Upper limb prosthetic use in Slovenia
H. Burger *
C. Marincek *
The article deals with the use of different types of upper limb prostheses in Slovenia.
Four hundred and fourteen upper limb amputees were sent a questionnaire on the type of their prosthesis, its use and reasons for non-use, respectively. The replies were subject to statistical analysis.
Most of the questioned upper limb amputees (70%) wear a prosthesis only for cosmesis. The use of a prosthesis depends on the level of upper limb amputation, loss of the dominant hand, and time from amputation. Prosthetic success appears to be unrelated to age at the time of amputation and the rehabilitation programme.
The most frequent reason for not wearing a prosthesis is heat and consequent sweating of the stump.
More than a third of amputees are dissatisfied with their prostheses.
Even though upper limb prostheses were known already in ancient Egypt, they have never succeeded to completely substitute the three functions of the human hand - motor, sensibility and expressive functions. As an extension of the stump, a prosthesis should improve, not impede, its function. It should be used in the way the non-dominant hand is normally used (Hermansson, 1991). However, even the best prosthesis is only a poor substitute.
As reported by various authors, an upper limb amputee accepts and uses the prosthesis if it is comfortable, functional and has a pleasing appearance. Acceptance and successful use also depend on the quality of the stump, amputation level, level of education and employment status of the user, time from amputation to fitting a first prosthesis, use of a temporary prosthesis, training in use, and patient's motivation (Millstein et al., 1986; Roeschlein and Domholdt 1989). Opinions on the importance of manual dexterity and loss of the dominant hand, respectively, differ considerably. Patients of the same age and with the same amputation level, who after completed rehabilitation and training achieved the same degree of independence, may use the prosthesis throughout the whole day or be reluctant to wear it.
According to different reports, upper limb prosthesis are used with different levels of success (Fletcher, 1970; Herberts et al., 1980; Stein and Walley, 1983; Heger et al., 1985; Vitali et al., 1986; Stürup et al., 1988; Roeschlein and Dumholdt, 1989).
According to Atkins (1989), a high rejection rate of upper limb prostheses can be attributed to development of one-handedness, insufficient training in use, poor comfort, poor construction, and the reactions of other people.
The objective of this study is to determine the use and reasons for non-use of different types of upper limb prosthesis in Slovenia. The study also considered how amputees and their environment react to their prostheses.
Methods of work
The dispensary files of all persons who visited the Orthotic and Prosthetic Outpatient clinic at the University Rehabilitation Institute Ljubljana between 1 January, 1988 and 31 December, 1992 were surveyed. Upper limb amputees with a permanent residence in Slovenia were selected. They were sent a questionnaire on the extent to which they actually used their prostheses.
The responses were statistically analysed by the SPSS program (Statistical Package for Social Sciences). Data were analysed by frequency distribution, Chi-square test, variance analysis test, and Student's t-test.
In the last five years (1 January, 1988-31 December, 1992), 414 upper limb amputees were examined in the Prosthetic and Orthotic Outpatient clinic of the University Rehabilitation Institute Ljubljana. Some came for an examination only once, whereas others came several times.
Some 295 responses (71.3%) were received. Of these, 266 (90.2%, representing 64.3% of the questionnaires sent) were filled in, and 29 were left blank (deceased, unknown, departed, etc). Not everybody answered all questions. All the questions which were answered in these 266 responses were analysed.
At the time of amputation, the persons concerned were fairly young, aged 20.0 years on the average (SD 14.1 years). As many as 238 (of the 266 responses) or 89.5% of the amputations resulted from accidents (127 or 47.7% were war injuries).
More than half (163 or 61.3% of 266) had trans-radial amputations, 54 or 20.3% had trans-humeral amputations and 34 (12.8%) had partial hand amputations; disarticulations in joints were rare (3 or 1.1% had disarticulation at the shoulder, 2 or 0.8% at the elbow, and 10 or 3.7% at the wrist.
Some 245 persons answered the question about handedness before amputation, 132 (53.9%) lost the dominant hand, 85 (34.7%) the non-dominant hand. Twenty-three (9.4%) had a congenital deficiency of the upper limb and in 5 (2%) bilateral amputation had been performed at the same level.
Results and discussion
The response rate to the questionnaire was within normal values.
As many as 63.5% (169) of responding upper limb amputees in Slovenia had a cosmetic prosthesis and no less than 69.5% (185) possess one single prosthesis. Considering body-powered prostheses, twice as many individuals had a prosthesis with a hand compared to those with a hook. Only 6 patients were provided with a myoelectric prosthesis.
