Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research

Abstract

Purpose

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military.

Methods

A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss.

Results

Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond.

Conclusions

Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes.

Implications for rehabilitation

• Identify at an early stage of rehabilitation those veterans at risk for poorer adjustment, by examining their propensity or not to adopt goal pursuit and goal adaptation strategies

• Offer psychological support prior to and after the transition to civilian life

• Target psychological therapies, such as Cognitive Behavioural Therapy and Acceptance and Commitment Therapy, to veterans who are experiencing high levels of pain

• Encourage peer support programmes and provide support and training to peer mentors

Keywords:

• Amputation
• limb loss
• military
• qualitative
• veteran

Introduction

Across the world, limb loss is a major cause of disability. For example, there are nearly 6,000 new cases of amputation per year in the UK, or around 50,000 in total [1], and in the United States this figure is around 185,000 per year [2], or 2 million in total [3]. The possible causes or reasons for amputation are varied, complex, and differ according to the socioeconomic climate of different global regions [4]. For example, in Western countries, where mortality rates following amputation are high, limb loss typically occurs in the older population as the result of infections, peripheral arterial disease and diabetes, resulting in a much higher incidence of lower-limb than upper-limb amputations [1,5]. Approximately 80% of these amputations, which are primarily vascular in cause, occur in individuals over the age of 60 [6]. This differs to amputations in developing countries where they tend to occur as a result of trauma such as landmines [7] or combat during war [8], accidents in the workplace [9] and traffic accidents [10].

Following amputation there is a period of adaptation to an altered body and material circumstances. As a consequence, there are a number of psychological issues that can affect such individuals. For example, anxiety and depression are relatively high up to 2 years post-amputation [11] and are significantly higher than in the general population [12]. Body image disturbance is a frequent consequence of limb loss [13], while intimate relationships are often negatively impacted [14]. Previously held occupations [15] and leisure activities [16] might no longer be possible or are curtailed due to physical limitations imposed by limb loss. However, several psychological characteristics or attitudes have been found to help people adapt well. These include being able to find meaning following amputation, dispositional optimism and perceived control over disability [17], and the adoption of adaptive goal-related strategies, including seeking instrumental help, being determined, accepting limitations, and receiving emotional support from friends and family [18].

Over the last three decades, several military conflicts (including the Gulf, Iraq and Afghanistan wars) have resulted in an increase in injuries and disabilities for military veterans. As a result, veterans have received increased research and clinical attention [e.g., 19–23]. This includes a focus on individuals who have lost a limb during combat, and those who have lost a limb during military exercise and road traffic accidents [22], as well as military veterans who undergo amputation after active service [21].

In more recent conflicts in Iraq and Afghanistan, the numbers of amputations experienced by military veterans increased in frequency [24] with Improvised Explosive Devices (IEDs) or other explosives causing 81% of all injuries [25], including amputation [26,27]. Over half of veterans with a major limb loss also have a traumatic brain injury [28]. These complex military injuries frequently result in higher levels of Post-Traumatic Stress Disorder (PTSD) and depression [26,29].

Research has found that rates of PTSD in US military veterans returning from Iraq and Afghanistan could be as high as 31% [30]. PTSD is associated with poor mental and physical health, a decrease in wellbeing, and a higher risk of suicide [20,31]. In the US, compared to civilians, male veterans are more than twice as likely to die by suicide [32], and veterans with PTSD have been found to be three times more likely to die by suicide than their civilian counterparts [33,34]. Despite these challenges, it has been found that veterans with amputation are able to better adjust following their amputation if they are satisfied with their prosthesis [27], suggesting that the correct support is important.

Lower limb amputations are the most common type of amputation amongst veterans with 29% of amputations acquired in combat being below knee, 27% being above knee, and between 21% and 30% experiencing amputation of multiple limbs [28]. Upper limb amputations occur in 22% of military amputees [28]. While many civilian amputations are planned and therefore allow time for discussion with medical professionals pre-amputation and time to psychologically and practically prepare, most military amputations are due to sudden trauma [21].

Within Western medical care, rehabilitation following amputation is encapsulated in nine phases [35]. The first three of these relate to surgical procedures: a preoperative stage involving patient education and postoperative prosthetic (artificial limb) plans; surgery and reconstruction procedures; and a stage of wound healing, pain management and emotional support. These are followed by three phases centred on the prosthesis: a pre-prosthetic stage, in which the stump or residual limb shrinks, is shaped, and muscle strength is increased; prosthetic prescription, during which an artificial limb is fabricated; and prosthetic training during which the wearing and utilisation of the prosthetic limb is inculcated. The final three phases relate to: community integration, during which the patient resumes family roles, recreational and community activities, along with gaining emotional equilibrium and developing coping strategies; vocational rehabilitation, where future job plans are assessed and if necessary modified through education and training; and lifelong “follow up” of prosthetic, functional, medical assessment and emotional support.

While military rehabilitation involves broadly the same processes (one possible exception being the opportunity of planning for limb loss), the emphasis and nature of provision are usually qualitatively different from that of civilian populations. For example, in the UK, the principle has long been established that military veterans who lose a limb should not be disadvantaged in accessing public services, and that they should receive special provision where appropriate, such as a modern high-end prosthesis [36]. Similarly, in the USA, “the very best prosthetic technology available” is provided to their military limb loss population, “with virtually no financial restrictions” [37,p.S186]. However, Gajewski and Granville [37] note, “it is not the myoelectric hands or microprocessor knees that enable return to such high levels of function. Rather, it is the intensity of rehabilitation and the discipline and dedication of the physiatrists, therapists, and patients that ultimately determine outcome” [p.S186]. Military veterans tend to receive more intense and extensive exercise-based rehabilitation, compared to their civilian counterparts [36]. This care is also provided through professionals with more direct knowledge, experience and skills regarding the complex types of limb loss (e.g., multiple amputations) that military veterans experience, compared to the more typical profile (older and less active, limb loss due to peripheral vascular disease and diabetes) seen in civilian prosthetic and amputee rehabilitation centres [36]. Help with accessing financial support and psychological therapy, amputee peer mentors and involvement of veteran advocacy groups are also aspects of the support that is offered [36,37]. Such care usually continues for these individuals in this manner as long as they remain in service. Although care will involve life-long follow-up (such as care of the residual limb and repairs and replacement of prosthetics), the most intense period of rehabilitation is typically in the first 12–18 months after amputation [38].

Although some military amputees return to duty, a high number are discharged from service [39], with research reporting that 89% of US military amputees do not return to duty following amputation [40]. Individuals acquiring a physical injury during service may be immediately medically discharged, gradually experience a downgrading of their role leading to medical discharge, or may choose to voluntarily leave service [41]. Following medical discharge, some military veterans can experience poor psychosocial integration due to a variety of factors: the adjustment from being a non-disabled person to disabled [42], adjustment to career change [43], and mental health difficulties [44]. There is also a loss of personally important aspects of being in the military, such as camaraderie, belonging, and providing a service [45]. In addition, recent research has found that the process of medical discharge itself, the way in which it was conducted, and follow up afterwards can impact on the challenges that veterans face [45].

Military amputees differ from civilian amputees in a number of ways. Approximately 85% of veterans with a limb amputation are under the age of 35, and therefore much younger compared to civilians [46]. The older age profile of the civilian limb loss community, coupled with co-morbidities related to their limb loss, means they are typically physically challenged with low exercise tolerance [47]. This is in contrast to military amputees who are younger, more physically able, but face other challenges such as mental health difficulties due to trauma and PTSD [36].

These differences between veterans and civilians with limb loss may also result in different experiences post-amputation. Experiences of the military can have an impact on the behaviour of veterans, and influence how they respond to challenges in everyday, civilian life [48]. Therefore it is important that health professionals working with this population have an understanding of the culture and experiences that come with being a member of the military to provide adequate care [49]. Hynes [45] points out that the culture of “self-sufficiency” which is ingrained in members of the military further highlights the challenges in accessing support following medical discharge and adapting to civilian life. Military culture is described as authoritative, masculine, physically demanding, disciplined and tough [50,51], and members are expected to not accept defeat, be selfless and display self-discipline and toughness [52].

