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Prosthetic Outcome of Unilateral Lower Limb Amputee Soldiers in Two Districts of Sri Lanka

Gunawardena, Nalika S. MBBS, MSc, MD; Seneviratne, Rohini de Alwis MBBS, MSc, MD, DipMedEd, MMedEd; Athauda, Thamara MBBS, MSc, MD, Dip

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JPO Journal of Prosthetics and Orthotics: October 2004 - Volume 16 - Issue 4 - p 123-129
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Thousands of armed forces personnel in Sri Lanka have undergone lower limb amputations as a result of war injuries during the past 20 years. The loss of a lower limb leads to a partial decline in functioning and often affects employment and quality of life. Amputees and their families are faced with a specific set of problems requiring clinical services to regain independence.1 Rehabilitation plays a major role in this process. Rehabilitation necessitates a combined and coordinated use of medical, social, educational, and vocational measures to restore the individual to the highest possible level of functional ability.2 The ultimate goal of rehabilitation of amputees is reintegration into the pursuit of daily activities. Prosthetic rehabilitation, a major component of a multidimensional rehabilitation approach, is important in achieving this goal. Amputees require initial prosthetic training to learn an energy-efficient gait and lifelong prosthesis care.

The aim of prosthetic training is to achieve daily functional prosthesis use with good balance, appropriate weight shifting, and an energy-efficient gait. The more energy it takes to walk, the less likely the prosthesis will be used. Once basic walking is mastered, daily functional activities are incorporated into the training.3,4 Young amputees are discouraged from using technical aids with prostheses because the aids could make the gait energetically inefficient and delay rehabilitation.5

In Sri Lanka, all amputee soldiers receive prostheses and training under sponsorship of the Sri Lanka Army. Many countries, including developing countries that have experienced war, have undertaken research aiming to assess prosthetic outcome of their war veterans. A formal evaluation of the prosthetic outcome of disabled war veterans in Sri Lanka has not been done to date.


The study settings were two of the 25 districts of Sri Lanka, Anuradapuara and Kurunegala. These districts were selected for the study because large numbers of soldiers in the Sri Lanka Army come from these districts.6 The initial rehabilitation program, follow-up medical care, and other social support services for amputee soldiers of the Sri Lanka Army are provided in Colombo, irrespective of the soldiers’ place of residence.

The study population included unilateral lower limb amputee soldiers (n = 461) from Anuradhapura (n = 231) and Kurunegala (n = 230). Inclusion criteria were: a male soldier in the Sri Lanka Army (currently in service, medically condemned, or retired) who have undergone unilateral amputation at the transfemoral or transtibial level as a result of an injury at war, surgery 8 months to 6 years before the beginning of the study, and completion of prosthetic training at the time of the study. Amputees who had not completed the gait training program or those who had any other coexisting severe disability such as upper limb amputation at any level, or conditions restricting optimum functioning of the upper limbs or the unaffected lower limb (unhealed fractures, nerve paralysis, and so on) were excluded.

The study was conducted between September 2001 and February 2002. An interviewer-administered questionnaire was used to collect information on prosthesis use and factors affecting its use. The Prosthetic Profile of the Amputee persons (PPA) questionnaire7 was used as the basis for the development of the questionnaire used in this study. Reliability and validity of PPA has been assessed and established for clinical use and research.8 In adopting this instrument in the present study, some areas were modified to suit the cultural setting. It was pretested outside the study settings. Field investigators were given training on identification of eligible subjects and on administering the study instrument.

The definition of “prosthetic use” varies in the literature.7,9–11 For our purposes, “prosthetic use” assessed the number of days the prosthesis was worn by an amputee during a week at the time of the study. A prosthesis wearer was defined as a person who currently wears the prosthesis at least once a week. A nonwearer was defined as a person who currently does not wear the prosthesis at least once a week. To assess the use of prostheses for walking, wearers were further categorized into cosmetic users and active prosthetic users. A cosmetic user was defined as a person who wears the prosthesis but does not walk with it. The active prosthetic user was defined as a person who wears the prosthesis and also walks with it.

