
s
ti
m

a
te

 (
S

E
) 

t 
v
a

lu
e
 

P
-v

a
lu

e
 

E
s
ti
m

a
te

 (
S

E
) 

t 
v
a

lu
e
 

P
-v

a
lu

e
 

E
s
ti
m

a
te

 (
S

E
) 

t 
v
a

lu
e
 

P
-v

a
lu

e
 

E
s
ti
m

a
te

 (
S

E
) 

t 
v
a

lu
e
 

P
-v

a
lu

e
 

In
te

rc
e

p
t 

1
1

2
.3

8
 (

6
.7

0
) 

1
6

.7
7
 

0
.0

0
0
 

1
2

6
.3

1
 (

6
.8

4
) 

1
8

.4
5
 

0
.0

0
0
 

7
4

.6
7

 (
5

.7
5

) 
1

2
.9

8
 

0
.0

0
0
 

8
7

.8
2

 (
5

.6
8

) 
1

5
.4

7
 

0
.0

0
0
 

1
0

.5
9

 (
9

.8
2

) 
1

.0
8
 

0
.2

8
3
 

 S
e

x
 (

F
 v

s
 M

) 
-2

.6
3

 (
2

.2
3
) 

-1
.1

8
 

0
.2

4
1
 

-1
.3

5
 (

2
.2

8
) 

-0
.5

9
 

0
.5

5
5
 

-3
.9

4
 (

1
.9

1
) 

-2
.0

6
 

0
.0

4
2
 

-2
.8

2
 (

1
.8

9
) 

-1
.4

9
 

0
.1

3
7
 

-0
.2

4
 (

3
.2

7
) 

-0
.0

7
 

0
.9

4
2
 

 A
g

e
 

-0
.5

 (
0
.1

) 
-5

.0
3
 

<
0

.0
0

1
* 

-0
.3

5
 (

0
.1

) 
-3

.4
7
 

0
.0

0
1

* 
-0

.4
1

 (
0

.0
9
) 

-4
.8

1
 

<
0

.0
0

1
* 

-0
.2

7
 (

0
.0

8
) 

-3
.1

8
 

0
.0

0
2

* 
0

.2
5

 (
0

.1
5

) 
1

.7
2
 

0
.0

8
7
 

C
V

A
 

-4
.3

9
 (

3
.0

8
) 

-1
.4

2
 

0
.1

5
7
 

-4
.3

5
 (

3
.1

5
) 

-1
.3

8
 

0
.1

7
0
 

-2
.7

5
 (

2
.6

5
) 

-1
.0

4
 

0
.3

0
1
 

-2
.5

 (
2
.6

1
) 

-0
.9

6
 

0
.3

4
0
 

2
.2

3
 (

4
.5

2
) 

0
.4

9
 

0
.6

2
2
 

D
e
m

e
n

ti
a
 

-1
5

.0
1

 (
5

.4
4
) 

-2
.7

6
 

0
.0

0
7

* 
-2

2
.7

3
 (

5
.5

6
) 

-4
.0

9
 

<
0

.0
0

1
* 

-8
.8

4
 (

4
.6

7
) 

-1
.8

9
 

0
.0

6
1
 

-1
4

.2
7

 (
4

.6
1
) 

-3
.1

0
 

0
.0

0
2

* 
-6

.0
7

 (
7

.9
7
) 

-0
.7

6
 

0
.4

4
8
 

H
ig

h
 b

lo
o

d
 p

re
s
s
u

re
 

-3
.4

9
 (

3
.1

3
) 

-1
.1

2
 

0
.2

6
6
 

-2
.9

3
 (

3
.2

) 
-0

.9
2
 

0
.3

6
1
 

-1
.7

4
 (

2
.6

9
) 

-0
.6

5
 

0
.5

2
0
 

-0
.5

5
 (

2
.6

5
) 

-0
.2

1
 

0
.8

3
5
 

5
.3

4
 (

4
.5

9
) 

1
.1

6
 

0
.2

4
6
 

 

