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International Journal of Psychological Research

Print version ISSN 2011-2084

int.j.psychol.res. vol.11 no.2 Medellín July/Dec. 2018

http://dx.doi.org/10.21500/20112084.3487 

Research articles

Body image, perceived stress, and resilience in military amputees of the internal armed conflict in Colombia

Imagen corporal, estrés percibido y resiliencia en militares amputados en el conflicto armado interno en Colombia

Daniela Herrera-Moreno1  , Diego Carvajal-Ovalle1  , María Angélica Cueva-Nuñez1  , Camila Acevedo1  , Fernando Riveros-Munévar1  , Katherin Camacho1  , Diana Milena Fajardo-Tejada2  , Mauricio Noel Clavijo-Moreno2  , Dary Luz Lara-Correa2  , Stefano Vinaccia-Alpi3 

1 Universidad de San Buenaventura, Bogotá, Colombia.

2 Ministerio de defensa-Dirección Centro de Rehabilitación Inclusiva, Colombia.

3 Universidad del Sinú, Montería, Colombia.

Abstract

The objective of this study was to determine the levels and the relationship between body image satisfaction, perceived stress and resilience in soldier amputee victims of the internal armed conflict in Colombia. It was a quantitative, cross-sectional study of correlational scope, with the participation of 22 Colombian soldiers who were victims of the internal armed conflict and with some degree of amputation. For each soldier, the Multidimensional Body Self-relations Questionnaire (MBSRQ), Perceived Stress (EEP-14) and the Connor-Davidson Resilience Scale (CD-RISC 10) were applied. The results show high scores in behaviors aimed at maintaining physical fitness, self-assessed physical attractiveness and physical appearance, low scores in stress and scores with high trends in resilience, as well as a negative correlation between stress and conducts aimed to maintain physical fitness.

Key words: corporal image; stress; resilience; armed conflict; amputation.

Resumen

El objetivo del presente estudio fue determinar los niveles y la relación entre satisfacción de la imagen corporal, estrés percibido y resiliencia en soldados con amputación víctimas del conflicto armado interno colombiano. Fue un estudio cuantitativo, transversal, de alcance correlacional, se contó con la participación de 31 soldados colombianos víctimas del conflicto armado interno y con algún grado de amputación, a quienes se les aplicó el Multidimensional body self relations questionnaire (MBSRQ), la Escala de estrés percibido (EEP-14) y el Connor-Davidson Resilience Scale (Cd-Risc 10). Los resultados muestran altas puntuaciones en conductas orientadas a mantener la forma física, atractivo físico autoevaluado y cuidado del aspecto físico, puntuaciones bajas en estrés y puntuaciones con tendencias altas en Resiliencia, así como una correlación negativa entre el estrés y las conductas orientadas a mantener la forma física.

Palabras-clave: imagen corporal; estrés; resiliencia; conflicto armado; amputación

1. Introduction

In the last fifty years, Colombia has lived through an internal conflict with special characteristics, which have led to a high cost of human lives and notable consequences for its development. The victims’ statistics for antipersonnel mines until now show a record of 11.567 in 2006, the year in which most cases were recorded; 80.3% of these victims were wounded while 19.7% died. It is necessary to highlight that several groups are affected in this conflict, including civilians, victimizers and the soldiers of the public forces, who make up 61% of the total number of cases registered (Dirección para la Acción Integral Contra Minas Antipersonal, 2017).

Bearing these statistics in mind it becomes necessary to carry out studies about the consequences of these events in the public forces, specifically with soldier amputee victims of the internal armed conflict in Colombia, evaluating effects on body image, anxiety, stress, and resilience (Dirección para la Acción Integral Contra Minas Antipersonal, 2017).

Corporal image is understood as a person’s self - perception or the perception from another of physical characteristics and implies three components: (a) perceptual, the appraisal of the body in its entirety or some of its parts; (b) cognitive, the valuations regarding the body or a part of it; (c) and finally the affective component, the feelings or attitudes around the body. The perception of body image is influenced by different sociocultural, biological and environmental aspects guided by the standards of beauty of each culture, which allow the formation of different concepts around the shape and decoration of the body (López Sánchez, Suárez, & Smith, 2018; Vaquero-Cristóbal, Alacid, Muyor, & López- Miñarro, 2013).