An amputee could use a combination of different modalities for mobilization within a day, including using a prosthesis (with or without technical aids), using a wheelchair, and other modes (bearing weight on technical aids such as armpit or elbow crutches, or bearing weight on a long below-knee (BK) residual limb, on buttocks, or on knees).

Each of the wearers was requested to identify the percentages of mobilization using each of these modalities within a typical day as 0%, 25%, 50%, 75%, or 100%. A cosmetic wearer was considered equivalent to amputees in “percentage mobilization 0%” in the modality of mobilization using a prosthesis. An active prosthetic user was considered equivalent to amputees in “percentage mobilizations 25% and above” in the same modality.

PPA has identified factors affecting prosthetic use through the use of the PRECEDE (predisposing, reinforcing, and enabling factors in educational diagnosis and evaluation) theoretical model.7,12,13 This model was adapted in this study to serve as a conceptual model in identifying factors affecting prosthetic use.

Predisposing factors, antecedent to behavior, provide the rationale or motivation for the behavior. Predisposing factors included in the present study are:

  1. Demographic characteristics: age, education, current civil status, income level, current employment status;
  2. Physical health status: level of amputation, medical conditions, condition of the nonamputated leg, condition of the residual limb;
  3. Prosthetic training: time interval between amputation and admission to prosthetic training, duration of prosthetic training, status (inpatient or outpatient) during prosthetic training; and
  4. Motivation: adaptation to amputation, adaptation to prosthesis.

Enabling factors, also antecedent to behavior, allow a motivation or aspiration to be realized. Included are personal skills as well as resources. Enabling factors included in the present study are:

  1. Ability to put on the prosthesis;
  2. Locomotor abilities with prostheses, including basic abilities (getting up from a chair, walking inside a house, walking outside on even ground, going up/down stairs with a railing) and advanced abilities (picking up an object from the floor, getting up from a lying position, walking outside on uneven ground or in adverse weather, going up/down stairs without a railing, carrying objects while walking); and
  3. Physical environment: architectural barriers in the living environment.

A four-point ordinal scale of “No, I am not able,” “Yes, I can if someone helps me,” “Yes, I can if someone is near me,” or “Yes, I am able to accomplish the activity alone” was used for each item, scored from 0 to 3. Locomotor Capability Index (LCI),14 included in PPA, was the basis for selecting activities to be included.

Reinforcing factors, subsequent to behavior, provide the continuing reward, incentive, or punishment for a behavior and contribute to its persistence or extinction. Reinforcing factors included in the present study are:

  1. Satisfaction with the prosthesis: comfort, appearance, weight, gait;
  2. Problems related to prosthetic use: effect of prosthesis wear on residual limb problems related to fixed heel height, mechanical problems;
  3. Social environment: recognition in society compared with before amputation, significant others’ acceptance of amputation and prosthesis, social discomfort;
  4. Social interaction: recreational and sporting activities; and
  5. Maintenance of physical status: regularity of exercising, medical follow up.

This study was approved by the Ethical Review Committee of the Faculty of Medicine, University of Colombo. Informed consent was obtained from all study participants.


The study included 461 amputee soldiers with a response rate of 98.3%. Of the 461 amputee soldiers, 413 (89.6%) were transtibial or BK amputees and 48 (10.4%) were unilateral transfemoral or above-knee (AK) amputees. The study included amputees who had undergone surgery 8 months to 6 years before the beginning of the study. The interval between surgery and study commencement was categorized as early (8 months up to 3 years) or late (3–6 years). A majority of amputees (283, 61%) were in the late category.

The mean age of amputees was 26.2 (± 4.5) years at the time of injury (Table 1). Land mines were the most frequent cause of the injuries (86.6%) leading to amputation. The mean age of amputees at the time of the study was 30.2 (± 4.6) years.

Table 1:
Distribution of the amputee soldiers by sociodemographic characteristics and level of amputation

After postoperative surgical management, all 461 amputees were admitted to a specialized rehabilitation center for prosthetic fitting and gait training. The average interval between surgery and prosthetic training was 4.5 (± 1.2) weeks. Mean training time for amputees was 1.9 (± 1.0) months.