T
a
b

le
 3

: 
M

u
lt
iv

a
ri
a
te

 a
n
a
ly

s
is

, 
F

IM
 T

o
ta

l,
 F

IM
 M

o
to

r 
a
n
d
 L

O
S

. 
*P

<
0
.0

5
 

https://doi.org/10.33137/cpoj.v3i1.33916


 

5 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
Total CCI or dichotomized CCI (>6 or <6 score) were not 

associated with FIM scores or LOS. The individual 

comorbidities that were shown to have an association with 

lower overall total FIM scores at admission, after univariate 

analysis, were cerebrovascular disease (CVA) (Beta=-8.09, 

CI=[(-14.94) - (-1.24)], P=0.022), dementia (Beta=-23.46, 

CI=[(-34.63) - (-12.30)], P<0.001), and HBP (Beta=-9.46, 

CI=[(-16.26) - (-2.65)], P=0.007). At discharge, CVA (Beta= 

-7.82, CI=[(-14.63) - (-1.01)], P=0.026), dementia (Beta= 

-28.85, CI=[(-39.57) - (-18.12)], P<0.001), and HBP (Beta= 

-7.78, CI=[(-14.59) - (-0.96)], P=0.027) also showed an 

association with lower overall total FIM scores. Age was 

also associated with a lower overall total FIM scores, at both 

admission (Beta=-0.58, CI=[(-0.78) - (-0.39)], P<0.001) and 

discharge (Beta=-0.47, CI=[(-0.67) - (-0.28)], P=0.000). Sex 

showed an association with motor FIM scores at admission 

such that females had lower scores (Beta=-4.36, CI=[(-8.46) 

- (-0.25)], P=0.040). At admission, the comorbidities 

associated with lower motor FIM scores were dementia 

(Beta=-16.39, CI=[(-25.84) - (-6.95)], P=0.001) and HBP 

(Beta=-6.41, CI=[(-12.11) - (-0.70)], P 0.029). Dementia was 

the only comorbidity to show an association with lower 

motor FIM scores at discharge (Beta -19.42, CI=[(-28.18) - 

(-10.66)], P=0.000). Age was negatively associated with 

motor FIM scores at admission (Beta -0.45, CI=[ (-0.61) -  

(-0.29)], P<0.001) and discharge (Beta -0.33, CI=[ (-0.49) - 

(-0.17)], P<0.001). The remaining univariate analyses are 

presented in Table 2. 

The factors that showed an association after the univariate 

analysis were then adjusted using multivariate analysis. For 

overall total FIM scores at admission and discharge, 

dementia (Admission P=0.007; Discharge P<0.001) and 

age (Admission P<0.001; Discharge P=0.001) were shown 

to be inversely associated with overall total FIM scores at 

admission after adjusting for confounders. Age was 

negatively associated with lower motor FIM scores at 

admission (Estimate=-0.41, SD=0.09, P<0.001). Being 

female was also inversely associated with lower motor FIM 

scores at admission after adjusting for other confounders 

(Estimate=-3.94, SD=1.91, P=0.042). Dementia showed a 

negative association with motor FIM at discharge 

(Estimate=–14.27, SD=4.61, P=0.002). Age also showed 

an association with poorer motor FIM scores at discharge 

(Estimate=-0.27, SD=0.08, P=0.002). Table 3 includes 

remaining data from multivariate analysis. 

DISCUSSION  

The aim of this study was to describe comorbidities and the 

association with functional outcomes and length of stay in a 

cohort of patients with recent dysvascular limb loss 

undergoing inpatient non-prosthetic rehabilitation. There 

are three main findings from this study including 1: We 

identified the distribution of comorbidities using the CCI in a 

cohort of patients with dysvascular limb loss admitted to 

inpatient rehabilitation, 2: Age and dementia were two main 

factors associated with inpatient Total and Motor FIM 

scores. 3: None of the individual comorbidities included in 

the CCI were associated with LOS in this cohort undergoing 

non-prosthetic rehabilitation. Many patients with limb loss 

entering inpatient rehabilitation programs have a burden of 

comorbidity in addition to their amputation. Identification of 

which factors possibly hinder these patients during inpatient 

rehabilitation may assist in supporting these often complex 

and frail patients after amputation surgery. 

