Secondary Logo

Journal Logo

Original Research Article

Utilization of Prostheses and Mobility-Related Assistive Technology Among Service Members and Veterans From Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom

Sprunger, Nathan A. MS; Laferrier, Justin Z. MSPT, OCS, SCS, CSCS, ATP; Collins, Diane M. PhD; Cooper, Rory A. PhD

Author Information
JPO Journal of Prosthetics and Orthotics: July 2012 - Volume 24 - Issue 3 - p 144-152
doi: 10.1097/JPO.0b013e31825b3a4b
  • Free

More veterans are returning with combat-related traumatic injuries1,2 such as spinal cord injuries, severe burns, traumatic brain injury (TBI), and various orthopedic injuries that result in lower limb amputation.3 In past conflicts, the severity of many of these wounds would have resulted in death. However, because of advances in body armor, surgical techniques, and on-site medical care, survival rates have increased substantially, leading to more veterans living with a number of disabling conditions such as lower limb amputations. Advances in technology and rehabilitation have evolved over the past decade, greatly improving the quality of life (QOL) of these individuals.4,5 Returning service members to their highest level of function after lower limb amputation is one of the primary focuses of the Department of Defense (DoD) and the Department of Veterans Affairs (VA).5 As of September 2010, more than 1621 service members have experienced major limb amputations because of injuries sustained in Operation Enduring Freedom, Operation Iraqi Freedom, and unaffiliated conflicts.6 These recent numbers significantly increase prosthetic service use from the more than 5380 veterans with major limb amputations from Vietnam.7 Because of the physical impairment and decreased functional capacity resulting from the loss of one or more amputated limb and in addition to concomitant injuries sustained, these veterans use a wide variety of mobility-related assistive technology (MAT). Mobility-related assistive technology is meant to help substitute for loss of mobility in people with amputations, helping improve their QOL through increased independence and participation in society. Although this technology successfully serves this purpose to varying degrees, some users are dissatisfied with their assistive devices and underuse or abandon these prematurely.8 A recent VA Health Services Research & Development–funded study conducted by the University of Washington/VA Puget Sound and Madigan Army Medical Center found that of 581 individuals surveyed 1 year after discharge, 10% to 20% had reverted to wheelchair use as their primary means of mobility rather than relying on prosthetic technology as their primary means of mobility.9 Two questions arose from this finding: 1) What are the underlying factors responsible for the transition from one type of MAT to another? and 2) Which veterans with amputation would fare better with rehabilitation focused on a different means of daily mobility such as wheeled mobility instead of prosthetic ambulation? For individuals who find walking with a prosthesis difficult, a focus on prosthetic rehabilitation may not lead to the most optimal outcome. A number of reasons have been reported in the literature related to prosthetic dissatisfaction and abandonment. Dillingham et al10 investigated the use, satisfaction, and difficulties experienced by individuals who sustained traumatic lower limb amputation from 1984 to 1994. In this study, of 146 individuals who received trauma-related amputations, only 63 participants (43%) of the sample reported being satisfied with their prosthetic devices.10 Several factors identified as potentially contributing to lower limb prosthesis underuse and/or abandonment by Dillingham et al10 included pain, poor prosthetic fit, inadequate prosthetic performance, comorbidities, changes in cardiovascular fitness and/or activity level, lack of consideration of the user’s needs in the prescription process, and changes in those needs.10–12 The economic cost related to MAT abandonment and the possible long-term effects of inappropriate initial prescription have motivated researchers to investigate underlying factors for underuse and/or abandonment to lower abandonment rates and improve MAT prescription guidelines for the more active individual with an amputation.12 Because the Armed Forces Amputee Care Centers currently focus on return to ambulation after lower limb loss with the use of one or more lower limb prostheses, this study largely focused on prosthetic use patterns and interaction with various types of MAT. Currently, the type of lower limb prostheses prescribed depends on the level of amputation and the anticipated level of activity the user is expected to perform with the use of the prostheses, as outlined by the Centers for Medicare and Medicaid.13 However, these guidelines may be outdated and applicable only to the older, nontraumatic individual with a dysvascular amputation.

