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Function and Body Image Levels in Individuals with Transfemoral Amputations Using the C-Leg®

Swanson, Erica RP, MOT, OTR/L; Stube, Jan PhD, OTR/L; Edman, Paul CP

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JPO Journal of Prosthetics and Orthotics: July 2005 - Volume 17 - Issue 3 - p 80-84
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Rehabilitation of persons with transfemoral amputations is more than providing a properly fitting prosthesis and gait training. A comprehensive rehabilitation program must also address reintegration into daily living activities, including social and vocational settings in which the person was involved before the amputation. The emotional loss of an amputation can be as great as the physical loss, making the psychosocial aspects a crucial component of rehabilitation.

A key psychosocial aspect of successful rehabilitation is body image. One definition of body image is “awareness and perception of one’s body related to appearance and function.”1 For persons with lower extremity amputation, increased levels of physical activity and function in life lead to an increased self-esteem and a more intact body image.2

In this study’s region of the United States, one type of microprocessor-controlled prosthetic knee joint for post-transfemoral amputation is primarily used. Participants using the Otto Bock C-Leg® (Otto Bock Health Care, Minneapolis, MN) were accessible for this study. Otto Bock developed the C-Leg, a microprocessor-controlled knee joint system, with the intent of providing optimal stability throughout the gait cycle.3 To date, most research studies involving the C-Leg have focused on the physiological benefits.4,5 As such, the metabolic benefits of the C-Leg have been documented. Beyond these physiological benefits, the functional aspects of a person’s life have yet to be explored. For individuals using the C-Leg, a more secure and natural gait is presumed to facilitate successful reintegration into their previous physical and social roles.

The purpose of this study was to determine if adults in this region of the United States who have transfemoral amputations and use the C-Leg are able to reintegrate into their life roles with an enhanced level of function, satisfaction, and a positive body image. The intent of this study was to explore the psychosocial and physical parameters of function afforded by the C-Leg among users in this sample.



This study took place in a prosthetics department of a Midwestern acute rehabilitation hospital. After Institutional Review Board approval was given, a purposive sampling method was used to recruit participants (n = 8). Inclusion criteria for participants were individuals with transfemoral amputation, currently using the C-Leg, older than 18 years, and without cognitive limitations. All eight participants were male and had been using a prosthesis for an average of 19.95 years, with a range of 8 months to 75 years. They had used the C-Leg for an average of 1 year 9 months, with periods ranging from 3 weeks to 3.5 years. Seven of the eight participants had sockets that were fit before this study and were comfortable with them. Six of the eight participants did not wear any type of cosmetic prosthetic cover and had prosthetic components exposed. Each participant signed an informed consent and completed three surveys: the Reintegration to Normal Living (RNL) Index, the Situational Inventory of Body-Image Dysphoria (SIBID), and the Function and Body Image Survey (FBIS). The surveys were administered by the principal researcher to each participant individually.


In previous studies, function has traditionally been measured by parameters such as applied gait analysis and energy expenditure4,5; however, in this exploratory study, function was defined by the survey measures to be everyday tasks. These tasks included such things as house mobility, getting around in the community, self-care comfort, spending the desired amount of time at work or other valued activities, recreation and social activities, and family or personal relationship time.

In addition, the situations that typically arise while completing these everyday tasks were measured. The situations encompass psychosocial issues such as: perceptions of how people view themselves/their body, feelings when the topic of conversation is on physical appearance, perceptions of desired appearance, feelings about being in photographs, and emotions regarding intimate relationships or circumstances. The surveys used in this study to capture physical and psychosocial function when using the C-Leg are described below.

The Reintegration to Normal Living Index

The RNL is an 11-item questionnaire that asks how a person manages activities, roles, and relationships on a day-to-day basis. The survey determines to what degree an individual has reintegrated into performing functional roles in a broad range of daily tasks. Participants respond by marking a 10-centimeter visual analog scale that ranges from “does not describe my situation” to “fully describes my situation.” The RNL has demonstrated validity and reliability documented in the literature.6

The Situational Inventory of Body-Image Dysphoria

The SIBID is a multidimensional body-image survey assessment of people’s negative body-image emotions in everyday situations and physical experiences. It has documented validity and reliability to assess therapeutic change.7,8 The survey includes a 5-point Likert-type9 scale format, with the values ranging from 0 = never to 4 = almost always. The SIBID is unique in that it captures an individual’s emotional experience within 50 specific functional situations involving social scrutiny, social comparisons, wearing certain clothing, body exposure, looking in the mirror, and exercising.

