Quality of Life, Physical Activity Participation, and Perceptions of Physical Rehabilitation among Community-Reintegrated Veterans with Lower Limb Amputation in Sri Lanka: A Mixed-Method Study (Preprint)

Abstract

Lower limb amputation (LLA) is a permanent disability that significantly impacts survivors’ physical activity (PA) participation, functional independence, and quality of life (QoL). To minimise the effect of these impacts, it is essential for LLA survivors to engage in lifelong rehabilitation tailored to their needs and preferences. However, in Sri Lanka, where a three-decade civil war resulted in trauma-related LLAs among a young male generation, access to rehabilitation was limited to the immediate post-injury period. Designing and implementing rehabilitation interventions for these veterans requires an understanding of their current health status and perceptions of rehabilitation.

This study was conducted to evaluate the QoL and PA participation of veterans with LLA; to explore perceptions of factors influencing their PA participation and expectations for a future community-based physical rehabilitation (CBPR) intervention.

This mixed-method study combined a comparative cross-sectional study with qualitative semi-structured interviews in five districts of Sri Lanka. QoL and PA participation were assessed for community-reintegrated veterans with LLA and compared with a matched able-bodied cohort, using the Mann-Whitney U test. PA was defined as metabolic equivalent of task (MET)-minutes/week and computed for walking, moderate-intensity, and vigorous-intensity activities. PA level was classified as either sufficiently active, low, or sedentary. The design of interview questions was guided by the Theoretical Domains Framework (TDF) and followed a phenomenological approach. Interviews were conducted with 25 veterans, analysed thematically, and perceptions of PA participation and CBPR codified using the Consolidated Framework for Implementation Research (CFIR).

All the participants were male (N=170) age ranging from 30 to 55 years. Scores for both physical and psychological well-being and PA participation in walking and vigorous-intensity activities were significantly lower among veterans (P<.05). Of the 79 veterans, 34 (43%) were classified ‘sedentary’ compared to 10 out of 82 (11.8%) in able-bodied group. Veterans mostly engaged in moderate-intensity PA inside the house (49/79, 62%) and in the yard (30/79, 38%). Barriers to PA exist at individual (e.g. burden of comorbidities), primary care (e.g. absence of community rehabilitation services), and policy levels (e.g. limited resources), and facilitators primarily at societal (e.g. inclusive community) and individual levels (e.g. pre-injury activity baseline and positive attitude towards exercises). Expectations on CBPR included individualised rehabilitation parameters, functional-biased exercises, and involvement from peers with LLA, amputee societies, and community healthcare providers.

Reduced PA participation, poorer QoL, and physical and psychological impacts for relatively young veterans reveals the long-term impacts of living with LLA in the absence of long-term rehabilitation. Policy level changes need to be implemented along with behaviour change strategies to promote PA participation and minimise physical inactivity induced health issues. Veterans’ perceptions regarding a future CBPR programme were positive and centred on holistic, individualised, and peer-led activities.