By and large, little research has focused on identifying the factors contributing to prosthetic use and abandonment or the reasons for transitioning to different forms of MAT as a means of mobility. Efforts to encourage prosthetic use with or without other types of MAT are primarily anecdotal and include encouraging the clinician to include the user in the selection process of the prostheses and prosthetic components, more in-depth training of the user with the device, and environmental and recreational evaluations to ensure that the device is practical for the users’ work environment and activity level. However, in the case of traumatically injured military service members, these techniques are used when the individual is a full-time patient receiving therapy from 2 to 6 hours per day in a highly controlled environment. In this multidisciplinary setting, with all the necessary resources available in one facility, correcting any prosthetic device issues that may arise (i.e., pain, poor prosthetic fit, and poor prosthetic performance) is much easier.4,14,15 These techniques are not fully able to predict how the prosthetic users’ daily activity level, cardiovascular fitness, prosthetic satisfaction, or access to care change after discharge when individuals are left without the considerable resources they may have become accustomed to during their initial rehabilitation. Because of the increased number of individuals sustaining traumatic amputations, advances in prosthetic technology have been steadily evolving, driven by the demands of individuals with amputations as well as availability of new technologies from engineering and prosthetic sciences.16 These efforts should provide significant benefit to individuals who continue to use this prosthetic technology. It is possible that the desire of the injured service member to return to his/her previous level of function and the focus of the rehabilitation team to help attain these goals have led to an “overprescription” of certain prosthetic devices. Although no research has addressed this theory, it is possible that this overprescription may place the severely injured individual at greater risk for prosthetic abandonment and/or long-term physical or psychological harm.

Higher activity levels and participation in team and individual sporting events can increase overall health and psychosocial well-being in individuals with amputations.17 Research has shown that improved mental health has been linked to increased physical activity.18 Veterans events such as the National Disabled Veterans Winter Sports Clinic help veterans to participate in events and increase their overall activity levels.19 Without participation in sporting and recreational activities, prosthesis users may become comfortable within their daily activity zone and confine themselves to only what is necessary to ambulate within the household and to perform transfers.20 Keeping the individual at a higher activity level may increase the chances of an independent lifestyle by helping them use independent community ambulation.21

The study described in this article was developed from a questionnaire and focused on the activity levels and use of prostheses and other forms of MAT in daily living situations and during participation in extracurricular activities such as sports and recreation. Physical and psychosocial well-being was investigated to provide feedback and make it possible to determine possible recommendations for further studies and guidelines in the rehabilitation process.



Fifty-eight participants, aged 23–67 years, all with lower limb amputations, completed our Lower Extremity Prosthetic Usage Questionnaire. The sample included service members and veterans of all branches of the US Armed Forces who currently use lower limb prostheses. Persons with both unilateral (n = 48) and bilateral (n = 10) lower limb amputations were included in the study. Veterans who did not use a prosthesis for primary mobility were excluded from this study. Participants were veterans or volunteers at the National Veterans Summer and Winter sports clinics, National Veterans Wheelchair Games, and the Warrior Games during 2009–2010.


The study was a survey-based study in which questionnaire-based data were collected from volunteers. The questionnaire included a demographic questionnaire with specific questions related to health status, prosthetic satisfaction and use, QOL (Health Related Quality of Life Scale), and pain (McGill Pain Questionnaire). Also included were questions on wheelchair use, mobility, and sports participation. The questionnaire consisted of eight sections. The first section asked about specific demographics and included information about military service. Health issues other than the lower limb amputation were explored as well as information related to medical professionals currently providing services to the study participant. Amputation information included date, level, cause of amputation, and length of rehabilitation. Prosthetic use data gathered included specific information about everyday use, sport-specific use, and common problems experienced. Access to certified clinicians was also investigated because this is an important aspect of the treatment experience.


Demographic data collected included present age, sex, height, weight, and ethnic origin. Current military status, including rank, branch, and component, was requested to determine general military information. Total time served in the military and future military plans were also recorded in the demographic section. Data regarding medical conditions besides amputation that limit the individual’s mobility were also collected. This section of the questionnaire included the cause of the other medical conditions and treatments currently being received from a medical professional.


Data regarding the side, level, and cause of amputation (Figure 1) were collected, as well as the exact date of lower limb amputation and length of inpatient rehabilitation stay. Cause of amputation recorded included trauma, peripheral vascular disease (PVD), diabetes, cancer, or any other cause of the lower limb amputation.

Figure 1
Figure 1:
Cause of amputation.


The prosthetic use section of the questionnaire included detailed questions about daily prosthetic use and included collection of data regarding recreational activities. Total number and type of prosthetic devices used for mobility since the injury, as well as current devices used, were collected. The type of prosthesis used for ambulation was collected, as well as which device was used most if the user has more than one device. Several questions inquiring about the users’ prosthetist were included to gain insight about patient care after the initial inpatient rehabilitation. This section also included frequency of visits, common reasons for visits, and rate of replacement of the device. Age of the prosthesis, days per week the prosthesis was worn, and average wear time in hours per day were also recorded. Indoor and outdoor activity level was asked, and participants were asked to rate their average activity levels on an ordinal scale from low to high. Typical problems with the device itself were collected, and options to answer types of prosthetic problems included poor socket fit, instability, weight, durability, and alignment. Participants were encouraged to explain their answers in text to fully answer this question. This made it possible to elaborate on the most common problems experienced. The use of other assistive devices was examined, which included walkers, crutches, and canes. Wheeled mobility was not included in this section. The rate of falls incurred while using the prosthesis was asked, as well as use of stairs or inclines while ambulating with the prosthetic device. Questions about recreational activity were included in this section. Ability, rate, and distance of running were recorded, as well as participation in other recreational/sporting activities.


