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Original Research Article

Effect of Socioeconomic and Health Factors on Prosthetic Use after Lower-Limb Amputation

Agrawal, Veena R. MD; Skrabek, Ryan Q. MD, FRCPC; Embil, John M. MD; Gross, Patrick BMR(PT); Trepman, Elly MD

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JPO Journal of Prosthetics and Orthotics: April 2014 - Volume 26 - Issue 2 - p 79-86
doi: 10.1097/JPO.0000000000000027
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The goals of amputee rehabilitation programs include restoring maximal functional independence inside and outside the home, improving risk factors associated with vascular and infectious causes of amputation, and improving quality of life.1 These programs may include fitting with a lower-limb prosthesis and gait training. However, few data are available about the use of, and satisfaction with, the prosthesis in functional situations after completing the rehabilitation program,2 and frequency of prosthetic use may vary substantially.3,4 Factors causing decreased prosthetic use include advanced age,5,6 level and number of lower-limb amputations,5–7 increased number of medical comorbidities,6 one-legged balance,6 nonambulatory status before amputation,5 impaired cardiac and renal function,5,6 impaired cognition,5,6 pain,4 smoking,5 decreased vision,7 decreased prosthetic satisfaction,7 delayed fitting time,2 and contralateral leg problems.7

Social supports such as living arrangement are important for rehabilitation.6 Greater prosthetic use after lower-limb amputation is associated with full- or part-time employment, higher education level, and being married or living with a partner.8 A study of functional status after amputation did not demonstrate a relation between social support and improved functional status,9 but another study had noted improved quality of life in amputees who had a stable social support system.10 Perceived quality of life after an amputation is associated with social support and other factors including perceived prosthetic mobility, age, and social activity participation.11

In the Canadian province of Manitoba, a mean of 310 lower-limb amputations are performed per year, mostly in patients with diabetes (77%).12 Indigenous (Aboriginal) Manitobans are at high risk for amputation because of their higher prevalence of diabetes (Aboriginal Manitobans, 10.4%; all Manitobans, 6.4%), and the frequency of amputation in Aboriginals with diabetes is more than threefold that of the general Manitoban diabetic population.12 In addition, living in a rural Canadian community is associated with poorer health,13–15 and some regions of Manitoba have higher premature mortality than elsewhere in the province.12 There may be limited access to allied health services, such as physiotherapy and occupational therapy, in smaller rural than larger urban centers.16–18 Furthermore, all prosthetists in Manitoba are based in the City of Winnipeg, and rural Manitoba communities are visited only monthly by two of the three prosthetic providers for adults. Accessing these services may be especially difficult in isolated Aboriginal rural and reserve communities.17,18 However, limited information is available about the effect of residence in a rural, reserve, or urban location in Manitoba on prosthetic use after lower-limb amputation.

We hypothesized that residence in a remote (rural or reserve) community and solitary living arrangement may have an adverse effect on the frequency of prosthetic use after lower-limb amputation. The purposes of this study were to determine the frequency and quality of daily prosthetic use 2 years after a major lower-limb amputation and to evaluate the relation between prosthetic use and socioeconomic factors such as community of residence and living arrangement.



From January 1, 2007, to December 31, 2007, there were 155 patients evaluated in consultation for rehabilitation after a major lower-limb amputation (transtibial or transfemoral amputation) at a tertiary care university hospital (Outpatient Amputee Clinic, Amputee Day Hospital, and inpatient unit [nine beds] of the Rehabilitation Hospital, Health Sciences Centre, University of Manitoba, Winnipeg, Manitoba, Canada). Patients who had an upper-limb amputation were excluded from the study. Patients were selected for rehabilitation on the basis of having adequate health stability, cognition, and physical ability to participate in rehabilitation and achieve either prosthetic ambulation or wheelchair independence. Patients underwent inpatient rehabilitation, outpatient rehabilitation, or a combination of inpatient and outpatient rehabilitation, depending on factors including availability of inpatient beds and proximity of residence to the hospital. Of the 155 patients evaluated, 118 patients (76%) participated in primary rehabilitation, including 75 patients (48%) who were fitted with a custom lower-limb prosthesis and completed the formal prosthetic rehabilitation program. The other 37 patients (24%) who were evaluated for rehabilitation were ineligible for the prosthetic rehabilitation program. Patients who had completed a prosthetic rehabilitation program successfully in the past but required retraining during the study because of deconditioning or prosthetic refitting were excluded from the study. Of the 75 eligible patients, 52 patients (69%) participated in the study and 23 patients (31%) were excluded (10 patients had died after rehabilitation and before the study was done, 10 patients declined to participate, and 3 patients could not be contacted). The study was reviewed and approved by the University of Manitoba Biomedical Research Ethics Board. All included patients provided written informed consent before participation in the study.