The distribution of demographic items in this dysvascular 

cohort was similar to prior studies. This study focused on 

patients with unilateral, transfemoral and transtibial limb 

loss with similar proportions of amputation level as well as 

average age in comparison with prior published work.21,22 A 

study conducted by Taylor et al. reviewing patients with a 

major LEA showed comparable ratios of patients with PVD 

and DM.23 Of note, the three most frequent comorbidities 

were PVD, hypertension and diabetes which may 

underscore the need for medical management and 

secondary prevention in this population. 

This study is unique in that it examines the distribution of 

the CCI items in patients with dysvascular limb loss and the 

association of each of these with inpatient non-prosthetic 

functional outcomes and length of stay. A study done by 

Arneja et al.24 examined functional outcomes between 

patients with LEA on dialysis and those not on dialysis. In 

their study only discharge FIM scores were included, while 

our study contained both admission and discharge FIM. 

Additionally, their study examined various comorbidities but 

did not use an established index such as the CCI. Overall, 

in our study the total CCI score did not show strong 

associations with functional outcomes in this cohort after 

multivariate analysis. FIM changes and scores in this cohort 

generally reflect acquisition of independence with transfers 

and wheelchair mobility as this study did not examine 

prosthetic gait outcomes. A study conducted by Stewart et 

al.25 provided evidence that patients with chronic conditions, 

such as cardiac and pulmonary disease, which are captured 

in the CCI, do have an impact on function. The discrepancy 

between these findings and the absence of associations 

from our data could be explained by the nature of the 

patients in our study. These patients are medically complex 

and admitted to rehabilitation for only a short period of time 

to address non-prosthetic independence, so their 

progression may not be as evident with the outcome 

measures studied. Conversely, the lack of differences 

attributed to specific comorbidities suggests that patients 

undergoing dysvascular amputation should still be offered 

non-prosthetic rehabilitation and can benefit from post-

operative rehabilitation services regardless of comorbidity 

burden. Moreover, there was no association of comorbidity 

with LOS suggesting that despite multiple comorbidities 

these patients can achieve a non-prosthetic functional level 

sufficient for discharge in a similar amount of time while 

admitted to inpatient rehabilitation. 

https://doi.org/10.33137/cpoj.v3i1.33916


 

6 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
While the total CCI score was not associated with functional 

outcomes, our results show that dementia had a significant 

association with FIM scores. Dementia was found to have 

an inverse association with overall total FIM, at both 

admission and discharge, and motor FIM, at discharge. A 

limitation in our study was that there were only six patients 

who fit the inclusion criteria and had dementia upon 

admission.  This finding is in accordance with past studies 

that have also demonstrated the relationship of cognitive 

impairment with poor functional outcomes after 

amputation.23,26-29  Given, the very low number of patients 

with dementia in this data set, this association must be 

interpreted with caution as additional research with a larger 

sample size would be required to draw broader conclusions. 

Age was another factor that was found to have an 

association with total and motor FIM at both admission and 

discharge, with advanced age resulting in lower FIM scores. 

This result is reasonable on account that it has been shown 

that patients are more likely to accumulate more medical 

conditions as they age.30 There are also additional studies 

that support the notion that advanced age is associated with 

poorer functional outcomes in patients with limb loss.27,31 

However, another report by Chopra et al. did not indicate an 

association between greater age and poorer ambulatory 

rates, which they attributed to their cohort size.18 

Limitations 

There was an association with dementia and functional 

outcomes however these patients represented a very small 

portion of the cohort and therefore future work should be 

directed to larger cohorts to better understand this 

association. Furthermore, this study examined only the 

post-operative and non-prosthetic component of 

hospitalized rehabilitation patients with recent limb loss.  