The standardized sections of the study included the McGill Pain Questionnaire (short form) and the Craig Handicap Assessment and Reporting Technique–Short Form 36 (CHART-SF36). The CHART-SF36 contains several questions about activities of daily living, including information on paid and unpaid assistance. This form also breaks down time spent out of bed or away from home. Paid and volunteer work, as well as school and recreation activities, was explored. Social experiences were assessed through questions about living situation, friends, and stranger interactions. The Trinity Amputation and Prosthesis Experience Scales standard section was also included. This section was broken down into parts 1 and 2. In part 1, physical and mental variables were asked on a 3-point scale. Part 2 inquired about general and amputation-related health, including the residual limb and phantom pain levels and duration.


A number of individuals with lower limb amputation use a combination of prostheses and a wheeled mobility device as a primary or secondary means of mobility. The wheelchair information section of the lower limb amputation questionnaire asks specific questions about type, make, and brand of wheelchair used. Other questions included frequency of wheelchair use, self-propulsion, and advanced mobility skills, such as the ability of the participant to perform wheelies for curb climbing, and others.


Participants were asked whether they had experienced prosthetic device failures because of breakage of components. Activities that lead to component failures were also identified to determine what causes the most stress on the prosthesis. Components of the prosthetic device were divided into different categories based on function and standard manufacturer classification. These classifications were as follows: Socket classifications included thermoplastics, carbon fiber, and other types. Suspension mechanisms were separated into five functional classes, which included pin/shuttle lock, belt, lanyard, vacuum, and suction. Transfemoral prostheses incorporate a knee joint and were classified accordingly. Pneumatic, hydraulic, four bar, microprocessor, and “other” were the selections offered. Manufacturer, make, and model were selected for the knees as well as the feet. Many participants ambulated on more than one prosthetic device, and failure of any or all components was accounted for in the questionnaire. The activities that led to the failure of one or more components were questioned. Standing, walking, hiking (with or without backpack), jumping, golfing, and running were all included. The direction the user was moving at the time of failure was separated into specific categories. Participants were asked to explain in detail the events and activities that led to the failure of any part of the device and what was done about the failure once it occurred. Replacement, repair, and any injuries sustained were recorded as part of the data in this section.


All participants in the study were military service members or veterans with at least one lower limb amputation who used a prosthesis for mobility. The study was explained in detail to each participant, and informed consent was obtained before the collection of any data. Participants were then given the questionnaire and sufficient time to complete it. Participants with impairments restricting their ability to complete the questionnaire (such as visual impairment) were assisted by a volunteer or staff member. All recorded data were secured and deidentified according to the study protocol.


Because of the various levels of amputation and unilateral versus bilateral amputations, for data analysis, we grouped the study participants at approximate functional levels as follows:

  • Group 1: amputations at transtibial levels and below
  • Group 2: amputations at transfemoral level, including knee disarticulations
  • Group 3: amputations above transfemoral level and all bilateral amputations

An α of p < 0.05 was established a priori. Then, each continuous dependent variable (e.g., age, height, weight) was investigated for its distribution normality, range of answers, and mean, standard deviation, and variance. Normally distributed continuous variables were analyzed using an independent-group one-way analysis of variance to compare groups 1, 2, and 3. We then compared the continuous variables between groups. The next step was comparison of normally distributed continuous variables between whites and all other minority groups by using an independent-group t test. Categorical variables were investigated for ranges of answers, as well as median and mode. Chi-square statistics were used to compare groups 1, 2, and 3 with the categorical variables such as prosthetic characteristics and activity level, in which sports participants played, and secondary assistive device use.

All recorded categorical variables were analyzed so that general descriptive statistical information could be determined, such as mean, median, mode, and percentages. The percentages and number of participants for categorical variables are recorded in the Results.


We analyzed and compared groups 1, 2, and 3 for significance to establish differences in MAT use and activity level. However, after running the tests, no statistically significant results were found. We then wanted to determine whether differences in ethnicity would be detected, so we dichotomized the groups by white versus nonwhite because whites comprised 74.1% of the total study participants. Again, no statistically significant differences were found in the data between whites and nonwhites.