In synthesis, body image is defined as the union between feelings and attitudes lodged in the memory that are evoked when perceiving the body (Gallego del Castillo, 2009). In constructing this, resort to elements of social and cultural type that respond to aesthetic collective ideals that can trigger health problems in people according to individual transcendence, that is to say alterations of body image that are generated by particular judgments distant from reality (Chávez, Macías, Gutiérrez, Martínez, & Ojeda, 2004).

These alterations of body image are the result of a disturbance in cortical functioning that can generate, among others, the Phantom Limb syndrome, which is defined as the perception of sensations of an amputated limb that is still connected to and works with the body (Raich, 2004).

In Western cultures body image appears to be based on youth and physical appeal. This emphasis may over- shadow other personal attributes (Taub, Blinde, & Greer, 1999), which affect the importance given to the physical body and can have a negative impact on people with amputations, especially in body perception (Sousa, Corredeira, & Pereira, 2009). After an amputation, people face loss of functionality and many times the loss of the ability to continue working, which may also have an effect on their self-concept (Horgan & MacLachlan, 2004); In addition, these stigmas generate depression and generalized anxiety and tend to be associated with poor adjustment in terms of increased activity restriction (Horgan & MacLachlan, 2004).

Limb amputation has been reported as a significantly stressful event for an individual (Horgan & MacLachlan, 2004). Sometimes trauma inflicted during an accident or an explosion may result in a partial amputation that must be surgically completed to avoid complications (Tintle, Keeling, Shawen, Forsberg, & Potter, 2010). Amputation represents an irreversible surgical option that can cause bodily and physical disfigurement. Several investigations in this field report that the traumatic loss of a limb is a highly stressful vital event that can significantly affect quality of life (Sinha & Van Den Heuvel, 2011).

Exposure to such events creates a risk of developing a depressive disorder due to multiple factors such as feelings of loss, self-stigma, and difficulty in overcoming the impediment (Mckechnie & John, 2014). Stressful events leading to amputation, especially if the amputation is accident-or explosion-induced, may induce symptoms of post-traumatic stress disorder (Abeyasinghe, de Zoysa, Bandara, Bartholameuz, & Bandara, 2012).

In this regard, post-traumatic stress is a common diagnosis in victims of the internal armed conflict in Colombia and is considered a debilitating disease that occurs after a traumatic event such as a violent act or an accident. Due to recurrent memories of the event, those who experience it have a predisposition to suffer from depression accompanied by irritability, anger, guilt, evasion and denial (National Institute of Mental Health, 2015).

In Colombia Corzo and Bohórquez (2009), conducted a cross-sectional descriptive study, applying the Clinical Administered Posttraumatic Stress Disorder Scale (CAPS) to a sample of 140 hospitalized patients with combat wounds in the Hospital Militar Central of Bogotá. They performed a bivariate data analysis where prevalence and frequency were measured. With a prevalence for post-traumatic stress disorder and no evidence of acute stress disorder, their findings provide clear evidence that injuries caused during perceived traumatic combats are a major risk factor to developing a post-traumatic stress disorder.

Therefore, amputation as an event produces high stress levels and a challenge to the coping strategies of the individual in the loss of a body limb. Ocampo, Henao, and Vásquez (2010) found that traumatic amputations bring with them psychological alterations that have emotional, family and social repercussions for individuals who suffer from them, and involve a radical change in their lifestyle and quality of life. This study shows that there are 5 stages of mourning for the loss of a limb: the first is of shock, the second denial, the third anger, the fourth depression and finally the fifth is acceptance.

This is why resilience has been studied, approximately since the second half of the twentieth century, as a phenomenon based on the evidence that some people have a greater ability than others to cope with adversity (Becoña, 2006; Rutter, 1985, 1993, 2006, 2007). Resilience is a fairly broad construct and there are different definitions, but they all focus on the ability to adapt and cope with adversity (Vinaccia, Quiceno, & San Pedro, 2007).

In studies related to protective factors against body dissatisfaction, it has been found that resilience could be a significant protection factor (Cook-Cottone & Phelps, 2003). In this regard Choate (2005) proposed a model of resilience of body image where five specific protection factors were identified that could serve as a basis for a specific resilience model. Protection factors would include: (a) support from the family of origin, (b) gender role satisfaction, (c) positive physical self-concept, (d) problem-centered coping strategies, and (e) psychological well-being levels. In addition, this model of resilience implies the maintenance of self-esteem, encompassing physical self-esteem (body esteem) and purpose in life (Richardson, 2002).

