Abstract Introduction: Rehabilitation of traumatic upperlimb amputees depends on a multitude of factors. Thisstudy attempts to evaluate the success of prosthetic reha-bilitation in this group of patients, determine the reasonsfor non-compliance and find ways to increase prostheticacceptance. Materials and methods: The prosthetic reha-bilitation status of 71 traumatic upper-limb amputees wasassessed by a questionnaire and clinical review. A Pros-thetic Rehabilitation Scoring (PRS) system, based on pa-tient satisfaction, prosthetic usage and activity level, wasdevised to quantify the success of rehabilitation. Results:The rehabilitation was found to be equally good in above-elbow and below-elbow amputees. The delay in fitting ofthe prosthesis had no correlation with successful rehabili-tation. Chances of successful rehabilitation decreased whenthe prosthesis fitting was done in older patients. The mainreasons for inadequate use of the prosthesis were repeatedmechanical failure and the high cost of repair and replace-ment. Conclusion: In order to achieve an optimum benefitfor the patient in a developing country, the prosthesisshould be durable, inexpensive and have a low cost ofmaintenance.

Keywords Amputee · Prosthesis · Rehabilitation ·Upper limb

Introduction

Traumatic upper-limb amputations are a devastating psy-chological, physical and socio-economic blow to the pa-tient. In contrast to congenital amputations, where the in-dividual has never known the advantage of having an armand hand, a patient with a traumatic amputation has toadapt to the loss of a part that was previously functional[7]. The patient has to accept that the prosthesis will notprovide the delicate sensation and proprioceptive appreci-ation of the normal hand. As noted by Beasley [2], trau-matic upper-limb amputation is a more devastating eventthan the loss of a lower extremity. Males in the age groupof 20–40 years are most commonly affected.

In terms of physical impairment, a patient with one nor-mal hand can usually perform 90% of activities of dailyliving and, with some gadgets and effort, can perform theremaining activities to be fully independent. In a bilateralamputee the disability is much severer [3]. In the upperlimb, following a loss of the prehensile function, the mostuseful remaining function is sensation. When the limb be-comes encased in a prosthesis, this function is impairedand could represent a significant reason for the prosthesisbeing abandoned [8, 9].

The aim of our study was to assess the success of pros-thetic rehabilitation in traumatic upper-limb amputees, de-termine the reasons for non-compliance and find ways toincrease prosthetic acceptance in our patients.

Patients and methods

The study group had 103 patients with traumatic upper-limb defi-ciency who were fitted with a body-powered prosthesis at our in-stitution. They were under the care of a hand surgeon, a qualifiedprosthetist and an occupational therapist. All the patients were senta questionnaire. They were asked about the use of the prosthesis athome, work, social occasions and the activities that they could per-form with its help. Patients were also queried regarding the num-ber of repairs and replacements of the prosthesis and the durationof its usage. In those patients who had discontinued the use of theprosthesis, the reasons were enquired into, as was the patient’s will-

Kumar Bhaskaranand · Anil K. Bhat ·K. Narayana Acharya

Prosthetic rehabilitation in traumatic upper limb amputees (an Indian perspective)

Arch Orthop Trauma Surg (2003) 123 : 363–366DOI 10.1007/s00402-003-0546-4

Received: 30 September 2002 / Published online: 25 June 2003

ORIGINAL ARTICLE

K. Bhaskaranand (✉)Hand and Microvascular Surgery Unit, Department of Orthopaedics, Kasturba Medical College, 576119 Manipal, Karnataka, IndiaTel.: +91-8252-71201 ext 22231, Fax: +91-8252-70062,e-mail: drbhaskaranand@yahoo.com

A. K. Bhat · K. N. AcharyaDepartment of Orthopaedics, Kasturba Medical College, 576119 Manipal, Karnataka, India

© Springer-Verlag 2003

ingness to continue the use of the prosthesis if it was suitably mod-ified.

Patients were grouped into three categories, namely, shoulderdisarticulation, above-elbow amputation and below-elbow amputa-tion. This was done as these three were the only types of prosthe-sis used. Information obtained from the questionnaire was corre-lated with the case records or a clinical review. The patients whodid not respond to the questionnaire or for whom case records andclinical review were not possible were excluded from the study.Only 71 patients for whom complete data could be obtained werechosen for the final analysis.

A Prosthesis Rehabilitation Score (PRS) was devised (modifiedfrom the Prosthetic Success Score used by Gaine et al. [5]) to eval-uate the degree of the prosthetic rehabilitation (Table 1). Statisticalanalysis was done using SPSS software. The Spearman rank corre-lation test was done to study the correlation of variables with thePRS values.