Of the total group of study participants (n = 58), the mean age was 48.3 ± 14.3 years. The participants ranged in age from 23 to 67 years. All participants were men. The ethnicity of the participants was examined, and it was determined that 74.1% were white, 15.5% were African American (black), 5.2% were Hispanic (Latino), and 5.1% were of other descent. The information included rank as 77.6% enlisted and 22.4% officer. Branch of service was reported as 30 Army (52%), 12 Marine Corps (21%), 6 Navy (10%), 5 Air Force (8.5%), and 5 nonanswer (8.5%). Three participants served in two or more branches of the Armed Forces throughout their careers. At the time of amputation, 45 (77.6%) of 58 participants were on active duty.


Self-reported overall health was measured on an ordinal scale of 1 (very poor) to 5 (very good). Sixteen participants (28.1%) reported their health as being very good (ranking of 5), 29 participants (50.9%) reported that their health was good (ranking of 4), and 9 participants (15.8%) reported their health as being fair (ranking of 3). One participant each (1.8%) reported his health as being poor (ranking of 2) or very poor (ranking of 1), with one response missing (1.8%). Fourteen of the study participants reported having medical conditions other than the lower limb amputation that limited their mobility. Spinal cord injury, TBI, visual impairment, osteoarthritis, and chronic back pain were all reported as mobility restrictions. Any medical problems related to the amputation, such as residual limb pain and phantom pain, are discussed in detail in a later section. Trauma (88.2%) was the leading cause of amputation for the participants in this study. Peripheral vascular disease, diabetes, cancer, and infection represented the remaining causes. Statistically, dysvascular reasons are the leading cause of lower limb amputation in the civilian population.22 The high percentage of trauma-related amputations is expected in this study due to the participants being primarily from a military population. The length of inpatient rehabilitation among the subjects ranged from 1 to 27 months. The average inpatient rehabilitation length of stay was 5.77 months, with a standard deviation of 6.79 months.

Level of amputation varied among the participants. Level of amputation has been used in past studies to predict use of MAT, functional level, and activity level, with higher amputation levels lowering the efficiency of prosthesis use.23–25 Participants were categorized into groups based on self-reported level of amputation: group 1, n = 26 (44.8%); group 2, n = 22 (37.9%); and group 3, n = 10 (17.2%).


Of the total 58 study participants, 34 (57.9%) used wheeled mobility devices in addition to their prosthetic devices. Of the 34 participants who used wheeled mobility, 18 (54.5%) used their prostheses for most of their mobility needs (>80%), 19 (27.3%) used a wheelchair for most of their mobility needs, and 6 (18.2%) used their prosthesis and wheelchair equally throughout the day for mobility. Of those who used a wheelchair for mobility, 18 (62.1%) used it daily. All study participants who used manual wheelchairs could self-propel, and 41.4% were taught proper propulsion techniques while in rehabilitation. Of the 58 participants, 39 (67.2%) used secondary MAT in addition to their prosthetic devices. Table 1 contains the distribution of secondary MAT use among study participants.

Table 1
Table 1:
Sports participation


The participants were asked to self-report their indoor and outdoor activity levels. They were categorized into three groups: level 1, prosthesis wear of less than 4 hrs/day (transfers and household ambulation); level 2, prosthesis wear of 4–6 hrs/day (ambulating most indoor environments); and level 3, ambulation of more than 6 hrs/day (all indoor environments). Level 1 indoor activity levels were reported by 8 participants (14%), level 2 ambulation was reported by 11 participants (19.3%), and 38 subjects (66.7%) rated themselves as level 3 indoor ambulators. Outdoor activity level was separated into three levels also: level 1, walking less than 4 hrs (flat, unobstructed terrain); level 2, walking 4–6 hrs/day over varied terrain; and level 3, ambulating more than 6 hrs/day over varied terrain. Level 1 outdoor activity was reported by 13 (22.8%) of participants, level 2 was reported by 16 (28.1%) of participants, and 27 (47.4%) participants rated themselves as level 3 outdoor ambulators. One participant (1.8%) failed to answer the outdoor activity level question. In group 1, 11 participants (57.7%) used some sort of MAT in addition to the prosthesis (not including wheeled mobility). Just more than 81% of the participants in group 2 used MAT, and 60% of the participants in group 3 used MAT at least some of the time (Figure 2). Of those who used MAT, 38.1% needed the MAT all the time, whereas 47.6% used their assistive devices only for long walks or challenging terrain (Figure 3). Nearly 45% (25) of the participants could run using their prosthesis. Of the 44.8% that were able to run, 29.2% could run about a mile. Being able to run more than 1 mile but less than 2 miles and being able to run more than 2 miles one to three times per week (avid runner) were split evenly at 20.1%. A total of 30.6% of the participants reported that they could run but choose not to do so. Of those who run, 66.7% were taught by a physical therapist, 14.8% were self-taught, 11.8% learned how to run using their prosthesis by participating in adaptive sports, and 7.4% received training from a prosthetist. Sports participation (Table 2) among the respondents was defined as actively participating in sports or recreational activity while wearing prosthesis. Type of activity in which subjects participated and frequency of participation were determined. Just more than 77% of the subjects participated or had participated at some time in sports/recreational activities while wearing a prosthetic device. Cycling was the most popular activity, with 26 (44.8%) subjects participating in this activity. Snow skiing was the second most popular sport, as 34.5% of the subjects reported skiing. Golf and track and field events were the third most popular sport, with levels of participation at 29.3% and 25.9%, respectively. Basketball and swimming both had a 20.7% participation rate reported by the subjects. Football, soccer, hockey, and kayaking all had at least one subject with participation. Of subjects who participated in sports/recreational activities, 61.9% reported that they participated once or more a week, 15.5% reported that they participated once or more a month, and 9.5% participated in events two to four times annually. Approximately 7% reported as participating once a year or less, and 6% reported that this was the first sporting experience in which they participated because they were newly discharged from having their amputation.