While burden of comorbidity and specific comorbidities did 

not show associations with functional outcomes in this 

cohort it raises a number of additional points. While, one 

would hypothesize that a greater burden of comorbidity 

such as cardiovascular disease would impact ambulatory 

function, this cohort admitted for non-prosthetic 

rehabilitation was not impacted. This suggests that patients 

referred post-operatively after amputation who may never 

be prosthetic candidates may still benefit from inpatient 

rehabilitation to recover from surgery and restore 

independence prior to discharge. The CCI reflects specific 

medical comorbidities however other factors may also play 

a role in rehabilitation after limb loss including the condition 

of the contralateral limb, visual impairments, delayed wound 

healing and mental health status, which could be explored 

in future studies. An important comorbidity which may 

disproportionately impact function and may not be fully 

reflected in the CCI is that of end-stage renal disease in 

patients receiving hemodialysis. In patients living with limb 

loss who also receive dialysis, the mortality and functional 

outcomes are much poorer than those with dysvascular 

amputation and no hemodialysis.21,32 In order to better 

address this question in a non-prosthetic inpatient 

rehabilitation setting additional comparative studies 

(dyvascular amputation vs dysvascular plus dialysis) are 

needed. Furthermore, this cohort represents one post-

amputation care model in Canada and therefore the results 

may not be directly generalized to other forms of 

rehabilitation which can vary locally, nationally and 

internationally. 

CONCLUSION 

In summary, we report the distribution of comorbidities in a 

cohort of patients with dysvascular limb loss using the CCI. 

There was an association with dementia and functional 

outcomes as represented by the FIM, however larger 

sample sizes will be needed to better explore this 

association. Age did show negative associations with FIM 

scores. There were no associations of comorbidity with 

inpatient rehabilitation length of stay. Finally, given that 

there were no significant associations between total or 

specific comorbidities and functional outcomes and LOS in 

this cohort, medically complex patients with limb loss may 

still derive benefit from post-operative, non-prosthetic 

inpatient rehabilitation to restore independence prior to 

discharge from hospital. 

 

ACKNOWLEDGEMENTS 

The authors would like to acknowledge the staff in the 

Health Information Management office at Providence 

Healthcare for their support and assistance with this project. 

DECLARATION OF CONFLICTING 

INTERESTS 

The authors have no conflicts of interest to declare.  

AUTHOR CONTRIBUTION 

Michelle G. Marquez:  

Completed data collection, data interpretation, literature 

review and manuscript writing. 

Matthew Kowgier:  

Assisted in study design, led statistical analysis and 

contributed to manuscript development. 

W. Shane Journeay:  

Conceived the study and design, data interpretation and 

manuscript writing. 

 

SOURCES OF SUPPORT 

Michelle G. Marquez received a Providence Healthcare 

student research stipend. 

 

https://doi.org/10.33137/cpoj.v3i1.33916


 

7 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
ETHICAL APPROVAL 

This was a retrospective cohort study and was approved by the 

Research Ethics Board of Providence Healthcare and closed by the 

Unity Health Toronto Research Ethics Board. 

REFERENCES 

1.Schofield CJ, Libby G, Brennan GM, MacAlpine RR, Morris AD, 

Leese GP. Mortality and hospitalization in patients after 

amputation: a comparison between patients with and without 

diabetes. Diabetes Care. 2006; 29:2252-6. DOI:10.2337/dc06-

0926 

2.Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, 

Brookmeyer R. Estimating the prevalence of limb loss in the United 

States: 2005 to 2050. Arch Phys Med Rehabil. 2008; 89(3):422-9. 

DOI: 10.1016/j.apmr.2007.11.005 

3.Kayssi A, de Mestral C, Forbes TL, Roche-Nagle G. A Canadian 

population-based description of the indications for lower-extremity 

amputations and outcomes. Can J Surg. 2016; 59:99-106. DOI: 

10.1503/cjs.013115 

4.Imam B, Miller WC, Finlayson HC, Eng JJ, Jarus T. Incidence of 

lower limb amputation in Canada. Can J Public Health. 2017; 

108:e374-e380. DOI: 10.17269/cjph.108.6093 

5.Kayssi A, de Mestral C, Forbes TL, Roche-Nagle G. Predictors of 

hospital readmissions after lower extremity amputations in Canada. 

J Vasc Surg. 2016; 63:688-95. DOI:10.1016/j.jvs. 2015.09.017 

6.Hussain MA, Al-Omran M, Salata K, Sivaswamy A, Forbes TL, 

Sattar N, et al. Population-based secular trends in lower-extremity 

amputation for diabtes and peripheral vascular disease. CMAJ.  

