Threat Related Attention and Coping with Lower Limb Amputation

It is fairly common practice for adult patients to undergo amputation of a lower limb as a complication of diabetes mellitus neuropathy. Coping with such a dramatic and potentially lethal event is crucial for future physical and mental health. There is no reliable method for evaluating coping differences amongst patients. Our aim was to examine a potential tailor-made evaluation tool based on attention differences. Methods: A Cognitive test of Attention Bias was transferred using the Double Dot Probe Task (DDPT) amongst diabetic patients in need for amputation. The test is differentiating between “avoidant” and “anxious” coping styles. A prospective follow-up was conducted using The Katz Questionnaire, healing of the surgical stump, Hgb-A1C values and whether prosthesis had been adapted. The relationship between the attention bias tests and the indices examined was tested to assess the ability to cope with the new condition. Results: 16 pre-amputation diabetic patients were evaluated. Those found to cope “avoidantly” were older than those coping “anxiously”. The average hospitalization duration was shorter amongst those with an avoidant coping style. Deteriorated daily functioning was recorded in the anxious group. From an aspect of the post-operative Hgb-A1C values, the results were not consistent. Conclusions: there is an important difference in coping and outcome, between the two groups. In order to determine whether DDPT software enables us to evaluate patient’s ability to cope with the amputation, we need to expand the patient groups and adapt the software to the patients’ ability.

and coping with its results. Parkes et al. [2] projected Kobler Ros' [3] five stages of grief onto dealing with amputation: Denial, anger, bargaining, depression, and acceptance. Holmes and Rahe [4] described the grief process suggest that increased and exceptional emotional response during grief may prevent the patient from recovering due to profound physical and emotional morbidity.
Emotional response to threat in the forms of anxiety, depression, posttraumatic stress symptoms, and pain has been associated with biased attentional processing of threat-related information [5][6][7] The dot probe task [8] is a widely used to measure of threat-related attention biases [9][10][11]. In this task, two stimuli, one threat-related and one neutral, are simultaneously shown on each trial, and their offset is followed by a small probe appearing at the location just occupied by one of the stimuli. Participants are asked to indicate probe position as fast as possible without compromising accuracy.
Response latencies on the dot-probe task are held to provide a "snapshot" of the distribution of participants' attention, with faster responses to probes presented in the attended relative to the unattended location. Attentional bias toward threat is inferred when participants are faster to respond to probes that replace threat rather than neutral stimuli whereas the reverse pattern is thought to reflect threat avoidance [12].
Attentional threat avoidance measured by the dot-probe task emerged as predicative of susceptibility to PTSD following combat exposure in deploying Israel Defense Force soldiers [13] and US Army soldiers [14] Further research suggests that attentional training designed to reduce attentional threat avoidance can reducing risk for PTSD symptoms following deployment [15,16].
In the current pilot study, we preliminarily characterize threatrelated attention patterns of orthopedic patients planned for lower limb amputation and evaluate how these attention patterns relate to patients' ability to adjust to life post the surgical procedure.

Research Assumptions
Patients with baseline attentional threat avoidance would:

1.
Display greater trouble accepting the need for limb amputation.

2.
Struggle to adapt to the new situation following the surgical procedure and their rehabilitation will be slower, as reflected in the KATZ questionnaire scores (Appendix 1).

3.
Struggle to remain healthy, balance diabetes, and would have higher values of Hgb-A1C and more stump complications.

Materials and Methods
Our research is a prospective, analytic, and observational.

Methods and Measures
Attention to threat was assessed using 120 trials of the angryneutral faces dot probe task (TAU-NIMH ABMT initiative; http://tau. ac.il/∼yair1/ABMT.html). Sequence of events on a dot-probe trial is depicted in Appendix 2. In each trial, a fixation cross appeared first (500ms), followed by two faces of the same actor (500ms), Participants completed the dot-probe task at baseline, shortly before the time of limb amputation. During the patient's hospitalization period, their ability to perform daily living activity was assessed using the KATZ questionnaire (Appendix 1). Based on this questionnaire a score of 6 = full independence, 4 = medium decline in functioning; and 2 or less = severe decline in the functioning in daily routine activity.

Statistical Analysis
Descriptive statistics were extracted to describe the distribution

Results
Of the 16 patients enrolled in the study 14 provided data at the 3-months follow-up. In addition, attention bias scores of participants were not available due to technical failure. Thus, all reported analyses were conducted on the 13 patients who provided complete data sets.

Patients' Demographic Data
Patients' demographic and clinical data are described in Table   1: pre-and post-surgery (Table 2).

Discussion
Lower limb amputation due to diabetes and vascular disease complications is a common procedure. A post-surgery follow-up of these patients reveals that a significant percentage requires additional interventions, and many are unable to deal with the new situation. To the best of our knowledge, factors related to patients' psychological character and cognitive processing style are not taken into consideration by healthcare providers. Here we tested whether threat-related attention biases recorded at pre-amputation relate to patient's recovery from a limb amputation. The main limitation of the study stems from its small sample size, therefore, all the findings should be taken with a limited confidence.
Our main finding showed that avoidant attentional pattern seems more adaptive for the patients after amputation. This finding is supported by the work of Sheppes et al. [17] showing that under extreme threat people usually select to regulate their emotion using avoidance strategies rather than re-appraisal ones. As mentioned earlier, the research has several limitations is small sample size, the difficulty to operate the dot-probe task by some of the patients, reliance on self-report questionnaire rather than an objective functioning test etc. However, despite tie low evidence of effect in the current study it appears that the extant trend level finding does appear to warrant additional research with a larger sample.

Conclusions
It is crucial to find tools to evaluate the mental and cognitive coping of people undergoing a major medical procedure such as amputation. Due to those findings, along with the long reaction times, we concluded that the DDPT as currently exists, is unsuitable for the population chosen for the research, and needs to be adjusted. We believe that, in order to evaluate and supply these patients with better physical and emotional resources, we would need to find an easier cognitive tool for evaluation. Our preliminary results presented here, may serve as a steppingstone to a larger more controlled and elderly suited study. We estimate that trauma patients arriving at the Orthopedic Department could be a better research group due to their younger age. This group is thought to be more homogenous, due to fewer background diseases, and fewer variables interfering with statistical comparisons. Younger patients are probably more skilled in computer use and would be able to operate the software significantly faster.