Literature in the field of military amputees is limited, and the need for research in this area to help understand how to support these individuals either in civilian life or in the military has been highlighted [36]. In the West, government policy has also paid attention to the particular health and social care needs that limb loss veterans may have when compared to civilians. For example, in the UK, Murrison [36] made recommendations to support those who have undergone an amputation during military service in the transition to civilian healthcare, and to improve their experience of amputee care. Similarly, in the US, the Department of Veterans Affairs created the Amputation System of Care (ASoC) in 2008 which aims to enhance the quality and consistency of care following amputation amongst military veterans [53].

As indicated above, current research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. Qualitative research, with its commitment to obtaining first-person accounts, is well suited to accessing and elaborating the meanings and experiences of lived phenomena and there is a growing body of such work in relation to limb loss for veterans. Qualitative approaches to researching limb loss are argued to be well-suited to identifying the meanings of limb loss from the vantage point of those concerned [54]. A systematic review of qualitative research on the lived psychological experience of amputation and rehabilitation among veterans would allow for an integrated account of research on this topic, in turn assisting health and social care professionals in understanding military veterans’ unique experiences and better improve the delivery of services [55]. One approach to doing this is that of qualitative metasynthesis [56,57], in which the findings of qualitative research are synthesised in an explanatory account of particular research concerns. Metasyntheses provide in-depth understanding of a phenomenon and so are useful in informing health care policy and practice [58–60]. In achieving this, the metasynthesis seeks to go beyond a descriptive summary of the original studies to produce novel insights. Consequently, the present review aims to synthesise qualitative research exploring the psychological experience of amputation and/or rehabilitation among existing or previous members of the military.

Method

The PRISMA guidelines and 2020 checklist were used to facilitate the transparent reporting of the present review [61] together with the ENTREQ guidelines for reporting the synthesis of qualitative research [62].

Search strategy

To identify qualitative empirical papers on the experience of amputation and rehabilitation for military veterans the following procedures were adopted. Six databases covering literature in psychology, medicine and nursing were systematically searched to identify eligible articles: PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus. Title and abstract searches were completed according to pre-defined search terms involving three areas: the sample/population (veterans), the phenomenon of interest (amputation), and the design of the study (qualitative). The search strategy was reviewed by a specialist university librarian. Additional searches were conducted by searching for articles citing selected papers, and then searching the reference lists of selected papers. Date restrictions were not applied. Searches were first completed in September 2021 and repeated in January 2022 to identify any additional papers. An additional paper was subsequently published in March 2022, identified through an automatic computer alert, and incorporated into the analysis. Details of the search strategy and search terms for each database can be found in Table 1.

Table 1. Search terms applied to each database.

Search terms combined with AND
PsychINFO
Amputation	(DE "Amputation" OR DE "Prostheses") OR TI ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*)) OR AB ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*))
Military	(DE "Military Personnel" OR DE "Air Force Personnel" OR DE "Army Personnel" OR DE "Enlisted Military Personnel" OR DE "Navy Personnel" OR DE "Volunteer Military Personnel") OR TI (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*)) OR AB (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*))
Qualitative	(DE "Qualitative Methods" OR DE "Focus Group" OR DE "Grounded Theory" OR DE "Interpretative Phenomenological Analysis" OR DE "Narrative Analysis" OR DE "Semi-Structured Interview" OR DE "Thematic Analysis") OR TI ((Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived)))) OR AB ((Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived))))
AMED
Amputation	((ZU "amputation") or (ZU "amputees")) OR TI ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*)) OR AB ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*))
Military	(ZU "military personnel") OR TI (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*)) OR AB (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*))
Qualitative	(ZU "qualitative research") OR TI (TI(Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived)))) OR AB (TI(Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived))))
Medline
Search terms combined with AND
Amputation	(MH "Amputees") OR TI (Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*) OR AB (Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*)
Military	((MH "Military Personnel") OR (MH "Warfare and Armed Conflicts") OR (MH "Iraq War, 2003-2011") OR (MH "Afghan Campaign 2001-") OR (MH "Vietnam Conflict")) OR TI ("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*) OR AB ("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*))
Qualitative	(MH "Qualitative Research+") OR TI (Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived))) OR AB ( Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived)))
CINAHL
Amputation	(MH "Amputation+") OR TI ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*)) OR AB ((Amput* OR ((Limb* OR leg* OR arm* OR foot OR feet OR hand*) N3 (loss OR artificial)) OR limb-loss or prosthe*))
Military	((MH "Military Personnel+") OR (MH "Military Services+")) OR TI (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*)) OR AB (("armed force*" OR veteran* OR military OR “ex-service" OR “service member*” OR army OR soldier* OR navy OR naval OR airforce OR air-force (military N5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR “national guard” OR “air force” OR RAF OR troop*))
Qualitative	(MH "Qualitative Studies+") OR TI ((Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived)))) OR AB ((Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) N3 (of OR personal OR lived)))
Web of science
Amputation	TI = ((Amput* "OR" ((Limb* "OR" leg* "OR" arm* "OR" foot "OR" feet "OR" hand*) NEAR3 (loss "OR" artificial)) "OR" limb-loss or prosthe*)) OR AB = ((Amput* "OR" ((Limb* "OR" leg* "OR" arm* "OR" foot "OR" feet "OR" hand*) NEAR3 (loss "OR" artificial)) "OR" limb-loss or prosthe*))
Military	TI = ("armed force*" OR veteran* OR military OR "ex-service" OR "service member*" OR army OR soldier* OR navy OR naval OR airforce OR air-force (military NEAR5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR "national guard" OR "air force" OR RAF OR troop*) OR AB = ("armed force*" OR veteran* OR military OR "ex-service" OR "service member*" OR army OR soldier* OR navy OR naval OR airforce OR air-force (military NEAR5 (sailor OR pilot OR marine* OR reserv* OR serving))OR combat OR war OR conflict OR combat OR "national guard" OR "air force" OR RAF OR troop*)
Qualitative	TI = (Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) NEAR3 (of OR personal OR lived))) OR AB = (Qualitative OR interview* OR “grounded theory” OR phenomenol* OR “thematic analysis” OR narrative OR semi-structured OR “focus group*” OR IPA OR “content analysis” OR ethnog* ((experience* OR perception*) NEAR3 (of OR personal OR lived)))
Scopus
Amputation	((INDEXTERMS ("amputation")) OR ( TITLE (amput* OR ((limb* OR leg* OR arm* OR foot OR feet OR hand*) W/3 (loss OR artificial)) OR limb-loss OR prosthe*)) OR (ABS (amput* OR ((limb* OR leg* OR arm* OR foot OR feet OR hand*) W/3 (loss OR artificial)) OR limb-loss OR prosthe*)))
Military	((INDEXTERMS (military)) OR (TITLE ("armed force*" OR veteran* OR military OR "ex-service" OR "service member*" OR army OR soldier* OR navy OR naval OR airforce OR air-force OR (military W/5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR "national guard" OR "air force" OR raf OR troop*)) OR (ABS ("armed force*" OR veteran* OR military OR "ex-service" OR "service member*" OR army OR soldier* OR navy OR naval OR airforce OR air-force OR (military W/5 (sailor OR pilot OR marine* OR reserv* OR serving)) OR combat OR war OR conflict OR combat OR "national guard" OR "air force" OR raf OR troop*)))
Qualitative	((INDEXTERMS (qualitative)) OR (TITLE (qualitative OR interview* OR "grounded theory" OR phenomenol* OR "thematic analysis" OR narrative OR semi-structured OR "focus group*" OR ipa OR "content analysis" OR ethnog* OR ((experience* OR perception*) W/3 (of OR personal OR lived)))) OR (ABS (qualitative OR interview* OR "grounded theory" OR phenomenol* OR "thematic analysis" OR narrative OR semi-structured OR "focus group*" OR ipa OR "content analysis" OR ethnog* OR ((experience* OR perception*) W/3 (of OR personal OR lived)))))

Inclusion and exclusion criteria

Inclusion criteria for papers to be selected were: (1) the sample included adults who underwent a major limb amputation during military service; (2) study included data collection and analysis which used qualitative research methodology; (3) results of the study documented key themes; (4) published in a peer reviewed journal; and (5) written in English. (Grey literature and material not available in English was not included due the limited time and financial resources available for the review.) Studies were excluded if: (1) the sample included people with other disabilities and the results did not separate out the experiences of those who had experienced limb loss; (2) the findings were not evidenced with quotations from study participants; and (3) they included participants who experienced amputation after leaving military service and the results did not separate this from participants who experienced amputation during military service.

