Report Review: A Different Amputee Survey
"Child Amputees: Disability Outcomes and Antecedents,"1 by Dr. Ned Sharpies2 is the report of a survey of child and adult amputees who are present and past patients at the Area Child Amputee Center in Grand Rapids, Michigan.3 The study involved a careful review of 159 unilateral, upper-extremity amputees between ages 14 to 41. About half of the amputees had congenital, the rest had acquired amputations; about half were adults, the others were adolescents. Medical records and home interviews were used to gather the information. Its purpose was to identify and understand the problems of these amputees in an effort to improve patient care. This survey addresses itself to the reasons governing the acceptance or rejection of prostheses by upper-extremity amputees.
Some of the conclusions of this survey were:
1. Unilateral, upper-extremity amputees generally perform at levels equivalent to people not missing arms.
Unilateral amputees can do virtually all tasks usually thought to be bimanual activities. While the means of accomplishing tasks often differed from the normal method and were sometimes awkward, most of the amputees were able to complete tasks quickly and with acceptable ease. Comparisons with brothers, sisters, fathers, and mothers revealed that the amputees were likely to do as well or better in their educational and occupational achievements, and in all physical and social activities used for comparisons.
2. Although nearly all the amputees had been fitted with prostheses, only about 50 per cent actually wore their arms.
At the first examination this figure varied from 40 to 70 per cent-40 per cent were actually wearing prostheses at the first interviews, and 70 per cent said they wore prostheses. Upon closer questioning, about 50 per cent said they wore their prostheses all or most of the time.
3. A significant number of amputees stopped wearing their prostheses after a short trial period.
Nine per cent of all the amputees stopped wearing their prostheses after trying them for only a few weeks. And surprisingly, these amputees were rated the highest in physical and social performance. Presumably, the reason the prostheses were discarded was because the amputees did well without them. Most of this group were congenital amputees.
4. A significant number of amputees stopped wearing their prostheses past age 21 after a substantial period of wear.
Fourteen per cent of the adult amputees had used a prosthesis for a substantial period of time but discontinued use after age 21 mainly because of the cost of replacement and the inconvenience of obtaining repairs.
5. The amputees reported four basic problems:
MECHANICAL-About 40 per cent indicated major problems with their prostheses.
MEDICAL-About 33 percent had stump problems requiring medical attention after initial treatment.
SOCIAL RELATIONS-Almost all were concerned about questions by strangers, and many had not learned to handle this problem. Problems in dating, getting a job, and receiving assistance from others were common.
PSYCHOLOGICAL ADJUSTMENT-Acceptance of loss and self-consciousness were often enduring problems.
The general attitude of the amputee toward his prosthesis greatly influenced his level of wear and performance.
About two-thirds wore the prosthesis primarily for utility, the others wore it for appearance, the groups scored high and low respectively in physical performance. Also, those who undertook simple maintenance and repair, those who felt that the prosthesis does not get in the way, and those who didn't want help all scored higher in physical performance.
Some of the recommendations resulting from the survey are:
Since some amputees try a prosthesis for a few weeks and then discard it, it might be economical to provide a trial prosthesis initially.
A need exists to provide prosthetic repair services quickly and easily. A system of interchangeable parts might be devised to handle repairs more efficiently.
The following quotes highlight the importance of the amputees' attitudes toward their prostheses in eventual wear and performance:
"... among unimembral upper-extremity amputees, the provision of a mechanical appliance, even with extensive fitting, training, maintenance, and follow-up activities, does not directly determine the later performance levels because social and psychological factors of relatively greater influence intervene. Because the physical needs of amputees are now being met, advancement of mechanical techniques to deal with physical problems ... are unlikely to produce a significant improvement in either eventual physical functioning or in social performance."
"The important characteristics of limbs used in these applications might be reassessed starting with this implication that artificial limbs used by unimembral, upper-extremity amputees may not need to approximate the physical functions of an arm and hand."
"... it may be concluded that the meaning of an artificial arm to its wearer may be the single most significant predictor of outcome."
Some of the specific comments concerning attitudes and acceptance of prostheses by amputees are as follows:
An introduction of the patient to the amputee clinic appears critical in order that his experience is not different from his expectations.
Certain patients might be admitted to treatment at the same time, thus promoting their interaction and mutual teaching opportunities.
Counselling should be provided to almost all amputees regarding the acceptance of their loss, dating and social activities, how to answer questions from strangers, how to get a job, etc.
The negative experiences of delays in the fitting and repair of prostheses should be avoided.
With regard to the overall state of the art in prosthetics, some definite implications can be drawn from Dr. Sharpies' report.
There is a discontinuity of patient care in many cases when the amputee is no longer eligible for treatment at child amputee clinics. He is often left to fend for himself prosthetically as well as financially. Perhaps more comprehensive adult amputee clinics are needed.
The clinic team approach to the treatment of amputees has proven itself. Moreover, the more sophisticated mechanical, electrical, hydraulic, and pneumatic systems being added to the armamentarium of components accentuate the need for the multidisciplinary approach, especially with accompanying concerns of cost, training, repair, and amputee acceptance. This development may mean that in the future prosthetics will be practiced more institutionally than privately due to the necessity of providing comprehensive patient care.
The way to achieve greater amputee acceptance of prostheses as well as improved ease of fabrication and repair may be to use skeletal or modular prostheses having an internal rigid structure and controls, with a soft, cosmetic covering which can be removed for adjustment, repairs, or replacement.
Maurice A. LeBlanc, CP.
Staff Engineer, Committee on Prosthetics Research and Development, National Academy of Sciences, Washington, D.C.
1. This project was supported by Grant No. PC-1003 from the Children's Bureau, Department of Health, Education, and Welfare, Washington, D.C.
2. G. E. Ned Sharpies, Ph.D., is Assistant Professor in the Department of Health Development at the University of Michigan at Ann Arbor.
3. The Area Child Amputee Center is supported by the Michigan Division of Services to Crippled Children. It is one of the present 29 child amputee clinics cooperating in the prosthetics research program sponsored by the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development. Clinic chiefs are George T. Aitken, M.D., and Charles H.