2019; 191:E955-61. DOI: 10.1503/cmaj.190134 

7.Vogel TR, Petroski GF, Kruse RL. Impact of amputation level and 

comorbidities on functional status of nursing home residents after 

lower extremity amputation. J Vasc Surg. 2014; 59:1323-1330. 

DOI: 10.1016/j.jvs.2013.11.076 

8.Melchiorre PJ, Findley T, Boda W. Functional outcome and 

comorbidity indexes in the rehabilitation of the traumatic versus the 

vascular unilateral lower limb amputee. Am J Phys Med Rehabil. 

1996; 75:9-14.  

9.Lavery LA, Van Houtum WH, Armstrong DG. Institutionalization 

following diabetes-related lower extremity amputation. Am J Med. 

1997; 103:383-388. DOI:10.1016/S0002-9343(97)00163-0 

10.Dillingham TR, Pezzin LE. Rehabilitation setting and associated 

mortality and medical stability among persons with amputations. 

Arch Phys Med Rehabil. 2008; 89:1038-1045. DOI:10.1016/ 

j.apmr.2007.11.034 

11.Dillingham TR, Yacub JN, Pezzin LE. Determinants of postacute 

care discharge destination after dysvascular lower limb amputation. 

PM R. 2011; 3:336-344. DOI:10.1016/j.pmrj. 2010.12.019 

12.Kayssi A, Dilkas S, Dance DL, de Mestral C, Forbes TL, Roche-

Nagle G. Rehabilitation trends after lower extremity amputations in 

Canada. PM R. 2016; 9:494-501. DOI: 10.1016/j.pmrj.2016.09.009 

13.Stineman MG, Kwong PL, Kurichi JE, Prvu-Bettger JA, Vogel 

WB, Maislin G, et al. The effectiveness of inpatient rehabilitation in 

the acute postoperative phase of care after transtibial or 

transfemoral amputation: Study of an integrated health care 

delivery system. Arch Phys Med Rehabil. 2008; 89:1863-72. DOI: 

10.1016/j.apmr.2008.03.013 

14.Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new 

method of classifying prognostic comorbidity in longitudinal studies: 

development and validation. J Chronic Dis. 1987; 40:373-383. 

DOI:10.1016/0021-9681(87)90171-8 

15.Charlson ME, Charlson RE, Briggs W, Hollenberg J. Can 

disease management target patients most likely to generate high 

costs? The impact of comorbidity. J Gen Intern Med. 2007; 

22(4):464-469. DOI:10.1007/s11606-007-0130-7 

16.Hamilton BB, Laughlin JA, Fiedler RC, Granger CV. Interrater 

reliability of the 7-level functional independence measure (FIM). 

Scand J Rehabil Med. 1994; 26:115-119.  

17.Keith RA, Granger CV, Hamilton BB, Sherwin FA. The functional 

independence measure: A new tool for rehabilitation. Adv Clin 

Rehabil. 1987; 1:6-18.  PMID: 3503663 

18.Chopra A, Azarbal AF, Jung E, Abraham CZ, Liem TK, Landry 

GJ, et al. Ambulation and functional outcome after major lower 

extremity amputation. J Vasc Surg. 2018; 67:1521-1529. DOI: 

10.1016/j.jvs.2017.10.051 

19.Cheng R, Smith SR, Kalpakjian CZ. Comorbidity has no impact 

on unplanned discharge or functional gains in persons with 

dysvascular amputation. J Rehabil Med. 2019; 51(5):369-375. DOI: 

10.2340/16501977-2554. 

20.Mayo AL, Cimino SR, Hitzig SL. A depiction of rehabilitation 

patients 65 years and younger with dysvascular lower extremity 

amputation. Can Prosthet Orthot J. 2019; 2(1):1 DOI: 

10.33137/cpoj.v2i1.31950 

21. Nehler MR, Coll JR, Hiatt WR, Regensteiner JG, Schnickel GT, 

Klenke WA, et al. Functional outcome in a contemporary series of 

major lower extremity amputations. J Vasc Surg. 2003; 38(1):7-14. 