A majority (458, 99.3%) of amputees wore the prosthesis for 1 or more days per week and were categorized as wearers. All 48 (100%) AK amputees and 410 (99.3%) of 413 BK amputees were in this category. Three (0.7%) BK amputees who did not wear the prosthesis even for a single day of the week were categorized as nonwearers.

Among the wearers, BK wearers showed a higher mean number of hours of prosthesis wear (11 ± 3.9 hours) compared with AK wearers (8.2 ± 4.2 hours) (z = 3.24, P <.001).

Indoor and outdoor percentage mobilizations of prosthesis wearers are shown in Figures 1, 2, and 3.

Figure 1.:
Distribution of prosthetic wearers by percentage mobilization using prosthesis.
Figure 2.:
Distribution of prosthetic wearers by percentage mobilization using wheelchairs.
Figure 3.:
Distribution of prosthetic wearers by percentage mobilization using “other modes.”

All wearers were using their prostheses for at least 25% of their indoor and outdoor mobilizations (Figure 1). The percentage of wearers exclusively using prostheses for mobilization outdoors (292, 62.8%) was significantly higher compared with exclusive use of prostheses for mobilization indoors (196, 42%) (z = 6.54, P <.001).

More than 95% of the wearers did no indoor or outdoor mobilizations in a wheelchair (Figure 2). Likewise, a majority of wearers did not use “other modes” for their indoor (194, 42.4%) or outdoor (287, 62.7%) mobilizations (Figure 3).

As shown in Figure 1, there were no amputees in the category “percentage mobilization 0%” for both indoors and outdoors, meaning there were no cosmetic wearers in this study sample. Therefore, all amputees who were categorized as wearers in this study were active prosthetic users.

A majority used no aid for walking indoors (308, 66.4%) or outdoors (270, 58.2%). Of the amputees who used aids, the most commonly used aid was one elbow crutch indoors (103, 68.7%) and outdoors (115, 61.2%).

The factors affecting prosthetic use should be identified by comparing nonprosthetic users (nonwearers and cosmetic wearers) and active prosthetic users. In this study, there were only three nonprosthetic wearers and no cosmetic wearers. Because the number of nonusers was too small for comparison, factors affecting prosthetic use were studied by assessing the extent of prosthetic use among the users. For this purpose, responses to percentage mobilization using prosthesis (Figure 1) were amalgamated in the analysis into two levels, level 1 representing lower-level use (25% and 50%) and level 2 representing higher-level use (75% and 100%) (Figure 4). Level 2 of outdoor mobilization (374, 81.7%) was higher compared with the corresponding level of indoor mobilization (305, 66.6%) (P <.01).

Figure 4.:
Distribution of prosthetic users by extent of prosthetic use.

The effect of each of the PRECEDE factors on extent of prosthetic use was assessed by comparing its presence or absence between amputees in levels 1 and 2. The extent of prosthetic use, for both indoors and outdoors, was evaluated using bivariate and multivariate methods with the intention of describing the factors affecting indoor and outdoor use separately. Significant influencing factors for less prosthetic use (level 1) using bivariate and multivariate analyses are shown Tables 2, 3, and 4.

Table 2:
Significant predisposing factors for less prosthetic use
Table 3:
Significant enabling factors for less prosthetic use
Table 4:
Significant reinforcing factors for less prosthetic use


This study was a community-based household survey. Therefore, it was possible to include all amputees irrespective of employment or health status. Self-reported information regarding frequency of prosthesis wear was used in the categorization of prosthetic wearer/nonwearer. The social undesirability bias associated with wearing or nonwearing of prostheses was reduced by the addition of a neutral introductory statement before these questions were asked, reassuring the respondent that both these behaviors were considered acceptable.

Respondents were requested to identify the percentage of mobilizations done within a typical day at the time of the study using three specified modalities of mobilizations out of a total of 100% mobilizations. The percentages were specified from 0% to 100% on a 25-point scale. Prosthetic use was quantified into two major categories depending on the extent of use to identify the factors affecting use. For this purpose, 25% and 50% use formed the lower level (level 1) and 75% and 100% use formed the higher level (level 2).