Search results

Following the searches, and prior to the application of inclusion and exclusion criteria, 403 papers were exported into a reference manager (Endnote version x9). Duplicates (n = 205) and non-English papers (3) were removed through a manual review by the second author. The remaining 195 papers were screened and assessed for relevance by two reviewers (the first and second authors), based on their titles and abstracts. No disagreements occurred in this process. This resulted in the exclusion of 168 papers. The full texts of the remaining 27 papers were accessed; the reviewers excluded 12 as they did not meet the criteria. Reference sections of papers selected for inclusion were assessed for additional papers, and the final set of papers were citation-searched for any additional papers. This resulted in the identification of one additional paper. A further paper was subsequently published in March 2022, identified through an automatic computer alert, and incorporated into the analysis. This brought the total number of papers included in the present review to 17 (Figure 1).

Figure 1. Diagrammatic representation of search process [61]. PRISMA flow diagram showing the identification, screening, and inclusion of papers for the systematic review.

Characteristics of the selected papers

The selected papers were published between 2009 and 2022. Two sets of papers (3 in the UK [63–65] and 4 in the USA [66–69]) used the same sample and data set. Therefore, although 17 papers were selected for the review, it is important to recognise that these pertained to 12 studies.

Participants were from four countries, namely the USA (n = 10, from 7 studies), the UK (n = 5, from 3 studies), Denmark (n = 1), and Ukraine (n = 1). Sample sizes ranged from 2 to 33, and participants had all undergone amputation whilst serving in the military. Eleven papers reported exclusively male samples, three reported mixed but predominately male samples [64,65,70], two did not report gender [68,69], and only 1 used an exclusively female sample [71]. Ages of participants were not uniformly reported, but where they were these ranged from 24 [72] to 95 years [65]. The information provided on types of amputation ranged from a general description that samples had lost a limb (e.g., [63]) to a more detailed breakdown (e.g., one above-knee, one below knee, one double below-knee, one double above elbow, and one right arm disarticulation [71]). Where information on the military conflicts that veterans had been involved in was provided, these included WWII [63,64], Gulf War 1 [63,64], the Falklands and Northern Ireland [64], UN peacekeeping missions [63], Vietnam [73], and the Iraq [66–68,74] and Afghanistan [66,74] wars. The majority of papers involved data collected via interviews on one single occasion. Exceptions to this were papers by Messinger [66–69] who combined data collection via interviews and observation over a two-year period, Caddick et al. [65] who interviewed participants on 1-3 occasions, Foote et al. [73] who interviewed 15 of their 20 participants twice, and Christensen et al. [75] who combined interviews with participant observation during 4 weeks of rehabilitation sessions. One study [76] used written accounts (namely, secondary data, consisting of patient statements from the evaluation process associated with applications for new microprocessor-controlled prosthetic limbs). Further available details of the selected papers, including nature of amputation, data collection and analysis are summarised in Table 2.

Table 2. Summary information of the selected papers.

Author(s)	Year	Location	Research question/Aim	Participants	Design & data collection	Data analysis
Caddick, McGill, Greaves & Kiernan [63]	2018	UK	Explore how lives are experienced at the intersections of aging, disability and militarism. To consider (a) the links to a military biography regarding how individuals might approach disability in later life, and (b) veterans’ approaches to dealing with mobility and impairment in later life.	Sample: n = 33^a Gender: All male Age: ‘Mid-life to old age’ Military background: UK Military, served in various conflicts from WWII to Gulf War 1, UN peacekeeping missions and those never deployed. Amputation: Limb lost either during or post service.	Detailed life history interviews (participants interviewed on 1–3 occasions).	Narrative analysis
Cater [71]	2012	US	To increase understanding of the psychosocial adjustment issues American service women experience after a traumatic amputation.	Sample: n = 6 Gender: All female Age: unknown, however age at amputation given: 20–36 (mean = 24). Military background: All Army/Army National Guard members. Amputation: Traumatic amputation of one or more limbs. Five of the six women lost one or more limbs in combat. One was above-knee, 1 below knee, 1 below and above knee, I double below knee, 1 double above elbow, and 1 right arm disarticulation.	Phenomenology, In depth interviews (four of the interviews were broken into two or three segments to accommodate the participant’s schedule, and two were completed in one session).	Phenomenological analysis
Christensen, Langberg, Doherty & Egerod [75]	2017	Denmark	To increase understanding of the military identity influence on the organisation of rehabilitation and investigate factors of importance for successful rehabilitation services.	Sample: n = 6 Gender: All male Age: 25–36 (mean = 32) Military background: Danish veterans Amputation: unilateral transtibial or transfemoral lower limb amputation.	Qualitative exploratory design triangulating semi-structured interviews and participant observations.	Inductive latent thematic analysis
Foote, Mac Kinnon, Robbins, Pessagno & Portner [73]	2015	US	Understand and describe the long-term experiences of living with combat related limb loss from the veterans’ perspective.	Sample: n = 20 Gender: All male Age: not stated Military background: Vietnam veterans Amputation: combat related limb loss	Mixed method, cross sectional study, including in-depth interviews (15/20 interviewed twice).	Descriptive analyses using inductive techniques
Jeppsen, Wood & Holyoak [74]	2019	US	To explore the experiences of combat-related amputation among military Veterans and explore pathways to resilient behaviours.	Sample: n = 6 (+ 5 spouses) Gender: all male Age: not stated Military background: Veterans with combat related amputation from Operation Iraqi Freedom and/or Operation Enduring Freedom. Amputation: Sustained military combat related traumatic limb amputation during deployment operations, either leg or arm amputation.	Semi-structured interviews	Content analysis using Metatheory of Resilience and Resiliency (MRR) as a conceptual framework
Khmiliar [77]	2020	Ukraine	To clarify the psychological features of the perception of the world by the servicemen who have lost their limbs due to combat injury and are experiencing phantom pain, how they perceive their previous and present bodies, and how they decode pain in the context of their previous and present experiences.	Sample: n = 16 Gender: Male Age: 26–47 Military background: Servicemen of the Armed Forces of Ukraine. Amputation: Combat injuries varying in severity which resulted in limb amputation.	Observation, associative experiment, and narrative interview	Narrative approach
Leonard, Sayre, Williams, Henderson, Norvell, Turner & Czerniecki [78]	2022	US	To understand patient experiences around amputation and shared decision making in health care.	Sample: n = 12 Gender: All male Age: 50–89 Military background: US military veterans, identified in the Veteran’s Affairs Corporate Data Warehouse. Amputation: All lower extremity	Semi-structured interviews	Interpretative Phenomenological Analysis
Littman, Bouldin & Haselkorn [72]	2017	US	To better understand the barriers and facilitators to physical activity that persons with lower extremity amputation face.	Sample: n = 27 Gender: All male Age: 24–68 (SD = 13, mean = 54) Military background: US military veterans receiving care from the Department of Veterans Affairs. Amputation: All had lower extremity amputation (LEA); 6 participants had a bilateral amputation and/or an upper extremity amputation in addition to a LEA.	Semi-structured interviews	Qualitative descriptive analysis
McGill, Wilson, Caddick, Forster & Kiernan [65]	2021	UK	To explore the physical, psychological and social wellbeing of veterans who have experienced limb-loss and to ascertain the factors that contribute to the ability of veterans to maintain their independence at various stages in their lives.	Sample: n = 32 Gender: 30 Male, 2 Female Age: 43–95 Military background: Royal Navy and Royal Marines, British Army and Royal Air Force. Amputation: limb loss sustained either during (14) or after (18) military service. Lost limbs due to conflict in military service, accidents or illness in military service (but not directly due to combat) and various post-service causes. Majority lower limb loss.	Life story interviews (up to three per participant).	Framework Analysis Approach
Messinger [66]	2009	US	To explore the role that context of injury plays in the rehabilitation of military patients who sustained a limb amputation.	Sample: n = 2 Gender: 2 Male Age: unknown Military background: US Military personnel Amputation: limb loss sustained on military duty in Afghanistan or Iraq. Both lost upper limbs below elbow.	Case studies	Ethnography
Messinger [67]	2010	US	To contrast two models of rehabilitation.	Sample: n = 1 Gender: Male Age: unknown Military background: US Army Amputation: Sustained bilateral limb loss on the right side on duty in Iraq.	Ethnography	Ethnography
Messinger [68]	2010	US	To explore the different orientations to time experienced by clinicians and patients in the US Armed Forces Amputee Patient Care Program at Walter Reed Army Medical Center in Washington DC.	Sample: n = 5^b Gender: not stated Age: not stated Military background: US military Amputation: not stated	Ethnographic observations and interviews.	Ethnographic
Messinger [69]	2013	US	To explore the two emotional experiences of hypervigilance and attention.	Sample: not stated^c Gender: not stated Age: not stated Military background: US military Amputation: not stated	Ethnographic observations and interviews.	Ethnographic
Messinger, Bozorghadad & Pasquina [70]	2018	US	To explore how the social context of a rehabilitation programme influenced the way former patients with lower limb loss evaluated their outcomes.	Sample: n = 20 (+clinical care providers) Gender: 19 Male, 1 Female Age: Mid 20s – early 40s Military background: US Military Amputation: traumatic lower limb amputation sustained whilst on active duty in Afghanistan or Iraq.	Cross-sectional phenomenological-based interviews and observations.	Content analysis
Neal [79]	2015	UK	To establish the effect that wounds had on the rehabilitation of traumatic amputees from the military patients’ perspective.	Sample: n = 10 Gender: All male Age: 23–30 Military background: UK military Amputation: sustained the loss of one, two or three limbs between 2009 and 2011 due to traumatic amputation.	Ethnographic design using semi-structured interviews.	Inductive coding
Taylor [76]	2020	UK	To explore the reasons underpinning individual requests for specific types of prosthetic lower limb in a population of veterans with amputations.	Sample: n = 15 Gender: All male Age: 23–51 (mean 34.7) Military background: UK military veterans Amputation: 6 single amputees, 8 double amputees, 1 triple amputee. Primarily sustained in active duty during Iraq and Afghanistan conflicts.	Written personal statements (secondary data, consisting of patient statements from the evaluation process associated with applications for new microprocessor-controlled prosthetic limbs).	Thematic analysis
Wilson, McGill, Osborne & Kiernan [64]	2020	UK	To examine the housing needs of veterans experiencing limb loss, and the impact of limb loss on housing needs and home adaptations of ageing military veterans.	Sample: n = 32 Gender: 30 Male, 2 Female Age: 43–95 (SD = 14.56, mean = 69.4) Military background: Veterans of Royal Navy and Royal Marines, British Army and Royal Air Force. Amputation: Mixture of in service and post service, upper/lower limb, and number of amputations.	Semi-structured life story interviews (up to three per participant).	Thematic analysis