Rehabilitation consisted of strength training, cardiovascular reconditioning, residual limb desensitization, transfer training, prosthetic fitting, gait training, assessment of activities of daily living, recommendations for equipment and home modification, and risk factor modification. Prosthetic fitting was done by a certified prosthetist after the amputation site was fully healed. Upon completion of the program, patient function was evaluated with the Medicare Functional Classification Levels, which had been designed to predict prosthetic use potential (K-level: 0, nonambulation; 1, household ambulation; 2, limited community ambulation; 3, community ambulation; 4, high-level prosthetic use typical of an active lifestyle).19


The hospital medical records of all participants were reviewed retrospectively for information about demographics, amputation, and rehabilitation. From June to October 2009, the participants had a structured in-person or telephone interview about prosthetic use. A custom form was designed and used to collect socioeconomic information during the interview including household income and personal educational level completed. In addition, the subjects completed the Houghton Scale20,21 and the Locomotor Capabilities Index (LCI),22–24 which had been validated previously in lower-limb amputees to assess prosthetic use.

Aboriginal patients were defined as self-reported indigenous inhabitants of Canada, including the First Nations and Métis people, without regard to their separate origins and political or cultural identities.25 An urban community was defined as a city having a population of more than 20,000 people, and a rural community was defined as a town, village, or farming community (nonreserve) having a population of fewer than 20,000 people; a reserve was a tract of land set aside by the government of Canada for use by Aboriginal peoples. All urban participants were from Winnipeg, Manitoba, except for one patient who was living in Regina, Saskatchewan.

Functional prosthetic use was assessed with the Houghton Scale, which included six questions about the amount of time spent wearing the prosthesis; basic locations where the prosthesis was used to walk (inside or outside); gait aids used with the prosthesis; and sense of stability when walking on a flat surface, slope, or rough ground (maximum possible Houghton score, 12 points). A potential inherent limitation of the Houghton Scale was the structure of questions that included the assumption that patients would use a prosthesis inside before they would use it outside; however, many of the patients interviewed in this study preferred to use the prosthesis outside and a wheelchair inside for convenience. Therefore, to account for the outdoor preference for some patients, the Houghton Scale was modified in the present study by interchanging “inside” and “outside” as options on the scale.

Activity level with the prosthesis was assessed with the LCI, which included two sections (basic activities and advanced activities), each having seven activities. The patients rated their ability to perform each activity on a point scale (points: 0, complete inability; 1, ability with help; 2, ability with supervision; 3, full ability with independence). The points for all 14 activities were added to determine the total LCI score (maximum possible LCI score, 42 points).

Frequency of prosthetic use was determined by asking each patient to estimate daily prosthetic use as 0% to 25%, 26% to 50%, 51% to 75%, or 76% to 100% of the patient’s waking day. Data for 26% to 50% and 51% to 75% were combined and reported as 26% to 75% of the patient’s waking day. The patients were asked to rate their satisfaction with the prosthetist, cosmetic appearance of the prosthesis, and prosthetic fit, each on a scale of 10 points (0 points, least satisfied; 10 points, most satisfied).


Statistical analysis was done with the Fisher exact test and analysis of variance (SAS version 9.2; SAS Institute Inc, Cary, NC, USA). Data were reported as mean (SD) and 95% confidence interval. Statistical significance was defined by p ≤ 0.05.


Most patients lived in an urban community, were non-Aboriginal, were men, had amputation because of peripheral vascular disease associated with diabetes mellitus, had transtibial amputation, had diabetes mellitus, were smokers, and were either overweight or obese (Table 1).26 Most patients lived with either a spouse or family, were socially independent before the amputation, had a household income that was less than half the Canadian national median household income, and had not completed high school (secondary education) (Table 1). Most patients had had markedly decreased (either limited community or community) level of ambulation at discharge from rehabilitation than before the amputation (Table 1). The mean duration of the rehabilitation program was 118 days.

Table 1:
Demographic, medical, and socioeconomic characteristics of patients with lower-limb amputation

The patients living in rural or reserve communities more frequently lived with a spouse or family than the patients in urban communities; the non-Aboriginal patients more frequently lived alone than the Aboriginal patients (Table 1). The Aboriginal patients had lower income and education levels more frequently than the non-Aboriginal patients (Table 1).