Ferguson, Sperber Richie, and Gomez (2004) studied 68 victims of anti-personnel mines in 7 countries using a semi-structured protocol. The results indicated that the acceptance of the survivors of the loss of limbs and their state of psychological recovery were greatly influenced by the resilience characteristics of the individual, social support, healthcare, and the economic situation and social attitudes towards people with disabilities. The authors concluded that the recovery of traumatic amputation in mine survivors must be comprehensive and coordinated, and requires addressing the physical, psychological, economic and social needs of the individual in the context of the family, community and sociocultural environment in which he lives.

In another study developed some years later in Holland Van Dongen et al. (2017), applied the MOS-SF36, EuroQoL 6 and functional scale of the lower extremity questionnaires to Dutch soldiers who had been wounded and mutilated in combat between the years 2005 and 2014 in Afghanistan. The results were compared with people with non-combat serious injuries in extremities. In comparison with non-war wound patients, the war victims who had more severe wounds were considerably younger, needed more frequent operations and long periods of clinical rehabilitation. Their levels of social and cognitive functioning and well-being were considerably lower than those with non-combat-related injuries.

In summary, little empirical evidence has been found about the alterations in body image typical of soldier victims of armed conflicts. This supports the need for this study, whose objective is to determine the levels and the relationship between body image satisfaction, stress and resilience in soldier amputee victims of the internal armed conflict in Colombia.

2. Method

2.1 Type of study

This is a nonexperimental quantitative research project with a correlational scope (Hernández, , & Baptista, 2014).

2.2 Participants

The participants were 22 soldiers who were victims of the internal armed conflict in Colombia who signed informed consent to participate in the study and were selected by non-probabilistic convenience sampling. Participants were characterized by having some type of amputation and carrying out a process in the center of inclusive Rehabilitation in the city of Bogotá. All participants were men, with ages between 18 and 45 years (mean= 29, 𝑆.𝐷 = 7.120), the majority without children (54.5%) and with a level of high school studies completed (50%). Regarding to war affectation, 45.5% have lower limb amputations under the knee. The heterogeneity of the sample with respect to marital status and the place of birth was verified. Greater data about the sample can be found in Table 1.

2.3 Instruments

In body image, the Multidimensional Body Self Relations Questionnaire (MBSRQ) evaluates attitudinal aspects related to body image considering cognitive and behavioral factors. This scale has 45 items and the following sub-measures, all rated 0 to 5: SIC = Satisfaction with body image, ISC = Subjective importance of corporality, COMF = behaviors aimed at maintaining physical fitness, AFA = self-assessed physical appearance, and CAF = Care of physical appearance. It is designed for a population of 15 years and older and was applied in the Spanish-adapted version by Botella García del Cid, Ribas Rabert, and Ruiz (2009). A Cronbach’s alpha of 0.812 was found.

In stress, the Perceived Stress Scale (EEP-14) elaborated by Cohen, Kamarck, and Mermelstein (1983), is an instrument of 14 reagents Likert type questions with five options each: never, almost never, occasionally, often and very often. These give scores from 0 to 4, evaluating the perception of stress over the past month. For this study the adjusted Colombian version by Campo, Bustos, and Romero (2009) was used. A Cronbach’s alpha of 0.728 was found.

Finally, for resilience, the Connor-Davidson Resilience Scale (CD-RISC 10) originally developed by Campbell- Sills and Stein (2007) is a scale consisting of 10 items in a Likert format with 5 options from 0 to 4 points. It has been validated in Colombia by Riveros, Bernal, Bohórquez, Vinaccia, and Quiceno (2017). In the present study we obtained a Cronbach’s alpha of 0.922.

3. Results

The results are shown at a descriptive level for each of the variables, followed by the correlation analysis between them. According to the descriptive results shown in Table 2, high scores of above 4.0 are shown in the behavioral variables oriented towards maintaining physical fitness (COMF), self-evaluated physical attractiveness (AFA) and Care of physical appearance (CAF). Additionally, satisfaction with body image (SIC) showed average to high scores and subjective importance of corporality (ISC) also demonstrated low-stress scores and high resilience scores.

Table 1 Socio-Demographic data of the participants. 

