Factors related to successful upper extremity prosthetic use
R. A. Roeschlein *
E. Domholdt *
Surveys from 40 upper extremity amputees were analyzed to examine factors related to successful use of an upper extremity prosthesis. Factors which were associated with successful rehabilitation were fewer than two complicating factors, completion of high school education, employment at both the time of amputation and review, rapid return to work, acceptance of the amputation by the time of this review, and perception that the prosthesis was expensive. Factors which appeared unrelated to prosthetic success were age, loss of dominant hand, loss of elbow, marital status, use of rehabilitation services, use of a temporary prosthesis, and whether training in prosthetic use was provided. Many of these factors concurred with earlier studies. Previously unreported factors that may be of importance to the long-term success of upper limb amputees are the number of complicating factors and perceptions about the monetary value of the prosthesis.
Although upper extremity (UE) amputees are few in number compared to lower extremity (LE) amputees, the loss of the upper limb is a far greater catastrophe for the individual (Beasley, 1981). The loss of an upper limb results in a major and sudden restriction of function, sensation, and cosmesis. Yet, studies have shown that amputees have demonstrated a greater resistance to accepting upper limb prostheses than to accepting artificial legs (Carter et al., 1969). Many studies conducted over the past three decades have looked at the influence of certain factors in successful long-term use of various UE prostheses. Factors that have been shown to be related to prosthetic success include level of education (Andersson and Berg, 1975), employment status (Andersson and Berg, 1975; Carter et al., 1969; Davies et al., 1970), time from amputation to fitting of a prosthesis (Malone et al., 1981), level of amputation (Carter et al., 1969), age (Andersson and Berg. 1975; Davies et al. 1970; Frank et al., 1984; Northmore-Ball et al. 1980), use of a temporary prosthesis (Bailey, 1970; Jacobs and Brady, 1975; Jones, 1977; Malone et al., 1981; Robinson et al., 1971; Sarmiento et al., 1968), and training in prosthetic use (Carter et al., 1969; Herberts et al., 1980; Munroe and Nasca. 1975). Loss of the dominant hand has not been shown to be a factor that influences prosthetic success (Carter et al. 1969).
The primary purpose of this study was to evaluate amputee factors related to prosthetic success in a group of upper limb amputees and compare these factors to those previously published.
A secondary purpose was to determine whether certain types of prostheses were associated with greater levels of success.
Long-term UE amputees who had prostheses were surveyed with a 75-item questionnaire. The questionnaire addressed seven main topics: demographic and personal information, factors related to the amputation, activities of daily living, reliability of the prosthesis, cosmetic aspects of the prosthesis, durability of the prosthesis, and general concerns about the artificial limb.
Respondents were identified through the files of three prosthetic shops in Indianapolis, Indiana, USA, or through visits to the prosthetist in person. Questionnaires were distributed in a fashion that ensured confidentiality of response.
The data were compiled and stratified as needed. Means were calculated for various demographic items. Chi-square analyses to determine significant frequency differences between classes of amputees were conducted when appropriate. Analyses with an alpha level of .10 or less are noted in the tables and in the text.
Eighty-six questionnaires were distributed; 48 (56%) were returned. Eight of the returns could not be analyzed secondary to missing data. Thus, results are based on 40 usable questionnaire responses. Thirty-nine of the respondents were male. Eight had above-elbow amputations, 4 had elbow disarticulations, 17 had below-elbow amputations (one bilateral) and 11 had wrist disarticulations. All but three of the amputations were secondary to trauma. Fifteen amputees lost their dominant hand. Mean age of the respondents was 56.4 years (range 19-81 years). Mean age at the time of amputation was 30.8 years (range 4.5-62 years), and the mean time lapse from amputation to the completion of the questionnaire was 26.6 years (range 5-59 years).