The Function and Body Image Survey

This survey was designed by the principal researcher and consists of six open-ended questions regarding personal thoughts, opinions, and experiences about the C-Leg, and the individual’s current functional abilities. An open-ended qualitative format was chosen for this survey to capture thoughts and feelings of participants, eliciting additional information to supplement the other two survey measures.


Data were analyzed using the SPSS statistical software package (version 11.0.1).10 Open-ended questions were analyzed descriptively for content and frequency. Descriptive and exploratory analyses were conducted, including nonparametric correlational analysis. Response categories were operationally defined before statistical analysis was conducted. Correlation coefficients of the response categories were calculated using Spearman’s rho.9

Response categories included: social integration, body image, functional role performance, self-efficacy, social scrutiny, personal relationships, and psychological distress. Social integration was defined as the organization of organic, psychological, and social traits and tendencies of an individual into a harmonious whole.6 Social aspects were emphasized in this category as integral for successful reintegration into life after an injury. Body image captured personal satisfaction regarding body appearance and self-perception. “Body image is a multifaceted psychological construct that includes the subjective attitudinal and perceptual experiences of one’s body, particularly its appearance.”7Functional role performance was defined as an individual’s characteristic performance including physical and psychosocial aspects.6 Roles were further considered to be “socially expected behavior patterns associated with an individual’s status in a particular society” (p. 5).11

Self-efficacy refers to a person’s belief in their performance specific to a certain task. It does not concern the task or skill alone but rather the personal judgment of what one can do with one’s own skills.10Social scrutiny was considered as a situational and contextual event that affects emotions regarding one’s body image.7Personal relationships referred to a person’s ties with relatives, significant others, or friends.6Psychological distress referred to negative self-perceptions of appearance or functional abilities relating to body image and reintegration to daily living.7


Response categories of the RNL and SIBID were correlated using Spearman’s rho.9 The first hypothesis, that independence in functional role performance would be enhanced by use of the C-leg, was statistically supported by four categories of the RNL and SIBID (Table 1). As expected, the higher a participant’s functional role performance: the higher his self-efficacy (rs = 0.86, p < 0.01); the higher his social integration (rs = 0.74, p < 0.05); the higher his comfort level with personal relationships (rs = 0.71, p < 0.05); and the lower the feelings of psychological distress (rs = −0.77, p < 0.05). The response category of social scrutiny was not found to statistically correlate with functional role performance (rs = 0.03, p > 0.05).

Table 1
Table 1:
Spearman’s rho correlation coefficients among functional role performance and response categories on RNL and SIBID

The second hypothesis, that increased functional independence through use of the C-leg correlates with increased body image, was not statistically supported. However, a fair inverse relationship9 was found (rs = −0.43, p > 0.05). This indicated that as a person experienced more independence in functional role performance, he/she experienced less dysfunctional feelings about body image. Participant comments from the FBIS survey supported this directional trend by indicating feelings of self-confidence in both social and functional participation (Table 2).

Table 2
Table 2:
Participant comments on change in self-confidence and body image

Qualitative analysis revealed three overall patterns from the participant responses on the FBIS survey: role participation, functional activity performance, and self-confidence. Table 3 summarizes comments specific to function and role performance. For example, walking improvements were most commonly emphasized as an explanation for greater satisfaction in role participation and functional activity performance, followed by increased motivation and self-confidence. Walking improvements included better speed, endurance, and performance on stairs and uneven terrain. Motivation was exemplified by comments related to the ease and duration of performance in new or previously enjoyed activities.

Table 3
Table 3:
Participant comments on change in role participation and functional activity performance

Related to functional activity performance and self-confidence, feelings of safety and security were mentioned by 50% of the participants. Three participants stated that they experienced fewer falls and felt safer in basic and complex activities of daily living participation. Specifically, two participants cited better work performance, and three participants mentioned sports participation improvement. In addition, self-confidence was expressed by participants in terms of improved social participation.