In Slovenia, upper limb amputees wear a cosmetic prosthesis for about 10.2 hours and a functional (body powered or myoelectric) prosthesis for about 11.8 hours a day (no significant difference). This is a greater usage than reported by Millstein et al. (1986), according to whom amputees use a prosthesis with a cable operated hook about 8 hours a day, one with a cable operated hand 5 hours a day and a cosmetic prostheses 4 hours a day. However, what that author had in mind was use, whereas in this study the question was of wearing. Upper limb amputees in Slovenia make more extensive use of functional prostheses at housekeeping and farm work (p<0.001), at getting dressed and driving a car (p<0.5), and in personal hygiene (p<0.1) (Table 1). In other activities, prosthetic use is unaffected by the type of prosthesis.
The number of hours per day and the type of occupation in which a person uses a prosthesis depend on the following:
- time from amputation to the first fitting of the prosthesis (Table 2)
- amputation level (Table 3 and Table 4)
- age at amputation (Table 5)
- present age (Table 6)
- loss of the dominant hand (Table 7).
Table 2, Table 3, Table 4, Table 5, Table 6, and Table 7
The time of daily prosthetic use is not related to:
- the type of prosthesis
- the evaluation of the rehabilitation programme.
Time from amputation to the first fitting of the prosthesis
The relation between the time after the amputation and the number of hours of prosthetic use per day is completely non-linear (it was established neither by correlation coefficient nor variance analysis test, but only by (Chi-square test). A most relevant point to be considered is whether the patient got his first prosthesis during the first year after the amputation or not (Table 2).
The answers also displayed that at work, all prostheses are more readily used by persons who got them soon after amputation (p<0.1), while in a social setting they are more readily used by those who got them later (p<0.1). Persons, provided with a functional prosthesis soon after the amputation, more often use it in attending to housekeeping (p<0.1), at work (p<0.01), and performing simple repairs at home and at peasant labour (p<0.05).
These findings correspond with the statements by Robinson et al. (1975), Jacobs and Brady (1975), and Bailey (1970) that one of the first reasons underlying unsuccessful prosthetic use is delayed post-surgical fitting in upper limb amputation. After the amputation, amputees quickly learn to compensate for their loss by using the other upper limb. This compensation is often so efficient that the patient finds the prosthesis encumbering and is reluctant to accept it.
Persons with a partial amputation of the hand wear the prosthesis the lowest number of hours, while there is no difference in daily wearing of prosthesis between trans-radial and trans-humeral amputees (p<0.05) (Table 3).
The level of amputation does not affect prosthetic use at work, in performing simpler home repairs and in peasant labour (Table 4). These occupations seem to be of greatest importance to those persons who are most keen to attend to them. In all other activities, persons with a trans-radial amputation wear their prosthesis more than others. The reason may be that the prostheses hampered others, which many put down as a remark or stated as a reason for their non-use. This corresponds with the conclusions by Millstein et al. (1986) that transradial amputees alone use functional prostheses in daily activities, whereas the others find prostheses useless in attending to daily activities. As reported by Stürup et al. (1988), higher level amputees do not use body powered prostheses, while Roeschlein and Domholdt (1989) claims that the loss of the elbow is of no consequence to successful prosthetic use.
Age at amputation
Functional prostheses are used for slightly longer periods of time by persons who were young at the time of amputation (r = 0.26, p<0.05), and cosmetic prostheses by persons now older (r = 0.30, p=0.001).
Persons using the prosthesis in getting dressed and eating (p<0.05) and in a social setting (p<0.01) were at amputation characteristically younger than those who do not use their prosthesis in the above-mentioned activities (Table 5). As for attending to other tasks, no significant differences in age at the time of amputation were observed with regard to successful or unsuccessful prosthetic use.
The current age of amputees has even less influence upon prosthetic use. It is worth noting that persons using a prosthesis at work are now a little younger (p<0.05) than persons who do not, while those using it at peasant work are slightly older (Table 6).
Loss of dominant hand
All prostheses (p<0.05), particularly functional (p<0.01), are worn mostly by amputees who have lost the non-dominant hand and least by bilateral upper limb amputees. The loss of the dominant hand is not significantly related to the time of wearing cosmetic prostheses.
The loss of the dominant hand has the most significant impact upon the use of the prosthesis at eating, work, and recreation, where the prosthesis is most used by bilateral and congenital amputees and more often by non-dominant than dominant hand amputees (Table 7).
The above conclusions are contrary to those drawn by Stürup et al. (1988), according to whom a prosthesis is more widely used by persons who sustained the loss of the dominant hand. Likewise, they do not agree with the statement by Roeschlein and Domholdt (1989) that the loss of the dominant hand exerts no influence upon successful use of a body powered prosthesis.
Most of the respondents failed to indicate at which occupations and recreational activities, respectively, they used the prosthesis. Those who answered the question stated that they habitually made extensive use of functional prostheses for peasant work. More than a third of them use functional prostheses for all sorts of peasant labour. In recreational activities, preference is given to the use, or rather, wearing of cosmetic prostheses. From the point of view of different branches of sport (walking, jogging, cycling, skiing, football, gymnastics, bowling), prostheses are mostly irrelevant to function. The respondents most frequently used both types of prostheses at cycling. Sports such as referred to by Millstein et al. (1986) differ from those favoured in other countries where certain branches of sport enjoy greater popularity than others.