Figure 2
Figure 2:
MAT usage.
Figure 3
Figure 3:
MAT usage.
Table 2
Table 2:
Sports participation


Residual limb pain was reported by 58.9% of the study participants. Of those who experienced residual limb pain, 18.9% experienced this pain 7 days a week. In terms of pain duration, 54% of the subjects experienced pain for 2 hrs or less. “Discomforting” was how 40.5% of the participants reported their pain to be (2), whereas 29.7% reported their pain as “distressing” (3). However, 16.2% reported their pain as “mild” (1). “Horrible” and “excruciating” pains were each reported by 5.4% of the participants; 2.7% of the participants failed to respond regarding pain level. Of those who experienced residual limb pain, 75.6% reported some interference with normal daily activities (e.g., work, social, and family activities). Phantom pain was reported by 71.4% of participants. Of those who experienced phantom pain, the average number of times per week they experienced phantom limb pain was 3.23 ± 3.2, with an average duration of 2.46 ± 1.14 hrs. Phantom pain was reported to interfere with daily activities (1) or “not at all” by 42.5%, whereas 57.5% reported at least some interference with daily activities.


Of the 58 participants in the study, 32 (55.2%) experienced a failure of a prosthetic device at some point during use. Participants were asked to identify what they were actively doing at the time of failure as well as which direction (e.g., forward, left, uphill, and cutting). Walking, as expected, was the most common activity, with 14 participants (46.7%) experiencing a failure. Hiking (varied terrain) was the second most reported activity involving prosthetic failure, with a rate of eight participants (26.7%), with two reporting that they were carrying a backpack with a weight of more than 15 lb. Of the 25 (45%) of participants who said they could run, only 3 (10%) had a device failure during this activity. Golfing and agility training made up the rest of the failures, with one participant (3.3%) and three participants (10%), respectively. Forward was the most common direction of failure, with 19 participants (63.3%) reporting this direction. Side-to-side direction failures were reported by two participants (6.7%), and cutting, left, uphill, and downhill were reported by one participant each (3.3%). Socket failure was reported by 13 participants, with 10 (76.9%) reporting failure of a thermoplastic socket and 3 (23.1%) experiencing failure of a socket fabricated of carbon fiber. Suspension was reported as reason for failure by three participants (5.2%). A pin lock/shuttle lock system was reported by one participant (1.7%), and two participants (3.4%) indicated that a suction suspension system failed. Knee unit failures were experienced by five participants (16%) who reported failures. Hydraulic knee units were the most common, with three (5.2%) participants experiencing failure. A microprocessor knee failure was reported by one participant (1.7%), and one participant (1.7%) experienced malfunction by an “old mechanical” knee unit. Failures of the prosthetic foot caused the device failure for 38% (n = 12) of the participants. Walking feet had the highest failure rate, with 11 participants (91.7%), with 1 (8.3%) experiencing failure of a swimming foot. Of the 32 participants in the study who experienced failure of their prosthesis, 6 (10.3%) were injured when the device failed, with 1 participant failing to answer.


Veterans with an amputation, especially individuals who have experienced combat-related amputations, are often in peak physical condition at the time of their amputation, when they then instantly have their mobility altered. Amputations from nontraumatic etiology such as PVD or diabetes, although still a life-changing event, afford the individual an opportunity to work through the stages of loss and acceptance associated with the amputation. Advancements in assistive technology such as prosthetic devices are helping to ameliorate the sedentary lifestyle that can result from a lower limb amputation. The social, emotional, and overall physical health of the amputee can dramatically increase with the use of prostheses. By integrating the surgical procedures with the advances in prosthetic technology, the best QOL for the veteran with a disability can be acquired. Because many of the veterans are young and active, new technology needs to advance on a continual basis to accommodate their lifestyles.5