There was no relation between patient age and frequency of prosthetic use, but the younger patients had significantly greater functional prosthetic use (Houghton Scale) and activity level with the prosthesis (LCI) (Table 2). The patients with higher household income had significantly greater functional prosthetic use (Houghton Scale), and the patients with higher level of completed education had greater activity level with the prosthesis (LCI) (Table 2). The patients with greater level of ambulation (K-level) at discharge from rehabilitation had significantly greater frequency of prosthetic use, functional prosthetic use (Houghton Scale), and activity level with the prosthesis (LCI) at follow-up evaluation (Table 2).

Table 2:
Relation between demographic, amputation, socioeconomic, and medical characteristics on prosthetic use in 52 patients with lower-limb amputation

Most patients had 5 to 10 comorbidities (Table 2). At follow-up evaluation, the patients with more medical comorbidities had significantly lower functional prosthetic use (Houghton Scale) and activity level with the prosthesis (LCI) than the patients with fewer comorbidities (Table 2). No difference in frequency of prosthetic use was demonstrated for the patients with fewer or more comorbidities (data not shown). There was no effect of ethnicity, community of residence, amputation level, living arrangement, premorbid dwelling, or specific comorbidities on frequency of prosthetic use, functional prosthetic use (Houghton Scale), or activity level with the prosthesis (LCI) at follow-up evaluation (Table 2).

The mean scores for patient satisfaction with the prosthetist, cosmetic appearance, and prosthetic fit were high (Table 3). Satisfaction with the prosthetist was significantly associated with all three outcome measures: frequency of prosthetic use, functional prosthetic use (Houghton Scale), and activity level with the prosthesis (LCI) (Table 3). Cosmetic satisfaction was significantly associated with frequency of prosthetic use and functional prosthetic use (Houghton Scale) but not activity level with the prosthesis (LCI) (Table 3). Prosthetic fit satisfaction was significantly associated with frequency of prosthetic use and activity level with the prosthesis (LCI) (Table 3).

Table 3:
Relation between patient satisfaction and prosthetic factors in 52 patients after lower-limb amputation


In the present study, lower age, higher level of ambulation upon completion of rehabilitation, and lower numbers of medical comorbidities were helpful predictors for subsequent functional prosthetic use (as assessed by Houghton Scale) and activity level (as assessed by LCI) (Table 2). Furthermore, patient satisfaction was positively associated with measures of prosthetic use and activity level (Table 3). However, the data did not support the hypothesis that rural residence or living arrangement may have an adverse effect on prosthetic use (Table 2).

The present study showed that the frequency of prosthetic use was similar for patients in different ethnic groups or communities of residence, similar to previous findings (Table 2).16 However, the previous study showed that rural non-Aboriginal subjects had a significantly greater frequency of prosthetic use for all activities, both inside and outside the home, than other subjects.16 The present finding that activity level with a prosthesis was similar regardless of ethnicity or community of residence (Table 2) may be attributed to the different method in measuring activity level; in the previous study, patients reported global level of activity using a prosthesis, but the current study evaluated use of a prosthesis for specific activities and yielded a score based on the number of activities performed. In addition, the previous study involved only diabetic amputees, but the present study included both diabetic and nondiabetic amputees.16

In a previous survey of 27 patients (mean [SD] age, 66 [15] years) from northwestern Ontario at 21 (24) years after transfemoral amputation, all subjects lived in a residential house or apartment, and 85% of patients used a prosthesis (81% of patients indoors and 74% of patients outdoors); the mean [SD] daily wear time was 10 (6) hrs, and LCI was 34 (11).27 The effects of ethnicity or community of residence were not reported in that study, but the geographic region was similar to the present study with Aboriginal subjects who had a high prevalence of diabetes.27 The present patients mostly had transtibial amputation, but the mean (SD) daily wear time (8 [6] hrs) and LCI score (31 [12]) were similar to the previously reported data.27

Despite limited access to rehabilitation services available in the rural and reserve, compared with urban, communities in Manitoba,16–18 the three outcome measures were similar for all types of communities of residence (Table 2). The significantly greater spousal and family support in rural and reserve, compared with urban, communities (Table 1) may have compensated for the relatively limited availability of health services in rural and reserve communities, resulting in similar prosthetic functional outcomes for the varied communities (Table 2).