^aDetail not provided in paper, provided via personal communication with first author.

^bCalculated by counting the number of pseudonyms used in the paper. Contacted author for clarification however response not received at time of submission.

^cContacted author for clarification, however response not received at time of submission.

Critical appraisal of the selected papers

The Critical Appraisal Skills Programme qualitative checklist (CASP) (https://casp-uk.net/images/checklist/documents/CASP-Qualitative-Studies-Checklist/CASP-Qualitative-Checklist-2018_fillable_form.pdf) was used as a tool to assess the quality, and strengths and weaknesses of selected papers. The CASP consists of 10 questions split into three sections which look to assess the validity and appropriateness of the methodology, design, recruitment, data collection, the relationship between researcher and participant, ethical considerations, analysis, results, and the implications of the research. Following Duggleby et al. [80] these items were assessed using a three-point scale, with three points being scored for strong evidence, two points for moderate evidence and one point for weak evidence. The majority of papers were assessed independently by the second author, and a selection of papers were evaluated by an independent second rater to assess agreement of scores. Disagreements were discussed, leading to some alterations to the scoring. The scores for selected papers ranged from 9 to 22 showing variation in quality as determined by the CASP items. The CASP scores were intended to provide a framework for critically considering the studies and not to exclude any of them as there is no consensus on indicators of quality in qualitative research [81,82]. For example, it is important to consider that it is the “quality” of reporting that is being judged, not the quality of the research undertaken [83]. Although CASP scores were not used to include or exclude papers for review, the resulting themes were representative of a range of papers with differing CASP scores. Details of the CASP scores for the papers included in this review are displayed in Table 3.

Table 3. Quality appraisal of the selected papers using Critical Appraisal Skills Programme (CASP).

	Study
CASP (2019) Questions	Caddick et al. (2018)	Cater (2012)	Christensen et al. (2018)	Foote et al. (2015)	Jeppsen et al. (2019)	Khmiliar (2020)	Leonard et al. (2022)	Littman et al. (2017)	McGill et al. (2020)	Messinger (2009)	Messinger (2010a)	Messinger (2010b)	Messinger (2013)	Messinger et al. (2018)	Neal (2015)	Taylor (2014)	Wilson et al. (2014)
Was the research design appropriate to address the aims of the research?	3	3	3	3	2	2	2	3	3	3	2	1	1	3	3	2	3
Was the recruitment strategy appropriate to the aims of the research?	2	2	3	1	2	2	2	3	2	1	1	1	1	3	3	2	2
Was the data collected in a way that addressed the research issue?	3	3	3	3	2	2	2	3	3	1	1	1	1	2	3	3	3
Has the relationship between researcher and participants been adequately considered?	1	3	1	1	1	1	1	1	3	1	1	1	1	1	3	2	1
Have ethical issues been taken into consideration?	1	2	3	2	2	1	1	2	3	1	1	1	1	1	1	3	1
Was the data analysis sufficiently rigorous?	2	3	3	3	2	1	3	3	2	1	1	1	1	2	1	2	2
Is there a clear statement of findings?	2	3	3	2	3	2	3	3	3	2	1	2	2	3	3	3	3
How valuable is the research?	3	2	3	3	3	1	3	3	2	2	1	1	2	2	2	3	2
Total	17	21	22	18	17	12	17	21	21	12	9	9	10	17	19	20	17
1 = Little to no justification or explanation
2 = Moderate justification or explanation but not fully elaborated on
3 = Extensive justification or explanation

Data extraction and analysis

A metasynthesis of the papers returned through the systematic review was conducted using a meta-ethnographic approach described by Noblit and Hare [56] to address the aims of the research. This approach aims to generate new interpretations from various studies which focus on a similar topic using comparable methodologies [84]. Firstly, the selected papers were read several times in order to become familiar with the data and key findings and to ensure that all relevant data were identified. Relevant second order constructs (the authors’ interpretations of the participant data), were then extracted along with first order constructs (any supporting data excerpts from participants). Third order constructs were produced by synthesising the first and second order constructs across the set of reviewed papers to identify commonalties and variations and produce novel insights. Finally, three overarching themes were identified to reflect the experiences of members of the military who have experienced limb loss. These themes are described in detail in the results section below.

It is important to note that the nature of the meta-ethnographic approach requires the author to make interpretations to generate themes across the papers, and the author will have an influence on this process [85]. To mitigate the potential to introduce bias in this process, data and interpretations were compared between the first and second authors, and the third author questioned and audited the process of analysis [86].

Results

The analysis generated three overarching themes: (1) Making the physical and psychological transition to life after amputation, (2) The role of the military culture in rehabilitation, and (3) The impact of relationships and the gaze of others during rehabilitation and beyond. They are discussed in detail below (the contribution that each paper made to the themes are provided in Table 4).

Table 4. Contribution of each study to meta-synthesis themes.