The prosthesis becomes a major part of the individual’s life after initial recovery. Proper fit, choosing the right components, and learning to ambulate again are all important aspects in the rehabilitation process. The patient, therapist, and prosthetist all need to work together to derive the right combination of components for optimal function for the patient’s activity level. Prosthetic studies are needed to determine patient satisfaction and outcomes in all aspects of prosthetic care. Quality medical and rehabilitative care are essential to the amputee to regain a healthy lifestyle, and these studies can be tools in determining if the programs used for our service members and veterans are working at the level expected. The goals of the rehabilitation team should be to return the patient to their level of function before the amputation. The goals of the Armed Forces Amputee Care program intensely focus on returning the service member with a limb amputation to a high level of ambulation using a prosthetic device as his/her primary option for mobility as opposed to wheelchairs and other assistive technology.26 The decision of whether the patient should ambulate on a prosthesis is generally up to the patients themselves. The patient needs to be motivated enough to get through the rehabilitation process. A big factor on whether the patient will be able to ambulate efficiently on a prosthetic device is the actual level of amputation. Generally, the higher the level, the harder it will be to adapt to a prosthesis. Not only does a higher level of amputation create a much more unstable base, but also the added components to compensate for the knee joint make it a much more complicated event when relearning how to ambulate. Oxygen consumption and maximum oxygen consumption, the efficiency of the body as a whole, are decreased depending on the level of amputation.27–30 The DoD and the healthcare provided by the VA have led the way for research and development within the prosthetic community. These developments have helped increase the usability of some devices through new technologies such as myoelectric devices for upper limb amputations and microprocessor knees to help control ambulation.5 The innovations in new technology are meant to address the problems associated with everyday prosthetic use and ultimately decrease the rate of abandonment of the device. Abandonment of the prosthesis can be due to several different factors. According to Gauthier-Gagnon et al.,31 determinants for abandonment of the device can include “predisposing” conditions such as comorbidities like cardiovascular disease or PVD. Age and amputation level, as mentioned earlier, play a big role in the ability of the patient to ambulate with the prosthesis. “Reinforcing factors” such as length of healing time and knowing when to fit the prosthesis are major determinants for use of the device.32 The quality of fit is important for the amputee. Poorly fit sockets will cause pain and skin breakdown, leading to the disuse of the prosthetic device.33 When sores or cuts develop around areas of pressure, time off of the device is needed for healing, setting back the rehabilitation process, which affects not only ambulation training but also motivation to use the device. Satisfaction with the prosthesis is important to the user and will ultimately decide whether the prescribed device is used.

Length of inpatient stay was significantly longer for the veteran or service member after lower limb amputation as compared with length of stay in the civilian sector. The longer stay may result in better rehabilitation and can increase patient satisfaction with the prosthetic device. A longer inpatient period results in more intense therapy and gait training, which strengthens the patient’s ability to ambulate. An in-depth rehabilitation program gives the patient the best custom prescription for prosthetics and MAT. The residual limb fluctuates in volume for months after amputation, and this causes problems with optimal fitting of the prosthetic socket. A lengthy rehabilitation experience will result in proper postoperative care, such as desensitizing, proper fitting, and strengthening of muscles in the residual limb. This will ultimately make for a better experience learning how to successfully ambulate with the prosthesis. In addition, MAT selection and prescription are better used with a longer inpatient stay. With time, the patient and clinician can experiment and choose the best option for secondary MAT if needed (e.g., canes, crutches, wheeled mobility). Utilization of secondary MAT is sometimes important for patients with comorbidities and can increase activity level. Any increase in activity level, even slight increases, can have positive health benefits. All of these practices experienced in a well-structured inpatient rehabilitation program will increase the efficiency of the patient and may reduce abandonment rates after initial inpatient discharge.

High indoor and outdoor activity levels were reported as 66.7% and 46.4%, respectively. These activity levels suggest that a majority of the veterans surveyed live active lifestyles. Active lifestyles increase social acceptance, morale, and overall health and satisfaction with life. Participating in sports and recreational activities has an overall health benefit by increasing cardiovascular health, decreasing obesity, and preventing the onset of diseases such as diabetes. Participation in these events also gives the veteran the confidence and motivation to continue living a healthy lifestyle outside structured activities. By ambulating continually on the prosthesis, participants can maintain or improve the mobility they gained during their initial rehabilitation. This can reduce the chance of abandonment of the prosthesis and reduce the chance of reliance on wheeled mobility for primary ambulation. The fact that 77% of the study participants have, at some point, participated in sporting events is an encouraging statistic. Even more encouraging is the fact that 66.7% of those subjects participated weekly. This can be a result of a combination of influencing factors. One reason could be that the intense rehabilitation procedure at the initial stage prepares the veteran for a high activity level. Another reason is that most of our subject pool received the lower limb amputation due to injuries during combat, which implies that they were at peak physical condition before the amputation. Third, veterans and service members usually receive several prosthetic devices that can accommodate several activities.9 These devices can include running, cycling, swimming, and skiing prostheses. The increase in activity levels can also improve the rate at which lower limb amputees return to some form of active duty and continue in their military career. The subjects in this study were recruited at sporting clinics aimed at increasing participation in sports and recreation. This may have produced biased results; however, past sports participation among the subjects was found to vary greatly, from nonparticipation to weekly.