Amputees were characterized as successful users, partially successful users, or unsuccessful prosthetic users. Twenty-six successful prosthetic users wore and used at least one prosthesis every day, throughout most of the day. Ten partially successful users wore or used a prosthesis solely for certain tasks or hobbies. Four unsuccessful users did not use a prosthesis, or wore a prosthesis for cosmesis without using it in a functional manner. Table 1 shows personal characteristics of the amputees who were classified as either successful, partially successful, or unsuccessful prosthetic users. Differentiating factors were the presence of more than two complicating factors, and employment at the time of amputation and review. Unsuccessful amputees had more complications (visual handicaps, trauma to other limbs, heart problems, bone or joint problems, or phantom pain or sensation), and were less likely to be employed either at the time of amputation or at the time of this review, than their successful counterparts. Though not tested statistically, the successful users had a higher level of education than unsuccessful users, returned to work many times faster, and received their prostheses sooner than the unsuccessful amputees. Factors which did not differentiate between successful and unsuccessful users were age, cause of amputation, loss of dominant hand, and loss of elbow. Fig. 1 shows the distribution of amputation levels according to their successful use of a prosthesis. At each level, at least half of the amputees were classified as successful users.
Table 2 shows rehabilitation factors and their relationship to prosthetic success of each amputee. A significant differentiating factor was the acceptance of the amputation at the time of review. Understandably, the less successful amputees reported less acceptance of their amputations. Factors which did not differentiate between successful and unsuccessful amputees were use of rehabilitation services, and use of a temporary prosthesis.
Many of the items on the questionnaire were designed to elicit information about how particular prostheses met the daily needs of amputees. Unfortunately, the types of prostheses owned by the respondents were very similar. The forty respondents listed a total of 60 prostheses that they had owned since their original amputation. Almost two-thirds (39) were cable-operated prostheses with a terminal hook. Almost one-third (18) were cable-operated with terminal hands. At least four of the cable-operated hand prostheses were secondary prostheses that were used when greater cosmesis than the hook was desired. The remaining three were electrically powered. Thus, comparisons between types of prosthesis did not prove to be very useful, particularly because of the extremely small number of electrical prostheses in the sample. However, some basic data will be presented. A prosthesis was considered functionally useful if it was worn and used every day, throughout most of the day. A prosthesis was considered partially useful if it was used part-time or solely for certain tasks or hobbies. A prosthesis was considered not useful if it was not used at all or was worn only for cosmetic purposes. Of the 52 prostheses with sufficient data for classification, 27 were functionally useful, 15 were partially useful, and 10 were not useful. Fig. 2 shows the breakdown of usefulness categories by type of prosthesis. It can be seen that the majority of cable-operated hooks were functionally useful, that none of the cable-operated hands were functionally useful, and that one electrically powered prosthesis was in each usefulness class.
This study sought to validate the results of others, as well as investigate factors related to prosthetic success that have been overlooked by other investigators. Areas of agreement with other investigators are that education, employment status, and time from amputation to fitting are related to prosthetic success. The authors found, as have others, that the loss of the dominant hand is not a significant differentiating factor between successful and unsuccessful amputees. Areas of disagreement with the published literature are that in this study no differences were found based on level of amputation, use of a temporary prosthesis, or training with the prosthesis. Factors found that have been previously unexplored are the presence of more than two complicating factors and perceived cost of the prosthesis.
One problem with any retrospective survey is that subjects are not randomly selected. In this instance only those amputees who had seen a prosthetist at some point in their course of treatment were included. The return rate of just over 50%, while common for a survey of this type, may distort the sample. We do not know whether the amputees who did not respond have characteristics similar to those who did respond. A second problem with retrospective studies is that one is asking respondents to remember back into time. The accuracy of some of the data related to early rehabilitation could not be determined.
Rehabilitation of upper limb amputees will continue to be a challenge to the amputee and to the health care providers. The number of perioperative complicating factors and the amputee's perception about the cost of the prosthesis are factors that health care providers may wish to consider when evaluating the prosthetic potential of an upper limb amputee. The magnitude of the functional loss that accompanies upper limb amputations makes their study important; the small numbers of upper limb amputees makes their study most difficult.
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