Marital status Number of children
Frequency Percentage Frequency Percentage
Cohabitation 8 36,4 0 12 54,5
Single 14 63,6 1 5 22,7
2 4 18,2
Schooling level 3 1 4,5
Frequency Percentage
None 2 9,1 Type of amputation
Incomplete High school 2 9,1 Frequency Percentage
Complete High school 11 50 Disarticulated Knee 1 4,5
Incomplete technical studies 1 4,5 Both ends of the same hemi-body 3 13,6
Complete technical studies 3 13,6 Bilateral 1 4,5
Incomplete Bachelor’s degree 2 9,1 Bilateral lower limbs 4 18,2
Incomplete Postgraduate degree 1 4,5 Lower limb above knee 2 9,1
Lower limb below knee 10 45,5
Upper limb 1 4,5

Table 2 Descriptive data between the studied variables . 

SIC ISC COMF AFA CAF Stress Resilience
Mean 3,95 3,86 4,15 4,03 4,18 15,82 29,00
Standard Deviation ,54 ,56 ,75 ,95 ,53 7,69 14,15
Minimum 2,09 1,97 2,14 1,67 3,00 0 0
Maximum 4,60 4,60 5,00 5,00 5,00 30 48

Note: SIC = Body image satisfaction, ISC = Subjective importance of corporality, COMF = Behaviors oriented to maintaining physical fitness, AFA = Self-assessed Physical appearance, CAF = Care of physical appearance.

Table 3 shows the correlations between stress, age, and resilience with the satisfaction of body image (SIC), where it was found that there is a negative and statistically significant correlation between stress and behaviors oriented to maintaining physical fitness (COMF). However, no correlations were found between age and resilience with satisfaction of body image (SIC) or with other components.

Table 3 Descriptive data between the studied variables . 

SIC ISC COMF AFA CAF
Age Rho ,069 -,021 ,301 -,128 ,146
Sig. (bilateral) ,768 ,928 ,186 ,582 ,529
Stress Rho -,157 ,025 −,436∗ -,159 ,109
Sig. (bilateral) ,486 ,912 ,043 ,479 ,631
Resilience Rho -,207 -,143 -,117 -,134 -,090
Sig. (bilateral) ,355 ,525 ,605 ,552 ,691

4. Discussion

The numbers of victims of the internal armed conflict and the victims of amputations in Colombia are of high social impact (Dirección para la Acción Integral Contra Minas Antipersonal, 2017). However, only a scarce number of studies have been carried out with this vulnerable group, denotating the importance of conducting research on this population, The need for this study is highlighted by Ocampo et al. (2010), who show that traumatic amputations bring with them psychological alterations that have emotional, family and social repercussions for the individuals who suffer them.

In this regard, the results of this research on amputee soldiers evidence low levels of stress in relation to the averages of non-clinical populations based on research in Colombia (see Campo et al., 2009). These results are similar to numerous studies where anxiety, depression, stress, and hopelessness were measured in chronic Colombian patients who presented on average much lower levels of negative emotions than expected in relation to information found in the scientific literature (Vinaccia & Quiceno, 2012).

Body image scores show behaviors aimed to maintain physical fitness, high levels of self-assessed physical attractiveness and care of physical appearance, which leads to the inference that it is an important element for the population, bearing in mind that they are in a period of social adjustment and adaptation to their body. It is therefore crucial for participants to remain in suitable physical condition and thus maintain their attractiveness. Vaquero-Cristóbal et al. (2013) attribute this concern for the care and maintenance of the body image to a response to the social and cultural construction of specific patterns, corresponding to the findings of this study.

Other studies suggest that there may be an overestimation of body image as a representation of dissatisfaction (Perpiñá & Baños, 2007); this study includes no correlation measurements to evaluate this argument. These results also contradict the research of Horgan and MacLachlan (2004), who argue that patients with mutilations tend to develop low levels of body image satisfaction.

As for resilience this study shows high-trend scores which may be associated with Pedraza (2015) accounting of the existence of characteristics of these soldiers that favor the development of resilience, like having good levels of social support, being religious and/or spiritual, using problem-based coping strategies, having adequate levels of well-being, being part of functional families with a sense of belonging to the institution of the military and a positive self-image, as found in his research with a sample of 68 active Colombian soldiers.

A negative correlation was found between stress and behaviors oriented to maintaining physical fitness (COMF). This could be associated with research that proposes that people react differently to different stressors (Sandín, 2008). It has been suggested that regular physical activity produces a cumulative effect of reducing physiological reactivity to social stressors irrespective of the type of stressors assessed (Sandín & Chorot, 2010). This implies that physical exercise can produce a beneficial and protective effect against reactions to different stressors and their emotional (anxiety, depression, hopelessness) and psychophysiological (activation of the sympathetic system) manifestations in the individual (Sandín, 2010).