	Caddick et al. (2018)	Cater (2012)	Christensen et al. (2018)	Foote et al. (2015)	Jeppsen et al. (2019)	Khmiliar (2020)	Leonard et al. (2022)	Littman et al. (2017)	McGill et al. (2020)	Messinger (2009)	Messinger (2010a)	Messinger (2010b)	Messinger (2013)	Messinger et al. (2018)	Neal (2015)	Taylor (2014)	Wilson et al. (2014)
Theme 1: Making the physical and psychological transition to life after amputation	X	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x	x
Adapting to life after limb loss	x	x	x	x	x		x	x	x		x	x			x	x	x
Physical health and navigating healthcare systems		x	x	x		x	x	x	x
Mental health difficulties impede the ability to move on		x		x		x		x	x	x			x	x		x	x
Theme 2: The role of the military culture in rehabilitation	x	x	x			x	x	x	x	x	x	x	x	x	x		x
The military mindset and culture	x	x	x				x	x	x	x	x	x	x	x	x		x
Sense of self	x	x	x			x	x	x	x		x	x			x
Theme 3: The impact of relationships and the gaze of others during rehabilitation and beyond	x	x	x		x	x	x	x	x		x	x		x	x	x
Relationships with others		x			x		x	x	x			x		x	x	x
The perceived view of others	x	x	x		x	x		x	x		x	x		x	x	x

Theme one: Making the physical and psychological transition to life after amputation

This theme encompasses how military veterans transition to life after amputation, and how this can be impacted by various factors. It is represented by all 17 papers and is comprised of three subthemes: “adapting to life after limb loss,” “physical health and navigating healthcare systems,” and “mental health difficulties impede the ability to move on.”

Adapting to life after limb loss

For a number of participants, limb loss resulted in withdrawing from military service. For some this was difficult, as the military was seen as a big part of their life, with no alternative ever considered: “I hadn’t really give a lot of thought to well what will I do if I leave the army? What will I do if I got injured? You didn’t think about that necessarily” [65,p.3318]. The loss of military life led to feelings of being in limbo and that life had been taken away:

I just feel stuck, like I have no future or past. A lot of patients celebrate their alive day, you know the day they were hurt, to celebrate that they weren’t killed. But to me it’s like the worst kind of birthday because I feel a little like I was killed. No, not killed, I feel like on that day in October 2006 my life was taken away, everything in my life except for being alive. I’m like a baby again only I’m not sure that I’m going to grow up. [68,p.163]

For others, leaving the military was seen as a new opportunity, leading them to contemplate their future and place in the world, allowing them to explore different interests and careers: “If I have to sit at a desk, I may as well make a lot of money doing it.” [68,p.164]. However, for some, thoughts and plans for the future were in opposition to the goals of rehabilitation staff who focused more on physical functioning than exploring alternative careers and interests: “I want to decide about law school or try to find a career job. And, compared to the rest of my life, I got to tell you man, running [is] just not high on my list of priorities” [67,p.294].

Despite leaving the military, some still felt a strong connection and a sense of pride and comfort in having sacrificed their limb for their country. This was reflected in Cater’s paper [71], where military women compared themselves to civilian women with limb loss and spoke of the difference in camouflaging their prosthesis: “A lot of the women that I know who are military amputees, and the guys too, would be offended if you suggested that you hide [it].” [p.1450] and described finding meaning from their limb loss as it had “almost become a badge of honor.” When this sense of pride was affirmed by civilians, military veterans felt better cared for which impacted on their adjustment:

She [a lady who worked at the amputee clinic] asked me if I was a veteran and I said, “Yes, I am.” And she says, “Well we cannot have our Veterans walking around like that.” And from that day on, it got better … it was just like I was born again, and that’s the truth [72,p.603].

Adapting to life away from the military to civilian life, meant navigating new systems and it was felt there was a lack of guidance and information [64]. Some noted that help that had been available whilst in the military wasn’t available once they had left: “While you’re still in the military it’s available, once you leave the military [switch noise] no Headley Court. Nothing” [65,p.3319].

Physical health and navigating healthcare systems

Managing healthcare problems following discharge was reported as a problem for some, as there was confusion as to where to get support: “The GP can do nothing. District nurse says it’s not their business and (umm) [Occupational Therapists] no, physios no” [65,p.3319]. This difficulty in obtaining support was compounded by the difference between civilian and military services and the differences in prosthesis offered, with appropriate follow-up care being unavailable: “In the NHS there is a massive lack of qualified prosthetists who can actually deal with the robotic legs” [65,p.3319]. Aside from the specialist knowledge and skills that the military was perceived to have, some felt strongly that their care should remain within the military, highlighting the fundamental differences felt between veterans and civilians: “There is too big a difference between civilians and military personnel. The public healthcare system should not provide rehabilitation for military personnel, this should be provided within the military” [75,p.2257]. The reasons for such beliefs were attributed to the “authoritarian” mind-set of the military in which veterans had been inducted and how this contrasted with the values of patient involvement and shared decision-making in the civilian healthcare system.

Several physical health challenges impacted rehabilitation following limb loss, with pain being the most frequently mentioned complaint. One participant offered a vivid description of their phantom pain: “it may feel like someone is pounding ten penny nails into the bones of my foot, my toenails are being pried off, or beads of molten lava are going down my veins.” [71,p.1448]. Pain was reported to impact on their daily activities such as the ability to move and sleep [65], and withdrawal from daily life: “There’s times there that I won’t get out of bed for 2 days…my body’s too sore” [72,p.604]. As a result of pain and poor physical health, staying healthy and taking part in physical activity was challenging:

so any weight gain is an issue. But I also blame that on my lack of exercise. Because of my injuries, I don’t get as much exercise as I would like. So I guess battling the weight is probably the biggest issue that I deal with constantly [73,p.2857].

This highlights the stark contrast between the strong and able body experienced whilst in the military, and the body following limb loss.

In addition to phantom pain and pain from prosthesis, pain was also reported from the development of arthritis due to over-compensating over the years following limb loss [73]. An older participant spoke of needing to use a wheelchair due to pain, showing how limb loss had continued to have an impact on his life: “Now that I’m getting older I’m confined to a wheelchair. My leg hurts most of the time. My back hurts most of the time” [p.2859]. Building on the issue of aging with limb loss, some older veterans compared their experiences to younger veterans and felt that their experiences of adjustment were very different: “I mean look at them now, they get £50,000 legs and aftercare and everything. But before it was just a case of get on with it, you’re a wimp” [65,p.3319].

Mental health difficulties impede the ability to move on

Through synthesis of the papers, it was found that mental health difficulties impacted on the ability to accept one’s limb loss and move on following amputation. Post-traumatic stress was reported to be triggered by pain and could result in vivid memories of trauma. Here, pain is personified as a malevolent presence that cruelly reminds the participant of the “horror” experienced:

This pain is like an intruder for me. I feel it not only in my knee and in my right toes, but I also spontaneously returned to that tragic morning […]. On the one hand, the phantom pain reminds me that I can control my tank again, and, on the other hand, it brings back all the horror I have experienced. Phantom pain prevents me from forgetting it all [77,p.638].

With the persistence of the pain the memories stayed present and there is a constant reminder of the loss of limb: “I’m constantly in pain. It hurts to walk, even with prosthesis. It never lets you forget” [73,p.2859].

For some participants it was difficult to disentangle what could be a result of post-traumatic stress following limb loss or simply part of military training and identity. For example, Messinger [69] described hypervigilance of environment and how some soldiers felt this was a result of army training and not their injuries from a bomb blast: “I’ve always been that way, you know, situationally aware. But being in the Army just makes it more …intense or more a part of how I am.” [p.200].

Lack of social contact due to reduced mobility could also impact on mental health difficulties, and one participant spoke of how spending time alone resulted in rumination and negative emotions: “I am bored being stuck at home and it allows me to ponder and think long and hard about this and it does make me angry and it does get me upset.” [64,p.8].

There was a lack of support reported for help with mental health difficulties: “there was no psychologists, no psychiatrists, nobody I could talk to in confidence. My mind wasn’t functioning correctly” [73,p.2858], and there was a reluctance to accept support that was available. For example, Messinger [66] described Ronald who felt that seeking help for his difficulties could have a negative impact on his military career. For some, avoiding seeking help led to further mental health problems:

I guess the way I dealt with PTSD for so many years was to put it in the back of my mind…I had no one to talk to. I had no one to relate to. I was so alone that I contemplated suicide most of the time [73,p.2858].

