Comment on: Functional Outcomes of Patients with Amputation Receiving Chronic Dialysis for End-Stage Renal Disease

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To the Editor:
As a future physical therapist who is interested in the recovery of individuals who have undergone an amputation, I value the attention paid to the subject by the American Journal of Physical Medicine & Rehabilitation article, “Functional Outcomes of Patients with Amputations Receiving Chronic Dialysis for End-Stage Renal Disease.” The article concludes that there were significant differences between the end-stage renal disease (ESRD) and non-ESRD group in terms of length of stay and functional independence measure scores through discharge and upon follow-up. Although the information given was appreciated, it was clear that the authors may have failed to control for noncompliance with treatment owing to the emotional states of the ESRD patients. It also became apparent that there could exist a connection between diabetes and the data collected for functional independence measure scores as well as length of stay.
The authors describe the demographics of the study, yet do not highlight the statistical and scientific significance of having a test group where every member suffers from a condition (diabetes) that is well recognized for its effects on the study’s metrics.1 There are well-known complications with diabetes including but not limited to wound healing. In fact, wound healing of an individual with diabetes can be slow, which results in chronic infection-prone wounds.2 Independent of ESRD, diabetes could be sufficient to explain the difference of the length of stay and functional independence measure score between the two groups.
Another significant factor that was not expanded upon in the analysis of ESRD and non-ESRD patients was their emotional state. According to the journal Psicothema, kidney patients can have an increase in anxious and/or depressive states.3 This increase could affect the data collected, because such an emotional state can be a risk to therapeutic compliance.3 In fact, depressed patients are three times more likely than nondepressed patients to be noncompliant.4 These tendencies may be explained by a loss of optimism that treatment will be effective or be explained by other reductions in cognitive functioning.4 Such tendencies would be major factors when considering patients’ functional independence measure scores upon follow-up, because, once at home, patients lack the structured care that exists in a hospital setting. Indeed, the differences in scores at follow-up are larger than the differences in scores at discharge.
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