One limitation of this research is a small sample size due to stringent inclusion criteria, the location and constant displacement of the participants for medical treatments, licenses and places of residence. These factors make it difficult to generalize the present results.

Similar studies with a larger sample size of members of the Colombian armed forces who have been subject to war events with and without mutilations and wounds in combat should be conducted to assess whether the presence of post-traumatic stress is more associated with physical damage (Corzo & Bohórquez, 2009) argued.

The PSS-14 scale evaluates this factor in a generic way. The validation and development of clinical instruments that ensure the accuracy of measurements with this population is also recommended, considering their sociocultural and academic characteristics.

It is necessary to develop studies that deepen the characteristics of the state of body image in the amputee population, with the purpose of clarifying the variables involved that favor rehabilitation processes and generate the various positions that have been articulated in previous research.

References

Abeyasinghe, N. L., de Zoysa, P., Bandara, K. M. K. C., Bartholameuz, N. A., & Bandara, J. M. U. J. (2012). The prevalence of symptoms of Post- Traumatic Stress Disorder among soldiers with amputation of a limb or spinal injury: A report from a rehabilitation centre in Sri Lanka. Psychol- ogy, Health & Medicine, 17 (3), 376-381. [ Links ]

Becoña, E. (2006). Resiliencia: definición, características y utilidad del concepto. Revista de Psicopatología y Psicología Clínica, 11(3), 125-146. [ Links ]

Botella García del Cid, L., Ribas Rabert, E., & Ruiz, J. B. (2009). Evaluación Psicométrica de la Imagen Corporal: Validación de la versión española del Multidimensional Body Self Relations Questionnaire (MBSRQ). Revista Argentina de Clínica Psicológica, 18(3), 253-264. [ Links ]

Campbell-Sills, L., & Stein, M. B. (2007). Psychometric analysis and refinement of the Connor-Davidson resilience scale (CD-RISC): validation of a 10-item measure of resilience. Journal of Traumatic Stress: Official Publication of The International Society for Traumatic Stress Studies, 20(6), 1019-1028. [ Links ]

Campo, A., Bustos, G., & Romero, A. (2009). Consistencia interna y dimensionalidad de la Escala de Estrés Percibido (EEP-10 y EEP-14) en una muestra de universitarias de Bogotá, Colombia. Aquichan, 9(3), 271-280. [ Links ]

Chávez, A., Macías, L., Gutiérrez, R., Martínez, C., & Ojeda, D. (2004). Trastornos alimentarios en jóvenes guanajuatenses. Acta Universitaria, 14(2), 17-24. [ Links ]

Choate, L. (2005). Toward a theoretical model of women’s body image resilience. Journal of Counseling and Development, 83, 320-330. [ Links ]

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396. [ Links ]

Cook-Cottone, C., & Phelps, L. (2003). Body dissatisfaction in college women: Identification of risk and protective factors to guide college counseling practices. Journal of College Counseling, 6(1), 80-89. [ Links ]

Corzo, P., & Bohórquez, A. (2009). Prevalencia del trastorno por estrés agudo y trastorno por estrés postraumático en soldados colombianos heridos en combate. Rev Fac Med, 17 (1), 14-19. [ Links ]

Dirección para la Acción Integral Contra Minas Antipersonal. (2017). Víctimas de Minas Antipersonal. Retrieved from www.accioncontraminas.gov.co/estadisticas/Paginas/victimas-minas-antipersonal.aspxLinks ]

Ferguson, A. D., Sperber Richie, B., & Gomez, M. J. (2004). Psychological factors after traumatic amputation in landmine survivors: the bridge between physical healing and full recovery. Disability and Rehabilitation, 26(14-15), 931-938. [ Links ]

Gallego del Castillo, F. (2009). Esquema Corporal e Imagen Corporal. Revista Española de Educación Física(12), 45-63. [ Links ]

Hernández, R., C., Fernández, & Baptista, P. (2014). Metodología de la investigación. Mc Graw Hill. [ Links ]

Horgan, O., & MacLachlan, M. (2004). Psychosocial adjustment to lower-limb amputation: a review. Disability and Rehabilitation, 26(8), 37-50. [ Links ]

López Sánchez, G. F., Suárez, A. D., & Smith, L. (2018). Análisis de imagen corporal y obesidad mediante las siluetas de Stunkard en niños y adolescentes españoles de 3 a 18 años. Anales de Psicología, 34(1), 167-172. [ Links ]