Psychosocial and physical aspects of coping with a transfemoral amputation are many and varied. In this study, both aspects were investigated through survey of participants who use the C-Leg to better understand the functional benefits. In this study, we demonstrated connections between the physical functional aspects with the psychosocial issues of coping and living with a transfemoral amputation. Overall, the results indicated statistically significant relationships between a person’s participation in his/her valued roles and feelings about his/her performance. In addition, the participants’ comments are vivid self-expressions of the confidence and motivation they experience when using the C-Leg.

Of the statistically significant correlations found, self-efficacy is paramount to participation in life roles and tasks. Although the participants may not participate in more activities, they seem to be satisfied with the activities they do perform; and they can perform them in a safer and more efficient manner. They report enjoying an enhanced confidence and motivation. The technology may be seen as providing the physical basis for the psychological benefits experienced by the participants.

Psychological benefits may further be influential to social participation. At the point of taking the surveys, participants indicated a confidence in social participation, rather than an avoidance or lack of desire to participate. This is clinically significant in that many individuals did not avoid social participation. The C-Leg provided these participants with the ability to participate safely and efficiently in their desired social activities. Personal relationships, including family and friends, take both physical and emotional energy to thrive. Participants in this study conveyed the major improvement in this area as the ability to spend more time with people because their energies were not consumed by pain or fatigue.

Participants were less concerned with falls and the appearance of an abnormal gait, reporting comments such as feeling “more normal” and “safer.” When one does not have to focus attention on gait stability, it is possible to focus on successfully completing life’s challenges. This impression supports the statistical correlation found in this study between successful functional role performance and reduced psychological distress. Although these individuals did not experience psychological distress to a strong degree, feelings of social scrutiny were present. Interestingly, despite feeling somewhat socially scrutinized, participants still qualitatively reported satisfaction with functional role participation. This issue warrants future research; however, for the purposes of this study, it may be interpreted that when confidence regarding functional abilities is present, social scrutiny may not be influential enough to negatively affect these abilities.

Regarding the results of the second hypothesis, a fair inverse relationship between functional role performance and body image was found. This indicates to us that if an individual is capable of successfully participating in the activities desired, he/she may experience fewer negative feelings about body image. Participants indicated the reason for feeling more “normal” or “confident” is attributed to the functional abilities achieved from using the C-Leg. Possible explanations as to why this relationship was not statistically stronger include: the participants were less aware or concerned with body image, had long-standing issues with self-image, or had varying degrees of positive coping mechanisms regarding their amputation.


Several limitations to this study should be recognized. The nonexperimental nature of survey design is limiting to generalization of results to other individuals using the C-Leg. Our sample size (n = 8) is small and may not be representative of all individuals using the C-Leg. The small sample size also limited our ability to do comparative analysis. The sample also contained only men. Women may report different perceptions of function, roles, and body image. Consideration of gender, age, experience using the C-Leg, and secondary medical conditions are suggested for future related research. Finally, body image is a nebulous concept that may be perceived differently among individuals. There are many external factors that make it difficult to use survey research to quantify such an abstract concept. These factors can include individual differences in life experiences, personal relationships, mental health, and self-awareness issues.


As professionals in the field of prosthetics and rehabilitation, it is important to look beyond the physiological benefits the C-Leg can offer. Our results suggest that individuals using the C-Leg reported high levels of self-efficacy, social integration, and comfort with personal relationships. These high levels of psychosocial well-being further correlated with independence in functional role performance. The reported qualitative benefits by participants in this study support the idea that the psychosocial and independence factors should be definite considerations in the selection of prosthetic technology. Additional research is encouraged to examine these concepts with larger, more diverse samples.

This study helped us recognize that rehabilitation is and should be an all-encompassing endeavor of the human spirit, as well as the body. Our purpose was to examine qualitative benefits of advanced technology in the field of prosthetics for individuals with transfemoral amputation. An amputation has an effect on an individual both psychologically and physically. Benefits in both of these realms can be achieved with advanced prosthetic technology combined with an understanding of client priorities for function. A participant from this study summed it up well with this statement: “it is so nice to finally have a prosthesis that offers beyond the minimums of life.”


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body image; C-Leg®; function; psychosocial aspects; transfemoral amputation

© 2005 American Academy of Orthotists & Prosthetists