DOI: 10.1016/s0741-5214(03)00092-2 

22.Batten H, Kuys S, McPhail S, Varghese P, Mandrusiak A. Are 

people with lower limb amputation changing? A seven-year 

analysis of patient characteristics at admission to inpatient 

rehabilitation and at discharge. Disabil Rehabil. 2019; 41(26):3203-

3209. DOI:10.1080/09638288.2018.1492033 

23.Taylor SM, Kalbaugh CA, Blackhurst DW, Hamontree SE, Cull 

DL, Messich HS, et al. Preoperative clinical factors predict 

postoperative functional outcomes after major lower limb 

amputation: an analysis of 553 consecutive patients. J Vasc Surg. 

2005; 42: 227-235. DOI: 10.1016/j.jvs.2005.04.015 

24.Arneja AS, Tamiji J, Hiebert BM, Tappia PS, Galimova L. 

Functional outcomes of patients with amputation receiving chronic 

dialysis for end-stage renal disease. Am J Phys Med Rehabil. 2015; 

94: 257-268. DOI: 10.1097/PHM.0000000000000259 

25.Stewart AL, Greenfield S, Hays RD, Wells K, Rogers WH, Berry 

SD, et al. Functional status and well-being of patients with chronic 

conditions. Results from the Medical Outcomes Study. JAMA. 

1989; 262(7): 907-913. DOI:10.1001/jama. 1989.03430070055030 

26.Heinemann AW, Linacre JM, Wright BD, Hamilton BB, Granger 

C. Prediction of rehabilitation outcomes with disability measures. 

https://doi.org/10.33137/cpoj.v3i1.33916


 

8 

Marquez M.G, Kowgier M, Journeay W.S. Comorbidity and non-prosthetic inpatient rehabilitation outcomes after dysvascular lower extremity amputation. 
Canadian Prosthetics & Orthotics Journal. 2020;Volume3, Issue1, No.1.https://doi.org/10.33137/cpoj.v3i1.33916 

ISSN: 2561-987X COMORBIDITY AND INPATIENT REHABILITATION AFTER AMPUTATION 
Marquez et al. 2020 

 
CPOJ 

 
Arch Phys Med Rehabil. 1994; 75: 133-143. DOI: 10.1016/0003-

9993(94)90385-9 

27.Schoppen T, Boonstra A, Groothoff JW, de Vries J, Goeken LN, 

Eisma WH. Physical, mental, and social predictors of functional 

outcome in unilateral lower-limb amputees. Arch Phys Med 

Rehabil. 2003; 84: 803-811. DOI:10.1016/S0003-9993(02)04952-3 

28.Frengopoulos C, Burley J, Viana R, Payne MW, Hunter SW. 

Association between Montreal Cognitive Assessment Scores and 

measures of functional mobility in lower extremity amputees after 

inpatient rehabilitation. Arch Phys Med Rehabil. 2017; 98: 450-455. 

DOI:10.1016/j.apmr.2016.06.012 

29.Williams RM, Turner AP, Green M, Norvell DC, Henderson AW, 

Hakimi KN, et al. Relationship between cognition and functional 

outcomes after dysvascular lower extremity amputation: a 

prospective study. Am J Phys Med Rehabil. 2015; 94(9): 707-17. 

DOI: 10.1097/PHM.0000000000000235 

30.Johnson VJ, Kondziela S, Gottschalk F. Pre and post-

amputation mobility of trans-tibial amputees: correlation to medical 

problems, age and mortality. Prosthet Orthot Int. 1995; 19: 159-

164. DOI:10.3109/03093649509167999 

31.Covinsky KE, Palmer RM, Fortinsky RH, Counsell SR, Stewart 

AL, Kresevic D, et al. Loss of independence in activities of daily 

living in older adults hospitalized with medical illnesses: increased 

vulnerability with age. J Am Geriatr Soc. 2003; 51: 451-458. 

DOI:10.1046/j.1532-5415.2003.51152.x 

32.Serizawa F, Sasaki S, Fujishima S, Akamatsu D, Goto H, 

Amada N. Mortality rates and walking ability transition after lower 

limb major amputation in hemodialysis patients. J Vasc Surg. 2016; 

64(4): 1018-25. DOI: 10.1016/j.jvs.2016.03.452 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v3i1.33916