Mckechnie, P., & John, A. (2014). Anxiety and depression following traumatic limb amputation: a systematic review. Injury, 45(12), 1859-1866. [ Links ]

National Institute of Mental Health. (2015). Depression (NIH Publication no. 15-3561) (Bethesda, Ed.). MD: U.S.: Goverment Printing Office. [ Links ]

Ocampo, M., Henao, L., & Vásquez, L. (2010). Amputación de miembro inferior: cambios funcionales, inmovilización y actividad física. Facultad de Rehabilitación y Desarrollo Humano: Editorial Universidad del Rosario. [ Links ]

Pedraza, R. (2015). Resiliencia y combate: Un estudio con soldados colombianos. Facultad de Ciencias Sociales: Universidad de Palermo. [ Links ]

Perpiñá, T., & Baños, R. (2007). Distorsión de la imagen corporal: un estudio en adolescentes. Cuadernos de Psicopedagogia, 6(11), 1-13. [ Links ]

Raich, R. (2004). Una perspectiva desde la Psicología de la Salud de la Imagen Corporal. Avances en Psicología Latinoamericana, 22(1), 15-27. [ Links ]

Richardson, G. (2002). The metatheory of resilience and resiliency. Journal of Clinical Psychology, 58(3), 307-321. [ Links ]

Riveros, F., Bernal, L., Bohórquez, D., Vinaccia, S., & Quiceno, J. (2017). Análisis psicométrico del Connor-Davidson Scale (CD-RISC10) en población Universitaria Colombiana. Psicología desde el Caribe, 34(3), 169-189. [ Links ]

Rutter, M. (1985). Resilience in the face of adversity: Protective factors and resistance to psychiatric disorder. The British Journal of Psychiatry, 147 (6), 598-611. [ Links ]

Rutter, M. (1993). Resilience: some conceptual considerations. Journal of Adolescent Health, 14(8), 626-631. [ Links ]

Rutter, M. (2006). Implications of resilience concepts for scientific understanding. Annals of the New York Academy of Sciences, 1094(1), 1-12. [ Links ]

Rutter, M. (2007). Resilience, competence, and coping. Child Abuse and Neglect, 31, 205-209. [ Links ]

Sandín, B. (2008). Estres psicosocial: conceptos y consecuencias clínicas. Madrid: Klinik. [ Links ]

Sandín, B. (2010). Ejercicio físico y salud. Madrid: Klinik . [ Links ]

Sandín, B., & Chorot, P. (2010). Ejercicio físico y salud. In (pp. 101-124). Madrid: Klinik . [ Links ]

Sinha, R., & Van Den Heuvel, W. (2011). A systematic literature review of quality of life in lower limb amputees. Disability and Rehabilitation, 33(11), 883-899. [ Links ]

Sousa, A., Corredeira, R., & Pereira, A. (2009). The body in persons with an amputation. Adapted Physical Activity Quarterly, 26(3), 236-258. [ Links ]

Taub, D., Blinde, E., & Greer, K. (1999). Stigma management through participation in sport and physical activity: Experiences of male college students with physical disabilities. Human Relations, 52(11), 1469-1484. [ Links ]

Tintle, S., Keeling, J., Shawen, S., Forsberg, J., & Potter, B. (2010). Traumatic and Trauma-Related Amputations: Part I General Principles and Lower- Extremity Amputations. The Journal of Bone and Joint Surgery, 92(17), 52-68. [ Links ]

Van Dongen, T., Huizinga, P., de Kruijff, L., Van der Krans, A., Hoogendoorn, J., Leenen, L., & Hoencamp, R. (2017). Amputation: Not a failure for severe lower extremity combat injury. Injury, 48(2), 371-377. [ Links ]

Vaquero-Cristóbal, R., Alacid, F., Muyor, J., & López- Miñarro, P. (2013). Body image; literature review. Nutricion Hospitalaria, 28(1), 27-35. [ Links ]

Vinaccia, S., & Quiceno, J. (2012). Calidad de vida relacionada con la salud y enfermedad crónica: estudios colombianos. Psychologia, 6(1), 123-136. [ Links ]

Vinaccia, S., Quiceno, J. M., & San Pedro, E. (2007). Resiliencia en adolescentes. Revista Colombiana de Psicología, 16, 139-146. [ Links ]

Received: April 16, 2018; Revised: June 05, 2018; Accepted: July 17, 2018

*Corresponding author: Fernando Riveros Munévar. eriveros@usbbog.edu.co; efriveros45@hotmail.com

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