Results

Three of the 71 patients were bilateral amputees, and hencethe number of limbs fitted with prosthesis was 74. Of these,49 (66%) had a below-elbow amputation, 24 (32%) hadan above-elbow amputation, and 1 had a shoulder disar-ticulation. There were 64 male patients in the study, andthe right limb was involved in 69% of the unilateral cases.The common causes of amputation were traffic and occu-pational accidents. The mean age and standard deviation(SD) of the patients in the study group was 39.5 (11.7)years and the mean age and SD at the time of amputationwas 25.1 (11.6) years. The mean and SD of the duration offollow-up was 10.3 (5.7) years.

Based on our scoring system, the prosthesis usage wasrated as ‘good’, ‘satisfactory’ or ‘poor’ (Table 2). In the uni-lateral amputees, there did not appear to be much differencein the ratings of patients in the above-elbow group and thebelow-elbow group (e.g. 42% and 44% were rated ‘good’in their respective groups). A chi-square analysis of thesedata did not show any statistical significance. The 1 patientwith shoulder disarticulation was rated ‘poor’. Two patientswith bilateral amputation were rated ‘good’, while the thirdpatient did not use the prosthesis.

The nature of prosthetic usage is shown in Fig. 1.Though all the patients in our study were provided with abody-powered prosthesis, only 50 of the 74 prostheseswere being used for its mechanical functions. The rest wereused as a cosmetic prosthesis or not used at all. The rea-sons given for inadequate use of the prosthesis are shownin Table 3. The most common type of mechanical failurewas cable breakage (16 prostheses), while another involvedbreakage of the prosthetic shell.

The time interval between amputation and fitting of theprosthesis was a median of 1 year with an interquartilerange from 1 to 5 years. The Spearman rank correlationbetween this interval and the PRS was not statistically sig-nificant (r=0.233). The mean age and SD at the time ofprosthesis fitting was 29.23 (10.5) years. When this agewas correlated with the PRS, it did not show a statisticallysignificant relation (r=–0.143).

The mean and SD of the prosthetic life as assessed bythe number of repairs and replacements required during theperiod of active usage (only in patients with a ‘good’ rating)was found to be 2.64 years (SD±1.3).

Discussion

A prosthesis is basically a useful tool to assist the intactlimb. It would be unrealistic to expect that it can ever re-place the functions of a normal limb. The evaluation ofprosthetic rehabilitation has to take into consideration thepatient satisfaction, prosthesis usage and functional levelwith the prosthesis. Gaine et al. [5] have devised and useda scoring system for this purpose. As the general populationin our country has a lower standard of education and liter-acy, we had to simplify their scoring system while main-taining its overall utility. The modified system used in thisstudy (Manipal Prosthetic Rehabilitation Score) is simplerand hence better understood and reproduced by our patients.

The term ‘satisfied with reservation’ needs an explana-tion. From our experience, we have found that the cost of

364

Table 1 Manipal prosthesis rehabilitation score (PRS)

Points

Patient acceptance Satisfied 2Satisfied with reservation 1Not satisfied 0

Usage Active usage 2Used but discontinued 1Never used 0

Functional level Complex tasks (writing, etc.) 3Grasping, holding, lifting 2Regular cosmetic usage 1None/irregular cosmetic usage 0

Score rating 5–7 Good3–4 Satisfactory<3 Poor

Table 2 Comparison of rat-ings of different groups PRS rating Unilateral Above-elbow Below-elbow Shoulder Bilateral

cases amputees amputees disarticulation amputees

Good 29 (43%) 10 (42%) 19 (44%) 0 2Satisfactory 26 (38%) 10 (42%) 16 (37%) 0 0Poor 13 (19%) 4 (17%) 8 (19%) 1 1Total cases 68 24 43 1 3Average PRS score 4.22 4.38 4.23 0 3.67

the prosthesis repair and replacement is a major deterrentto the optimal use of the prosthesis. While many of our pa-tients are satisfied with their prosthesis, the high cost ofrepair prevents optimal usage. Hence, we believe that weare justified in including this parameter in the scoring sys-tem. All the prostheses used were of the body-poweredtype. Therefore, activities like writing, riding a vehicle,driving a four-wheel vehicle, etc. would merit the highestpoints in the functional rating. Mere cosmetic usage wouldamount to a partial failure but would score higher thannon-usage of the prosthesis. While patient motivation andpsychological counselling have not been considered in ourstudy, these undoubtedly play a major role in a successfulrehabilitation.

Previous studies [3, 4, 9, 10] have shown that the moreproximal the amputation (either congenital or traumatic),the less likely the patient is to be a user. This is becausethe prosthetic device does not significantly decrease dis-ability, though the restoration of a near likeness of the lostpart may be of great benefit. While our only patient witha shoulder disarticulation had a ‘poor’ rating, contrary toour expectation, we found no significant difference in theratings between patients in the above-elbow group and thebelow-elbow group. Though 2 of the 3 patients with bilat-eral amputation had a high PRS, the group is too small tobe taken into consideration.

