The association between quality of life, anxiety and depression, and residual limb and phantom limb pain in war-related amputees: a year-long observational study

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Background: Postamputation pain (PAP) is associated with significant reductions in quality of life and psychiatric co-morbidities, with the relationship being bidirectional. In military service members, amputation and its sequelae are associated with these decrements, though the relationship between PAP, psychiatric symptoms and quality of life (QoL) has not been explored. Methods: In a prospective cohort of 156 Ukrainian war-related amputees treated between June 2023 and September 2024, phantom limb pain (PLP), residual limb pain (RLP) (0-10 NRS), anxiety, depression (HADS-A/HADS-D), and QoL (0-100 VAS) were assessed longitudinally (baseline, 3, 6, 12 months). Mixed-effects repeated-measures models tested time effects and time-varying associations of anxiety, depression, and QoL with PLP and RLP. Cross-lagged panel models tested prospective, directional associations between psychological factors and subsequent PLP/RLP across follow-up while accounting for pain stability and within-wave correlations. Findings: Outcomes improved over time, with mixed-effects models showing a strong time effect for both PLP (P < 0.001) and RLP (P < 0.001). Higher QoL was associated with lower PLP and RLP (both P < 0.001), while higher anxiety and depression were associated with greater RLP (both P ≤ 0.005). In cross-lagged models, depressive symptoms and anxiety were associated with higher subsequent PLP, whereas QoL was associated with lower subsequent PLP; PLP showed no lagged associations with later depression, anxiety, or QoL. For RLP, the only directional lagged association was with later depressive symptoms. Interpretation: In war-related amputees, PLP and RLP improve substantially over 12 months alongside reduced psychological distress and improved QoL. QoL is robustly linked to both pain outcomes across recovery, while anxiety and depression show stronger (and time-varying) relationships with RLP than PLP. Cross-lagged models indicated that affective/QoL measures were linked to later PLP, while RLP was linked to later depressive symptoms, supporting distinct coupling mechanisms. Funding: The U.S. Department of Defense funded this study (personnel costs).

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