Apart from the face, the hands are the primary means of expression and social contact in human beings. They are almost always on display, and enhancement of their appearance with the addition of jewelry or cosmetics occurs in most societies. 1 When an individual has had the misfortune to lose a digit or part of the hand, the psychological effect can be as devastating as having lost an entire limb. It is well recognized that the degree of physical loss is not at all indicative of the degree of emotional loss. 2 Modern rehabilitation currently concentrates on the physical limitations caused by an amputation and the possibility of improving participation by improving functional capabilities. There is little emphasis placed on psychological rehabilitation.
Previously, individuals with digital/partial hand amputations, if provided with any prosthesis at all, would be provided with a polyvinylchloride (PVC) cosmetic prosthesis, which usually was cut from a cosmetic glove. Although these prostheses would return normal contour to the hand, the prostheses varied from normal skin color and markings. There have been recent advances in digital/partial hand prosthetics with the development of silicon prostheses. These prostheses are usually of high quality, match well with the patients’ remaining digits, and thus are more aesthetically pleasing.
In theory, clients with silicon prostheses should be more satisfied with their prostheses than clients with the more traditional PVC (nonsilicon) prostheses. The purpose of this study was to investigate if this were indeed the case. We also thought it was important to examine clients’ body image perception, to investigate the relationship between body image and emotional distress, and to determine any difference between the two groups in this regard.
METHODS
A retrospective analysis of all patients in the database of the Disablement Services Centre, Freeman Hospital, Newcastle-upon-Tyne, England, United Kingdom, was performed to identify surviving patients with digital (finger or thumb) or partial hand amputations (n = 17). Once identified, these patients were divided into silicon (n = 11) or nonsilicon (n = 6) prosthesis groups, depending upon which prostheses they had been prescribed. The records were then analyzed, demographic details ascertained, and method of injury documented.
A postal survey was conducted, inviting each client to complete three questionnaires: the Hospital Anxiety and Depression (HAD) scale, the Attitude to Artificial Limbs Questionnaire (AALQ), and the adapted Body Image Questionnaire (BIQ). The results were analyzed to discern clinical and statistically significant differences among the groups using the SPSS (SPSS version 10, Chicago, IL) computer statistics package.
THE HOSPITAL ANXIETY AND DEPRESSION SCALE
The HAD scale is a portable and easy-to-use measure of depression and anxiety. It is equally effective in hospital, outpatient, or community settings. This tool has been extensively researched and validated in the literature 3,4 and was used to investigate a relationship between emotional distress and body image. The HAD scale is scored as follows (with depression and anxiety scored separately): 0 to 7 = normal; 8 to 10 = borderline abnormal; and 11 to 21 = abnormal.
THE ATTITUDE TO ARTIFICIAL LIMB QUESTIONNAIRE
The AALQ was specifically designed to measure patients’ attitudes to their artificial limbs in a study performed by Keren Fisher and Rajiv Hanspal from the Royal National Orthopaedic Hospital, Stanmore, United Kingdom. 5 The questionnaire consists of 10 questions with responses on a 5-point Likert scale measuring agreement from “not at all” to “completely,” where low scores indicate negative responses. The total range of possible scores is 0 to 50. This was adapted for our purposes to assess satisfaction with digital prostheses overall, as well as their comfort, shape, color, and material. The questionnaire also asks how much the patients feel the prosthesis is part of them and their perception of how other people perceive them. It also asks if they feel their body image is restored and whether they feel the prosthesis could be improved.
THE BODY IMAGE QUESTIONNAIRE
Body image refers to the attitudes people have about their bodies and their appearance. An alteration in an individual’s body image sets up a series of emotional, perceptual, and psychological reactions. 6 Amputation results in an alteration of body image that can have long-term psychological sequelae. 7,8 The BIQ was developed by Breaky 9 in 1997 to assess amputees’ perception of body image and was derived from a Body Shape Questionnaire used in eating disorders. 9,10 This was adapted slightly to take into consideration the nature of these clients’ amputations. This particular measurement tool was used to assess if patients felt the prosthesis had restored their body image. The Body Shape Questionnaire is widely used in literature and is reliable. Low scores indicate satisfaction with body image. The total range of scores is 16 to 96.
RESULTS
Nine (82%) of the clients with silicon prostheses responded, and four (67%) of the clients with nonsilicon prostheses responded. The gender distribution was similar in both groups: 75% male and 25% female. The mean age of all clients was 39.5 years (range, 15–78 years). Analysis of the mode of injury revealed a wide variety of causes of digital amputation (Table 1). The most common cause of amputation was occupational injury.
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Table 1: Causes of digital amputation for the silicon and nonsilicon groups
HOSPITAL ANXIETY AND DEPRESSION SCALE
The mean HAD scores were lower in the silicon group than the nonsilicon group (Table 2). Clinically, the mean scores in the silicon group were within the normal range (0–7) and were borderline abnormal in the nonsilicon group (8–10), suggesting a clinically significant difference between the two groups. However, when the scores were subjected to statistical analysis, there was a statistically significant difference between the groups only in the depression scores (p = 0.009). This may be because of the small numbers involved in the study.
Table 2: Comparison of the questionnaire scores for silicon and nonsilicon groups
ATTITUDE TO ARTIFICIAL LIMB QUESTIONNAIRE
A comparison of the means of the two groups showed lower AALQ scores in the nonsilicon group than in the silicon group (Table 2). These figures would suggest lower acceptance in the nonsilicon group when compared with the silicon group but, again, when the data were subjected to statistical analysis, there was no significant difference between the two groups.
BODY IMAGE QUESTIONNAIRE
There was surprisingly little difference between the BIQ means for the two groups (Table 2), implying little difference in body image perception between the two groups.
DISCUSSION
The absence of a difference in body image perception as measured by the BIQ may be attributable to small study numbers, or the tool may not be sensitive enough to detect an alteration in body image in a group such as this. One individual in the silicon group met criteria for clinical depression and also had a high anxiety score, with a poor attitude about his artificial limb and a very poor body image. Given the limited numbers in the study, this may have skewed the results.
These results would suggest that enhanced cosmesis implies greater psychological well-being independently of body image. The results also show how a clinically significant difference may not be statistically significant.
CONCLUSIONS
Our results suggest that most individuals with digital amputations are men who have sustained their injuries in their line of work.
Our findings suggested that patients with silicon digital prostheses experienced less anxiety and depression than did those in the nonsilicon group; however, only depression was statistically significant.
We found that patients with silicon digital prostheses tended to have a better attitude toward their prostheses than did those with the traditional PVC prosthesis, although the difference was not statistically significant. There was surprisingly little difference in body image as measured by the BIQ, but this may have been attributable to the small sample size.
Digital amputation is a relatively common problem, and the small numbers in the database would suggest that there are many individuals who have experienced digital amputation who have not been assessed by a prosthetic service. We must endeavor to provide such individuals with the opportunity to access our services and thus potentially improve their psychological well-being and body image.
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