The lack of mental health support was linked to military attitudes of stoicism in a study involving older veterans, and so unhelpful coping strategies such as alcohol were used instead: “The military coping at the time was don’t be a cry-baby, just go out, get [drunk] and get over with it…get over it, soldier on” [64,p.12].

Theme two: The role of the military culture in rehabilitation

This theme encompasses the military culture and mindset and how they impact on individuals’ experience of amputation, rehabilitation and sense of self. This theme is represented in all but three papers [73,74,76] and is comprised of two subthemes: “the military mindset and culture,” and “sense of self.”

The military mindset and culture

The military mindset was reported to be useful during rehabilitation as it pushed military veterans, helped them to achieve physical goals and was helpful when experiencing set-backs during rehabilitation. The military instilled the importance of physical fitness and putting in significant effort, and these attitudes were carried through post limb loss and during rehabilitation:

The army set you in the mind set, don’t they, of “be the best” basically isn’t it. You always try to be at the top of your fitness, you always do every challenge set in front of you and all that lot. Obviously when you’re first wounded it’s not going to happen but, also, that mentality helps you to recover as well [79,p.67].

This mindset of pushing themselves tied in with the identity of being a soldier and was thought to be a permanent part of veterans’ makeup:

At the end of the day we still are soldiers and no one can take that away. And we will take that to our grave…So I think, you know, going back to being a wounded soldier, we like to push our boundaries. Even when we were fully abled, fighting fit we pushed our boundaries then and all we’ve done now is carry it on to help us [79,p.67].

The physical aspect of military culture was often valued during rehabilitation. Physical challenge, routine and the culture of exercise was something the veterans were used to. As exercise could provide structure to the day, which military veterans were accustomed to, it was a valued activity and therefore this structure helped encourage sports participation during rehabilitation [72]. Not all veterans experienced this sense of structure during their rehabilitation phases. Where this was the case they often “missed a sense of order, structure and regimes during my rehabilitation – basically, the military mindset.” [75,p.2557].

Some felt the rehabilitation environment had echoes of the military environment, especially being around other military veterans, which gave familiarity. Sometimes this was provided through health professionals who shared their military background:

There’s not too many medical things that I could ask him [surgeon], because he obviously knows what he’s doing. The only thing we had in common [the surgeon who had served in the air force] was that I worked with the F18s in the Marine Corps, and a few other aircraft, so I was like, at least we had that in common. [78,p.8].

Being around other veterans also provided friendly competition and encouragement which spurred them on during rehabilitation:

It felt good to be back in that kind of environment. Even if [we] don’t make a big deal of competing, [the patients] keep an eye out on what others are doing or can do… Seeing how others were doing was a huge motivator [70,p.91].

Independence was a major aspect of the military culture. For some it was important to not be seen as reliant on others and to be seen as capable: “I don’t ask anyone for help really. I've been a bit too independent really for that kind of thing [support]. I've always tried doing it for myself, yeah … I've always just got on myself and done it” [63,p.28]. The desire for independence clashed with views on the level of autonomy given to some over their healthcare, where some people reported a preference for being told what to do during rehabilitation. This may reflect the military culture of receiving orders from a higher rank:

I guess it goes back to being in the Marine Corps, the respect you give to, I treated my doctors like officers, that I had when I was in the Marine Corps, as far as “yes sir,” “no sir.” I just put my trust in them and made the leap that they were going to do right by me and do what they needed to do to get me up and going. [78,p.8].

As the military mindset favoured independence it could prevent people asking for help, which could lead to a continuation of suffering: “I am so independent, it is difficult to actually go to them and actually say (umm) I need help” [65,p.3320]. However, it was not always possible to maintain independence and veterans often had to rely on others which contrasted with the military mindset instilled in them:

When I was first in the hospital I felt like I was helpless and that I’d always be helpless, forever. This feels just like that, you know, I was walking with canes, planning to get a new [adaptive] car and now I’m back in the hospital with my wife wiping my ass [68,p.160].

Sense of self

For some, the military was a core part of their identity, and this is something that had stayed with them since leaving the military: “I was a Marine and I still think like one. And they took two words out of my vocabulary: I can’t.” [72,p.604] and will persist: “At the end of the day we still are soldiers and no one can take that away. And we will take that to our grave” [79,p.67]. However, for others there was a desire to disconnect their future self from the military. Messinger [67] described a veteran who, although he appreciated that the military was an important facet of his life, did not want it to encompass his life and future: “I want my service to be part of my life, I don’t want it define my life.” [p.295].

Rehabilitation was described as a time where an identity crisis took place, being unable to identify who they were now: “discussion with myself about asking …is that a different me or is that the same me? Is that a different person than who I am now?” [68,p.160]. During this identity crisis they were able to learn about themselves, change and develop, thus forming an altered identity and sense of self: “I feel like I’ve found out that my mind is as moldable as my body was.” [67,p.297].

There were also identity struggles in relating to that of the disabled identity whereby it was felt that identifying as disabled was undesirable: “I don’t want to declare myself as a technically (umm) a severely disabled person. Because in your head you don’t want to be that person, in your head you want to be normal” [65,p.3318]. This spurred participants on to make positive rehabilitation gains:

And pretty soon, I’ll be able to walk like normal. But at a shorter pace. That’s what I have to deal with each day, and I do my exercise. Especially without the cane, because I want to get to walking where I don’t need the cane, no kind of assistance from anything. Or anybody. It’s like a personal thing with me. I don’t want to be considered handicapped. That’s what I’m dealing with each day. [78,p.7].

In addition, there were also difficulties in finding their place in society, with a feeling of vast difference between veterans and civilians with limb loss:

I found it difficult to relate to the others [non-veteran amputees] as they were at least 60 [years old], had diabetes, their arms were crossed, and they felt sorry for themselves… and you felt - come on!… It felt like we were from two different worlds with different ambitions for rehabilitation and for our subsequent lives. [75,p.2556]

Theme three: The impact of relationships and the gaze of others during rehabilitation and beyond

This theme concerns how relationships with peers, staff and family can impact on military veterans’ experiences of rehabilitation and beyond. It is comprised of two subthemes: “relationships with others” and “the perceived view of others,” and is represented by all but four papers [64,66,69,73].

Relationships with others

Being around injured peers who were also undergoing rehabilitation for limb loss was found to be useful. Veterans who were further along in their journey provided others with someone to model from and a future reference point of where they could get to. This provided a sense of optimism, hope and inspiration: “I could see him [an amputee] ambulating…and I didn’t notice a limp with him. And I said to myself, ‘That’s where I want to be doing. That’s where I'm going to be.’” [72,p.603]. Peers also provided encouragement to one another and a sense of camaraderie. They could learn from each other and those who were further along in their recovery would pass on knowledge and support to the newly injured: “As I got stronger and I could walk on my leg I’d go up to [Walter Reed Army Medical Center inpatient ward] 57 and talk to new guys and try to cheer them up or give them some idea of what to expect” [70,p.90]. They would tease each other as a way of encouragement, and this was in keeping with the military culture they were accustomed to: “if someone was just kind of leaning on the machine or not doing much we’d talk shit to them. It wasn’t planned; it’s just that guys would always rag on guys who were being lazy. I worked hard to avoid [having] that [directed at me].” [70,p.91].

The sense of togetherness and teasing also had mental health benefits in preventing rumination: “so, you have banter and take your mind off it if you are worrying about it quite a lot” [79,p.67]. Commonality and feelings of togetherness was important, and some felt their rehabilitation would have been different if they had not been around other military veterans:

I imagine the road to recovery would have felt very lonely if I’d not been with other military guys. Say I’d been in the NHS and the prosthetic care I received was with other people [patients] with injuries like mine but they weren’t military I wouldn’t be able to relate to them even if they were suffering the same thing [79,p.67]

Moreover, some participants envisaged a future role which would draw on their amputation experience to help other veterans in the same position, thereby perpetuating this togetherness based on shared service and limb loss experiences:

I would love to teach the other guys. I might not even be able to teach them, I might just be able to be there and listen […] My own little contribution back to society would be, I could lead by example, I’d say, “hey, we’ve got to take care of everybody, each other particularly.” And it didn’t matter if they were in WWII or if they were in Afghanistan last week. [78,p.7].