The type of prosthesis
The fact that the type of prosthesis is not related to successful prosthetic use proves that in answering the question the respondents were not really referring to the number of hours per day during which they used the prosthesis but rather to how long they wore it. Thus, there seems no point in dividing persons into active, i.e. successful prosthetic users, and partially active and passive users, as proposed by Kejlaa (1992) and Roeschlein and Domholdt (1989).
Evaluation of the rehabilitation programme
The number of hours of prosthetic use does not depend on the evaluation of the rehabilitation programme (either for all prostheses together or separately by types of prostheses). No interconnection was established either by the variance analysis test or Chi-square test. This means that there is no interconnection between the rehabilitation programme that the persons were subject to and the number of hours during which they use prostheses.
What stops amputees from using a prosthesis
Table 8 refers to reasons that stop amputees from using a prosthesis, displayed separately for different types of prosthesis. The most frequent reasons are heat and sweating, and only in the third place (17.3%) the loss of sensation, even though McDonnell et al. (1989) state that the prosthesis weakens the amputee's sense of position in space.
The most frequent reasons to stop using a functional prosthesis are heat and sweating, and the loss of sensation. These two reasons are characteristically affected by the level of amputation (Table 9). Heat and sweating are most disturbing to persons with Trans-humeral amputation (p<0.01), and the loss of sensation to persons with a partial hand amputation (p<0.1).
The amputees, who stop using the prosthesis because of heat and sweating, are now younger (p<0.01) than the others, while other reasons for unsuccessful use are unrelated to age (Table 10).
Age at amputation has a significant influence only upon prosthetic non-use due to the weight of the prosthesis. The persons identifying the weight of the prosthesis as a reason for not using it, were significantly older at the time of amputation (p<0.01) (Table 11).
The persons who resist using the prosthesis due to loss of sensation, were fitted with their first prosthesis later after the amputation (p<0.05) than those who did not identify this reason. The time lapse from amputation to the first prosthetic fitting had no significant effect upon the other reasons for non-use.
Acceptance of the prosthesis by the amputee's social milieu
Healthy people in Slovenia react to different types of prostheses in much the same way (Fig. 1). This may result from the fact that among functional prostheses there are twice as many prostheses with a hand as a hook, so they do not differ greatly in appearance from cosmetic prostheses, A high percentage (169 or 77.2%) of the respondents report positive reactions from the population at large to the prosthesis. This percentage is much higher than the percentage of the amputee's expectations (126 or 53.8%).
Fulfilment of the amputee's expectations
It is interesting to note that no significant differences exist in the fulfilment of the amputee's expectations between cosmetic and functional prostheses (Fig. 2). A surprisingly high percentage of cosmetic prostheses have met expectations, from which it may be concluded that a large number of amputees are very sensitive about their cosmetic appearance. This is confirmed by the high percentage of cosmetic prostheses which are provided in Slovenia and by functional prostheses for the hand being fitted twice as often as the hook.
The fulfilment of expectations is not affected by the time lapse since amputation to the first fitting of a cosmetic or functional prosthesis.
The fulfilment of the amputee's expectations is significantly related to the number of hours per day during which they use a functional prosthesis (p<0.001) (Table 12). The persons stating that the functional prosthesis has met their expectations use it longest during the day, whereas those disappointed with the prosthesis use it the least hours in a day.
Cosmetic prostheses are worn most by persons according to whom the prosthesis has met their expectations to a limited extent. They are worn least by persons with whom the prostheses has failed to fulfil any of their expectations (Table 13).
The fulfilment of the amputee's expectations is not significantly related to either the age at amputation or the current age.
The majority of persons with a cosmetic prosthesis stated that it had not met their expectations as it was merely cosmetic and unsuitable for work. Secondly the view was expressed that it is aesthetically deficient. The fact that the prosthesis is not applicable at work, being more of an encumbrance than aid, is another reason for non-use.
Surprisingly enough, a third of the respondents were of the opinion that a functional prosthesis, too, is just a cosmetic aid. The reason underlying this belief may be that these amputees were not included in a suitable rehabilitation programme. Another third of the respondents, fitted with a functional prosthesis, stated that the prostheses were poorly made, not strong enough, and unreliable. These are further reasons for unsuccessful prosthetic use.
In the last few years, an obvious improvement in the general attitude to prosthetic use can be observed in Slovenia, though the use of upper limb prostheses is far from satisfactory.
In Slovenia, the use of upper limb prostheses is related to factors which are not under human control (level of amputation, loss of the dominant hand, age at amputation) and also factors that can and must be controlled. Two most outstanding of these are:
- time from amputation to the first prosthetic fitting
- type of prosthesis.
Another area open to external control is a suitable rehabilitation programme. Its influence upon the use of functional prostheses however has not been confirmed by this study.
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