Much emphasis has been placed on the importance ofearly prosthesis fitting to achieve maximum success inprosthesis use [4, 5, 6]. Beasley [2] has described a three-phase reaction to traumatic amputation: disbelief, realiza-tion and adaptation, and suggested that the realization phaseis the most crucial to subsequent rehabilitation. Gaine et

al. [5] also concur with this hypothesis. In our study wefound that the delay in fitting of the prosthesis had no cor-relation with the patient’s successful rehabilitation. Thedelay in our study has two reasons. Firstly, the majority ofthe amputations are performed in institutions other thanours and are referred here for prosthesis fitting at a laterdate, and secondly, our patients need time to find the finan-cial resources to pay for the prosthesis. A more selectiveand detailed study, on the lines of the Fitzsimons ArmyHospital study [4], would be needed to establish any cor-relation between early prosthesis fitting and rehabilitationand confirm Beasley’s hypothesis.

Contrary to the observations of Sturup et al. [10], whoopined that younger patients had a tendency to becomenon-users, our clinical experience has shown that youngerpatients are more motivated and accept the prosthesis in abetter fashion. In the present study, the correlation betweenage of the patient at the time of prosthesis fitting and thePRS gives a negative trend line, i.e. the score decreaseswith increasing age. This, however, was not statisticallysignificant, which can probably be attributed to the smallsize of the study group.

When the patients who rated ‘poor’ and ‘satisfactory’were analysed further, it was found that the predominantreasons given for inadequate usage were repeated mechan-ical failures and the cost of prosthetic repair and replace-ment. Patients who described financial constraints as themain reason for their inadequate usage were of the opinionthat better use would be made of the prosthesis if themaintenance costs were lower.

Other complaints regarding the prosthesis included me-chanical failure (cable breakage and joint loosening), stumppain when using the prosthesis (one patient had repeatedchest pain when using the prosthesis), displeasure over thefitting of the prosthesis in spite of repeated adjustments,and weight of the prosthesis. Along the lines of the studyby Atkins et al. [1], the most common mechanical problemwas cable breakage. One patient could not use the prosthe-sis due to an associated skin disease, and another stoppedusing it due to neurological problems.

Both conditions were unrelated to the prosthesis usage.Four patients did not give any reasons for their non-com-pliance with prosthetic usage.

We note that the cost of the prosthesis and its mainte-nance have not been taken into consideration in any of thecited articles. Given a study population in a developingcountry like ours, the financial constraints of our patientshave to be considered to improve the acceptance rate. Ifthe prosthesis provided by us is to be utilised optimally(rated ‘good’), we find that our patients would need tocome in every 2.64 years for repairs or replacements. Thisand the fact that the major problem in the group of patientswith a score of <5 is financial constraints go to show thatbetter rehabilitation of the patient requires a more durableprosthesis with a low cost of maintenance.

Acknowledgements We acknowledge the technical assistancegiven by Dr.Sreekumaran Nair (Department of Community Medi-cine), Mr. P. Balasubramaniam and Mr. K. Satishan (Departmentof Orthotics and Prosthetics).

365

Fig. 1 Nature of prosthetic usage by the patients

Table 3 Reasons for inade-quate usage of the prosthesis(it should be noted that manypatients had more than one rea-son and the 53 reasons givenwere only by those patientswho had a PRS <5; n=40)

Repeated mechanical failure 20Financial constraints 15Pain 5Poor fitting 5Weight of the prosthesis 2Associated disease 2Reasons not mentioned 4

References

1. Atkins DJ, Heard DCY, Donovan WH (1996) Epidemiologicoverview of individuals with upper-limb loss and their reportedresearch priorities. J Prosthet Orthot 8:2–11

2. Beasley RW (1981) General considerations in managing upperlimb amputations. Orthop Clin North Am 12:743–749

3. Beasley RW, Bese GM de (1986) Upper limb amputations andprostheses. Orthop Clin North Am 17:395–405

4. Burkhalter WE, Carmona LS (1976) The upper-extremity am-putee. J Bone Joint Surg Am 58:46–51

5. Gaine WJ, Smart C, Bransby-Zachary M (1997) Upper limbtraumatic amputees – review of prosthetic use. J Hand Surg Br22:73–76

6. Kejlaa GH (1993) Consumer concerns and the functional valueof prostheses to upper limb amputees. Prosthet Orthot Int 17:157–163

7. Lamb DW, Scott H (1981) Management of congenital and ac-quired amputation in children. Orthop Clin North Am 12:977–994

8. Law HT (1981) Engineering of upper limb prostheses. OrthopClin North Am 12:929–951

9. Scotland TR, Galway HR (1983) A long-term review of chil-dren with congenital and acquired upper limb deficiency. J Bone Joint Surg Br 65:346–349

10. Sturup J, Thyregod HC, Jensen JS et al (1988) Traumatic am-putation of the upper limb: the use of body powered prosthesesand employment consequences. Prosthet Orthot Int 12:50–52

366