Support was not only gained from peers, but also from rehabilitation staff. Staff offered encouragement and were important in helping veterans reach their full potential: “She didn’t take any excuse from any of us as to why we couldn’t push ourselves that day to perform what she expected to be done in our rehabilitation” [72,p.602]. Staff also provided an opportunity to step away from the expectations of “toughness” and unemotional communication associated with a military identity, showing their more vulnerable side and gaining comfort that might otherwise be unobtainable from peers: “It’s hard to stop being the bad-ass Marine, so it’s nice to have someone that you can talk to quietly who isn’t going to call you a [wimp].” [70,p.89]

Family and close relationships were also impacted by limb loss as partners were often required to take on the role of carer. This could put a strain on relationships and instil a feeling of dependence: “After I got hit I couldn’t believe what she had to do for me, things I have no memory of my mom doing for me. We had terrible fights; I was terrified about whether she’d want to be with me after seeing me like this” [68,p.161]. Limb loss and difficulties with mobility affected the ability to take part in activities with family and fulfil family roles. Being provided with appropriate prosthetics could have a positive effect on this and allow expectations to be met such as being a father: “added benefit that I can play outdoors and swim with my children” [76,p.8]. Allowing family members to be a part of rehabilitation and join in with exercise could help strengthen relationships: “as I’ve been getting into mountain biking a lot more, we’ve gone out, got pretty much everybody in the family a bike. So we’ll go on family bike rides now” [74,p.63].

The perceived views of others

For some military veterans, it was important to be seen as capable and to show others that they were coping well and succeeding; this meant appearing non-disabled:

I was determined that I was going to you know walk as normally. And in fact, most people up until quite recently, don’t realise that I wear a prosthesis. And that’s what I wanted. I wanted to be you know, accepted as normal [63,p.28].

Employment was described as a useful avenue in proving to others that they were just as capable as non-disabled people: “You’ve got to prove to yourself that you can do a job and just as important prove to others” [63,p.28], and for some it was important to go above and beyond, and accomplish more than non-disabled people in an effort to prove their abilities: “I want to prove, I am proving, that I can do more on one leg than most people can do with both.” [68,p.164]. To be seen as someone who is coping well, one participant spoke of taking part in a marathon where one of the main motivators was proving themselves to others: “And I did it because I wanted to anyway, to prove to myself like you’ve got to get on, but it was also I did it for my family to see I'm ok” [63,p.30]

Growing accustomed to reactions to their body in public was something veterans had to adapt to and accept; for example, a female who lost her leg during service felt she had to “adapt to everyday life, going out in public and dealing with the reactions of people on the street.” [71,p.1451]. These perceived negative views of others prevented accessing benefits and help veterans were entitled to and prevented disclosing their disability:

I don’t want to be seen as a charity. I want to know that I can go out there, earn the money in my own right … That’s why I won’t apply for all the disability benefits because I don’t want them…I don’t want … for the country to label me as a scrounger and as a dole-dosser … I want a job [65,p.3318].

The desire to appear “normal” often outweighed their own comfort and some would seek to appear “normal” even if it was an inconvenience to them. A participant described by Messinger [67] spoke of not hanging a bag off the crook of the elbow of their amputated arm whilst in public: “it’s not a normal thing, it’s not an everyday thing to have a stump. But, then it’s one thing to have it, it’s another thing to throw it in people’s face in a way that you don’t really need to” [p.292].

There was a difference in how participants felt about the views of others. Some felt the identity of a disabled veteran was undesirable: “it’s not that I’m not thankful about how nice they were, or that they appreciate me for what I did, but I want to be a regular person and not always a disabled vet” [67,p.295]. However, being seen as an injured veteran could sometimes offer benefits and some were proud of the attention they received: “I am really proud of how I lost my leg, and I am proud I wore the uniform.” [71,p.1450]. Here there is a contrast between being viewed as a disabled veteran and being viewed simply as a veteran, suggesting there is a difference between them, and perhaps more internalised stigma held amongst some veterans.

Discussion

This review has synthesised qualitative findings from 17 papers focusing on military veterans who have experienced limb loss and illustrates key aspects in their life during and after rehabilitation. This is the first meta-synthesis to bring together qualitative findings focusing on military veterans’ experiences of limb loss, providing novel insights to inform policy and practice.

Transition from military to civilian life (closely mirrored by the transition from able-bodied to a person with limb loss), and the role of military culture and others (health professionals, peers) were identified as over-arching areas of significance in veterans’ rehabilitation. One theoretical strand regarding such transitions and processes for persons with chronic illness and disability (CID) has focussed on psychosocial adaptation [87,88]. For example, Livneh’s [88] model of psychosocial adaptation to CID posits a diverse set of antecedents, processes and outcomes that incorporate biological, psychological, sociocultural and environmental factors. The importance of these facets can be seen in participants’ accounts, provided in the current review, relating to the physical changes brought by amputation, the psychological responses to this, and the wider influence of the military and others on their adjustment. Bishop [87] suggests that CID often leads to a change (frequently a reduction) in quality of life (QoL) due to diminished means for achieving satisfaction and control in personally important areas of life. People can respond to this reduction in QoL through adaptive changes both to external conditions or a change of personally held values.

Such responses as the above are an integral part of rehabilitation following limb loss. In the present review, veterans recounted a variety of challenges that their limb loss presented and the degree to which they felt able to adapt to their changed circumstances. Coffey and colleagues [89,90] have highlighted the role of “tenacious goal pursuit” (TGP), or striving towards goals, following amputation in speeding up progress in the attainment of valued goals and the experience of positive affect. Indeed, the present review highlights how the adoption of this outlook and ability to achieve some goals, such as to begin walking again, was valuable. Moreover, this process was aided for some by a military “mind set” that had instilled the importance of physical fitness and making significant personal effort. However, for other veterans, despite exhibiting this tenacious goal pursuit, they found the goals of the rehabilitation team were in opposition to those they personally held.

For other veterans, their particular circumstances (such as experiencing high levels of pain) meant their goals were difficult to achieve. Coffey and colleagues [89,90] suggest that when goals cannot be achieved through a strategy of TGP, then being able to disengage from or adjust one’s goals (flexible goal attainment, or FGA) is likely to buffer against negative affect that might otherwise ensue from disruptions in goal attainment. Again, evidence of this is apparent in the present review findings, such as veterans who were unable to stay in the military but were able to identify alternative, fulfilling career plans. However, for others, such as those with high levels of pain that impacted their ability to walk, or those who could not envisage alternative careers outside of the military, this was a response they had difficulty adopting. Some veterans, then, had difficulty in making either adaptive changes to external conditions or in changing personally held values. Such participants might benefit most from Coffey et al.’s [89] recommendation that those with limb loss should be encouraged to strive "towards attainable goals" and be provided with support "in adjusting or dissolving commitment to goals no longer feasible.”

The current review highlights the difficulties for some veterans in accepting limb loss and considering new roles and careers. Physical and mental health was found to impact on the ability to move forwards following limb loss, and the role of pain and post-traumatic stress was highlighted. The current review found that experiencing pain, such as phantom limb pain or pain in the residual limb, could trigger difficult memories. A recent systematic review and meta-analysis focused on PTSD and pain in veterans found that veterans with PTSD and pain experienced high levels of pain, disability and depression and were also found to have a higher level of catastrophising beliefs, sleep disturbance and healthcare utilisation, and had lower pain self-efficacy and level of function [91]. The current review adds an understanding of the meaning-making regarding these pain experiences and how they act to remind veterans of their lost lives and abilities, the traumatic circumstances in which they lost a limb, and the absence of the limb itself.