In the present study, BK amputees were proportionately higher than AK amputees, the ratio being 9:1. This is in contrast to approximately equal proportions found among war amputees at the Dundee limb-fitting center.15 Higher numbers of lower levels of amputations (BK) could be attributed to the cause of injury being locally manufactured land mines, which was the most frequent cause.

All amputees of the Sri Lanka Army had been referred for prosthetic training and had been fitted with prostheses. The fact that all have had prosthetic training at the same specialized rehabilitation center makes the factors in the prosthetic training program comparable among the study group. This also imposes the limitation that it cannot be evaluated against another program. The average interval for commencement of prosthetic training program after surgery (4.5 ± 1.2 weeks for all levels of amputation) was shorter than the corresponding average interval of 15 weeks as reported by a study on nonmilitary traumatic amputees.11

Average duration of prosthetic training for amputees (1.9 ± 1.0 months) was longer than the time taken by nonmilitary traumatic amputees.9,12 Although the optimum training period could show an individual variation, the wide range in the duration of training could reflect the nonuse of “critical paths” in the program. Critical pathways are an effective tool to expedite the communication and planning required in achieving a timely discharge as well as successful rehabilitation.4 This area needs to be studied further.

The present study found a mean wearing time of prosthesis of 11 (± 3.9) hours per day among BK amputees. This was shorter than the mean time of 12.5 hours among traumatic amputees and 12.1 hours among amputees of all causes.11,12 AK amputees wore prostheses for a mean duration of 8.2 (± 4.2) hours per day in the present study, which was also shorter than 9.7 hours as found in a study among AK amputees of all causes.12 A study among amputees at the Nova Scotia Rehabilitation Center revealed that 65% of the amputees wear prostheses for at least 9 hours per day.9

The present study defined prosthetic user based only on the use of the prosthesis for walking; its use for activities such as running, sports, driving, and so on, was not considered. This study categorized 99.3% as users, but it has to be emphasized that if other activities were included in identifying an amputee as a user, the percentage of “users” might not be as high. The proportion of prosthetic users can be considered very satisfactory compared with 92% found in studies on nonmilitary traumatic amputees using the same criteria.12 The proportions of amputees who exclusively used prostheses for their indoor and outdoor mobilizations were also higher in the present study when compared with prior studies.

Use of a wheelchair for mobilization is regarded as a negative indicator of success of prosthetic use. This study showed satisfactory results with more than 95% not using a wheelchair at all. In contrast, much lower percentages were found not to use wheelchairs in a study of amputees of all causes (75%)9 and in a study of nonmilitary traumatic amputees (79%).10

In the present study, 66.4% and 58.2% did not use an aid when walking indoors and outdoors, respectively, compared with much lower percentages reported by others.9

In a study among amputees of all causes in which the study units had a higher mean age, older age was found to be a predisposing factor in less prosthesis use.12 Less use of prostheses outdoors among amputees with higher monthly income and higher education in the present study could be the result of the fact that they did not engage in income-generating outdoor activities wearing the prosthesis compared with amputees with lower income and lower education. This was in contrast to the findings of lower education level and lower income to be negatively correlated with prosthetic use in a study of amputees of all causes.12

Less use of prostheses among AK amputees compared with BK amputees can be explained by the relatively higher energy expenditure required for AK amputees for walking resulting in fatigue. Other studies on unilateral amputees have shown similar results.4,12

Medical conditions in the amputees had no relationship with prosthetic use and could be attributed to the few amputees with these conditions. A study among older amputees of all causes found comorbidities to be affecting prosthetic use.12


Prosthetic use was satisfactory with a majority using prostheses for more than 50% of their mobilizations indoors (67.2%) and outdoors (82.3%). Only 42% and 62.8% used prostheses for 100% mobilization indoors and outdoors, respectively, indicating room for improvement. The study identified a range of predisposing, enabling, and reinforcing factors that can be implemented as primary strategies in the future or as secondary strategies among target groups to improve the use of prostheses.


The authors thank IDA/WB Health Services Project for providing funds and the Directorate of Rehabilitation in Sri Lanka Army for their assistance.


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amputee soldiers; lower limb amputees; prosthesis use; unilateral amputees

© 2004 American Academy of Orthotists & Prosthetists