Limited published information is available about the effect of living arrangement on prosthetic outcomes. The present study did not demonstrate an effect of living arrangement on prosthetic outcomes (Table 2). This may have resulted because of a limited effect of living arrangement on prosthetic outcome compared with other variables such as functional level achieved at the end of rehabilitation (Table 2) or total number of medical comorbidities. Limited statistical power because of sample size also may have precluded the demonstration of an effect of living arrangement on prosthetic outcomes. Previous studies have found conflicting results on the effect of social supports, which may include living arrangement, on an amputee’s general quality of life.9,10

The three different outcome measures evaluated distinct aspects of prosthetic use. The most basic information was the frequency of prosthetic use because the functional benefit of a prosthesis may be proportional to the duration of use. The Houghton Scale was simpler to administer than the LCI because the former had fewer questions. The modification of the Houghton Scale, by interchanging “inside” and “outside” as options on the scale, was necessary in this study because many patients preferred to use the prosthesis outside, not inside as assumed in the original Houghton Scale; further analysis would be required to confirm maintenance of scale validity despite this modification. Other studies also showed a higher frequency of prosthesis use outdoors.27

Higher socioeconomic status, assessed with income and education levels, was positively associated with prosthetic outcome in the present study (Table 2). There was no difference in the type of prostheses dispensed to patients with different income and education level because payment for the prosthesis and rehabilitation was covered by the provincial government health insurance program (Manitoba Health). Other studies have shown that socioeconomic status is a major determinant of health status in populations having so-called universal health coverage; despite a national health system in Canada, lower socioeconomic status is associated with limited access to health services,28–32 increased disease prevalence and severity,33,34 and higher mortality.32

The present study showed that increasing age may be a predictor of poor prosthetic outcome (Table 2), consistent with previous studies.5,6 In addition, the level of ambulation (K-level) upon completion of rehabilitation is a significant predictor of future prosthetic use, confirmed by all three outcome measures (Table 2). Attention to achieving subjective patient satisfaction with the prosthetist, prosthetic appearance, and fit may improve prosthetic outcome (Table 3), possibly by improving patient motivation and effort during and after the rehabilitation program. Previous findings have also suggested a positive association between overall prosthesis satisfaction and prosthetic use.3

The present study supported previous observations that prosthetic use is negatively associated with the number of medical comorbidities.6 Diabetes was not associated with prosthetic outcome in the present study (data not shown) or a previous study.5 Although smoking was not associated with prosthetic outcome in the present study (data not shown), a larger previous study had shown that smoking may be a predictor of poor prosthetic outcome.5

Previous studies have shown that transfemoral amputees use their prosthesis less than transtibial amputees.5–7 This was not confirmed in the present study, presumably because of the small sample size of transfemoral amputees (Table 1). In the 10 transfemoral amputees, 2 patients had prostheses with computerized knees that they felt improved prosthetic use. Furthermore, transfemoral amputees were accepted for prosthetic fitting and rehabilitation only if they showed levels of functioning and physical conditioning compatible with ambulation potential, but transtibial amputees also were accepted if the primary prosthetic goal was limited to facilitate transfers. Thus, a selection bias toward healthier patients may have been present for transfemoral than transtibial amputees, potentially resulting in improved rehabilitation potential for the transfemoral amputees.

Despite the high prevalence of patients who had diabetes, were smokers, and were overweight or obese, selection bias may have been present in favor of less debilitated patients because patients with the greatest rehabilitation potential had been selected to participate. This is reflected in the frequency of mortality in this study that was lower than the 2-year mortality reported previously (46%)8; only 10 of the initial 75 patients (13%) eligible to participate in the present study had died during the 1.5 years between completion of the rehabilitation period (December 2007) and beginning of follow-up data collection (June 2009).

In addition to potential selection bias noted, limitations of this study include those inherent with a retrospective survey, including possible inaccuracy of information in the medical records. Changes in income level were not evaluated, which may have occurred from the time of rehabilitation to the survey. In addition, potential heterogeneity in health between different rural areas,13 which may cause variations in prosthetic use among residents of rural communities, was not evaluated. Furthermore, the limited sample size may have contributed to an underestimation of differences between different patient groups or risk factors evaluated.


The authors thank Brenden Dufault for his assistance with statistical analysis.


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rehabilitation; prosthesis; transtibial; transfemoral; peripheral vascular disease

© 2014 by the American Academy of Orthotists and Prosthetists.