As indicated above, findings from the review highlight how the military culture can be helpful in pushing military veterans to achieve their goals during rehabilitation. It could also provide camaraderie and familiarity during rehabilitation. However, limb loss was found to impact on sense of self, and the review highlighted differences between veterans in the acceptance of the various identities, including the military identity or disabled identity, following limb loss. This has similarities with existing literature regarding limb loss for civilians, which describes individuals feeling as though they have become a different person following amputation [92], and go through a process of renegotiation or resistance in transitioning to a new disabled identity [93]. However, the particular identity and values forged through the military culture can result in distinct difficulties. For example, veterans’ experiences, understandings of, and attitudes towards a disabled identity often contrast with their military identity of being strong and capable. Although some participants in the current review were happy to receive attention from the public, others were keen to distance themselves from the military and the identity of an injured veteran, demonstrating a complex relationship with themselves, the military, and perceived public perception.

Finally, the importance of relationships with others and the impact of the perceived view of others was highlighted in the current review. Support from peers was found to be helpful during rehabilitation, and many felt it was important to show to others that they were capable and strong. Relationships with people who are separate to the military identity, such as rehabilitation staff, were also important in facilitating expression of more vulnerable and emotional aspects of the person which would otherwise be difficult around peers. The desire to be seen as “normal” or as a “regular person” was mentioned by various participants. Being able to pass as non-disabled or accomplish more than the average non-disabled person was important for some in feeling accepted and accepting themselves. Again, these can be seen as personally salient goals, that may be more or less attainable for different participants. Taking part in sport became one valued method for some in demonstrating to others (and themselves) that they were adapting well. This corresponds with literature in the field of sports and disability where sport has been found to enable people to show others they are able to achieve the same as able-bodied people [94].

Clinical implications

The findings of the review have several important clinical implications to assist military veterans adjusting to life following limb loss. As discussed above, theory regarding psychosocial adaption to CID highlights the role of biological, psychological, sociocultural and environmental factors, and work specifically in regards to limb loss has focussed on the process of goal pursuit and goal adaptation in increasing positive affect. Following limb loss, veterans’ experiences of rehabilitation elucidate the role of their military training, the rehabilitation offered by the military, and the veterans’ own values and goals in their recovery. Some veterans experienced difficulty in achieving valued goals or in adjusting goals based on their limitations. Such veterans are most likely to experience negative affect and poorer psychosocial adaptation, therefore it is vital that their needs are addressed. Therefore, where possible, such veterans should be supported by the rehabilitation team to pursue attainable goals and be provided with support in adjusting or dissolving commitment to goals no longer feasible [89]. However, in order to optimise recovery, it is important that rehabilitation goals are congruent with the personal ambitions of veterans. It may also be possible to identify (using standardised measures [90], or as part of psychological evaluation) at an early stage of rehabilitation those at risk for poorer adjustment, by examining their propensity or not to adopt goal pursuit and goal adaptation strategies [90]

The review highlights the importance of not just providing physical rehabilitation following limb loss amongst the military population, but rehabilitation to civilian life. This transition to civilian life could be challenging if the military mindset and values do not fit in with civilian life. Rehabilitation professionals trained in psychological interventions could be helpful in supporting veterans in exploring their new identity and helping them continue to live according to their values to ameliorate the feeling of not belonging. Therefore, access to psychological support should be available after leaving the rehabilitation centre to help with the transition.

The review found that pain could trigger PTSD symptoms and flashbacks, preventing moving on from the trauma. This suggests that targeted interventions delivered to those with severe phantom or residual pain following amputation may be beneficial. An important finding was the meaning that veterans ascribed to their pain, for example the reminder of lost abilities. An approach which focuses on changing these meanings and the relationship with pain could be beneficial, such as cognitive behavioural therapy (CBT) [95] or acceptance and commitment therapy (ACT) [96] (although these therapies could have broader relevance to the process of adapting to limb loss than just pain management). Pain management programmes are frequently underpinned by CBT principles and there is evidence which demonstrates its efficacy [97]. Existing research points out that veterans with PTSD and pain are likely to have catastrophising beliefs and low self-efficacy [91], so this could also be an important area to target CBT intervention. Alternatively, ACT may be useful as it helps people to identify and live according to their values, despite the presence of pain, and has been found to be as effective as CBT in managing chronic pain [98,99]. For individuals who experience traumatic memories when they experience pain, eye movement desensitisation and reprocessing (EMDR) [100], which was developed to treat psychological trauma, may be helpful and there is evidence that it is effective in reducing pain, depression and PTSD symptoms [101]. An integrated treatment approach for pain and PTSD may be beneficial, and research demonstrates the feasibility and clinical benefit of an integrated approach amongst veterans [102].

The role of other veterans during rehabilitation was found to be beneficial. This was provided in an informal way, for example seeing others on the rehabilitation unit and teasing and encouraging others. It may be beneficial for rehabilitation professionals to facilitate peer support in a more formal way if not already in place, such as being assigned a mentor or buddy. Peer mentors can also aid in the engagement with rehabilitation. For example, self-management treatment interventions, that have been found to improve psychosocial functioning and quality of life, have previously involved people with limb loss as trainers or leaders in session and content delivery, within existing civilian peer support groups [103] and in military settings [104]. Peer support can improve outcomes for individuals following amputation [105] and can provide a sense of belonging, hope and resilience [106]. Rehabilitation professionals with psychological training could be involved in providing support and training to mentors in providing peer support [106].

Limitations and future research

While the present review provides a comprehensive synthesis of the available published research evidence in peer-reviewed journals concerning veterans and limb loss, it remains reliant on what research has been conducted. This is a relatively small body of literature (17 papers detailing 12 studies). Two sets of papers drew on the same samples and data sets. However, the analysis was conducted while being mindful that the results of these studies could not be treated as separate and independent. Indeed, while some of these papers provide evidence together [e.g., 63–65] for particular themes in the analysis (as for “Life after limb loss”), it is important to note that on occasion papers made their own isolated contribution to evidencing the analysis (such as “Relationships with others” which was evidenced by McGill et al. [65], but not Caddick et al. [63] or Wilson et al. [64].

As noted earlier, quality ratings of the included papers in the present review ranged from low to high scores. However, CASP scores were intended to provide a framework for critically considering the studies and it is important to consider that it is the “quality” of reporting that is being judged, not the quality of the research undertaken. The three lowest scoring papers in the current review were all ethnographic studies comprised of interviews and observational data, published in formats (common for the methodological approach, such as not having a “method” section) which did not adhere to the conventional reporting that the CASP [107] is designed to evaluate. Moreover, these were the only papers to report longitudinal data collection (over two years) that documented experiences close to when they occurred in limb loss rehabilitation settings. Methodologically, then, these papers provide strengths not readily captured by the quality appraisal tool applied in the present review. Indeed, the particular value and unique contribution that ethnographic studies have made to the study and understanding of limb loss has recently been argued [4]. Therefore, despite scoring low on the CASP tool, these papers made a strong contribution to understanding the themes expressed in the synthesis and offer opportunities for further methodological innovation in studying limb loss.

The experiences of female veterans (few papers included women’s views, and only one paper focused solely on women’s experiences) and older veterans (where ages were provided, the large majority of studies comprised samples of middle-aged men) were largely absent. These remain important areas for future research to aid a better understanding of the experiences of female veterans and how to support an aging veteran population. In addition, the exclusion of grey literature, which might include research conducted by third sector organisations who support injured veterans, creates the potential to have missed additional valuable insights. It is also noteworthy that the included studies were all conducted in Western countries, mostly the UK and US, biasing the findings to Western cultures, and the military and healthcare systems within them. However, included papers were required to have been available in English, which could have added to this bias, although only three non-English papers were excluded. Future research exploring the experiences of limb loss amongst non-Western military veterans would help in making recommendations for health and social care needs for populations from different social, cultural and geographical regions.

Conclusions

This meta-synthesis is the first to synthesise qualitative findings exploring the experiences of amputation and rehabilitation amongst military veterans. It synthesised 17 papers from four countries and highlighted three themes which described post amputation life for military amputees. Results add to current understanding by emphasising the difficulties transitioning to civilian life and highlights the role of pain in post-traumatic stress, and the useful role of peers and the military culture during rehabilitation. The findings suggest several clinical implications for rehabilitation services including psychological support during the transition to civilian life, the use of peer support, and targeted treatment for those experiencing pain following limb loss.

Acknowledgement

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