Failure of the prosthesis was reported by 55.2% of our study participants. Although walking was the most common activity reported during the failure, several participants reported failure during higher intensity activities. Socket fracture was reported by a large number of subjects, which indicates that proper materials need to be used to fabricate sockets in the future. Finding new ways to reinforce components and innovations in technology by manufacturers can help reduce these kinds of failure. The prosthetic failure portion of the questionnaire was, in the end, a significant limitation to our study. This section was created as an in-depth, specific prosthesis failure questionnaire. The questions asked dealt with all aspects of the prosthetic device and was intended to gather data on exact components, such as manufacturer details and how the failure was fixed or replaced. Types of injuries and body parts injured during the failure were also included, but responses to all of these questions were either not included or not sufficient.

This limitation was observed by the researchers to be due to survey fatigue. The prosthetic failure section was the last section in the questionnaire, which was already very in-depth and lengthy to complete.


Although no evidence was found to be significant when comparing MAT use patterns and abandonment over time, we did record data that may have shown higher activity levels and QOL in this particular population as compared with those in the private sector. A majority of the veterans or service members surveyed in this study reported activity levels (indoor and outdoor) as level 3. This may correlate to the increased length of inpatient stay as opposed to the much shorter average length of inpatient stay in civilian medicine. It can be suggested by this study that high activity levels and self-reported overall health satisfaction can also be a result of participation in sports and recreational activities. Our results show that more than 77% have participated in sports and recreation and that 61.9% participate weekly. This is a good indication that our veterans are taking initiative and participating in their community after the annual sponsored events. Sports and recreation can help with maintenance of a high activity level and help keep the user in a higher state of ambulation for a longer duration. This should ultimately increase the overall satisfaction of prosthetic use.

Studies on prosthetic care within the VA system and military facilities are encouraged and necessary to constantly show how improvements can be made. Future studies are needed to meet the demand of our returning veterans as well as the veterans of previous conflicts. Residual limb pain, phantom pain, skin breakdown, and other medical problems associated with prosthetic use are all issues that need to be addressed to manage them better. Better management of these conditions will ultimately improve satisfaction and decrease abandonment rates for the prosthetic users. A longitudinal study using an online survey to track and record use of MAT over time may be necessary to accurately establish use patterns and determine abandonment rates. This type of study may help develop protocols for rehabilitation and establish prescription guidelines. An in-depth longitudinal study may also be an acceptable design for future prosthetic failure research. This would provide better quality data to analyze and determine which components are acceptable for different activity levels.


