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

Figures & data

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)))))

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

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.

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

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

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