1. Glasser RJ. A war of disabilities: Iraq’s hidden costs are coming home. Crimes of War: Iraq 2006.
2. Pasquina PF. Optimizing care for combat amputees: experiences at Walter Reed Army Medical Center. J Rehabil Res Dev 2004; 41 (3B): vii.
3. Laferrier JZ, Gailey R. Advances in lower-limb prosthetic technology. Phys Med Clin North Am 2010; 21: 87–110.
4. Pasquina PF, Tsao JW, Collins DM, et al.. Quality of medical care provided to service members with combat-related limb amputations: report of patient satisfaction. J Rehabil Res Dev 2008; 45 (7): 953–960.
5. Karmarkar AM, Collins DM, Wichman T, et al.. Prosthesis and wheelchair use in veterans with lower-limb amputation. J Rehabil Res Dev 2009; 46 (5): 567–576.
6. Fischer H. US Military Casualty Statistics: Operation New Dawn, Operation Iraqi Freedom, and Operation Enduring Freedom. 2010.
7. Maynard C, Flohr B, Guagliardo TA, et al.. Department of Veterans Affairs compensation and medical care benefits accorded to veterans with major limb loss. J Rehabil Res Dev 2010; 47 (4): 403–408.
8. Riemer-Reiss ML, Wacker RR. Factors associated with assistive technology discontinuance among individuals with disabilities. J Rehabil 2000; 66 (3): 44–50.
9. Reiber GE, McFarland LV, Hubbard S, et al.. Service members and veterans with major traumatic limb loss from Vietnam war and OIF/OEF conflicts: survey methods, participants, and summary findings. J Rehabil Res Dev 2010; 47 (4): 275.
10. Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. Am J Phys Med Rehabil 2001; 80 (8): 563.
11. Phillips B, Zhao H. Predictors of assistive technology abandonment. Assist Technol 1993; 5 (1): 36–45.
12. Reiber GE, Smith DG. VA paradigm shift in care of veterans with limb loss. J Rehabil Res Dev 47 (4): vii–x.
13. Romo HD. Specialized prostheses for activities: an update. Clin Orthop 1999; 361: 63.
14. Pasquina PF, Bryant PR, Huang ME, et al.. Advances in amputee care. Arch Phys Med Rehabil 2006; 87 (3): 34–43.
15. Pasquina PF, Fitzpatrick KF. The Walter Reed experience: current issues in the care of the traumatic amputee. J Prosthet Orthot 2006; 18 (6): P119.
16. Rothschild VR, Fox JR, Michael JW, et al.. Clinical experience with total thermoplastic lower limb prostheses. J Prosthet Orthot 1990; 3 (1): 51.
17. Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: a study of a lower-limb amputee population. Prosthet Orthot Int 2008; 32 (2): 186–200.
18. Taylor CB, Sallis JF, Needle R. The relation of physical activity and exercise to mental health. Public Health Rep 1985; 100 (2): 195.
19. Pasquina PF. National Disabled Veterans Winter Sports Clinic. J Rehabil Res Dev 43 (7).
20. Smith DG, Horn P, Malchow D, et al.. Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J Trauma 1995; 38 (1): 44.
21. Klute GK, Berge JS, Orendurff MS, et al.. Prosthetic intervention effects on activity of lower-extremity amputees. Arch Phys Med Rehabil 2006; 87 (5): 717–722.
22. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in the United States. South Med J 2002; 95 (8): 875.
23. Gordon WT, O’Brien FP, Strauss JE, et al.. Outcomes associated with the internal fixation of long-bone fractures proximal to traumatic amputations. J Bone Joint Surg 2010; 92 (13): 2312.
24. Jeans KA, Browne RH, Karol LA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg 2011; 93 (1): 49.
25. MacKenzie EJ, Bosse MJ, Castillo RC, et al.. Functional outcomes following trauma-related lower-extremity amputation. J Bone Joint Surg 2004; 86 (8): 1636.
26. Laferrier JZ, McFarland LV, Boninger ML, et al.. Wheeled mobility: factors influencing mobility and assistive technology in veterans and service members with major traumatic limb loss from Vietnam war and OIF/OEF conflicts. J Rehabil Res Dev 2010; 47 (4): 349–360.
27. Leung ECC, Rush PJ, Devlin M. Predicting prosthetic rehabilitation outcome in lower limb amputee patients with the functional independence measure. Arch Phys Med Rehabil 1996; 77 (6): 605–608.
28. Sansam K, Neumann V, O’Connor R, Bhakta B. Predicting walking ability following lower limb amputation: a systematic review of the literature. J Rehabil Med 2009; 41 (8): 593–603.
29. Van Velzen J, van Bennekom CAM, Polomski W, et al.. Physical capacity and walking ability after lower limb amputation: a systematic review. Clin Rehabil 2006; 20 (11): 999.
30. Chin C, Kazmucha J, Kim N, et al.. VO2@RER 1.0: a novel submaximal cardiopulmonary exercise index. Pediatr Cardiol 2010; 31 (1): 50–55.
31. Gauthier-Gagnon C, Grisé MC. Tools to measure outcome of people with a lower limb amputation: update on the PPA and LCI. J Prosthet Orthot 2006; 18 (6): P61.
32. Engsberg JR, Sprouse SW, Uhrich ML, et al.. Comparison of rectified and unrectified sockets for transtibial amputees. J Prosthet Orthot 2008; 18 (1): 1.
33. Stineman MG, Kwong PL, Kurichi JE, et al.. The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system. Arch Phys Med Rehabil 2008; 89 (10): 1863–1872.
34. Dillingham TR, Pezzin LE, MacKenzie EJ. Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil 1998; 79 (3): 279–287.
35. Kent R, Fyfe N. Effectiveness of rehabilitation following amputation. Clin Rehabil 1999; 13 (1 suppl): 43.
    36. Lenze EJ, Munin MC, Quear T, et al.. Significance of poor patient participation in physical and occupational therapy for functional outcome and length of stay. Arch Phys Med Rehabil 2004; 85 (10): 1599–1601.
      37. Munin MC, Espejo-De Guzman MC, Boninger ML, et al.. Predictive factors for successful early prosthetic ambulation among lower-limb amputees. J Rehabil Res Dev 2001; 38 (4): 379–384.

        combat; mobility; MAT; prosthesis; rehabilitation; traumatic amputation; prostheses; veteran; MAT; prosthetic technology

        © 2012 by the American Academy of Orthotists and Prosthetists.