Amputation usually leads to decreased quality of life, limited activity, and restricted participation in society.1 Also, upper-limb amputation can cause functional limitations, unattractive appearance, and serious psychological problems.2 It is reported that the average age of upper-limb amputation in Iran is 37.1 ± 17.6,3 and the most prevalent reason is trauma.4 The levels of upper-limb amputation can be from fingertip amputation to shoulder disarticulation and forequarter amputation.4 The most prevalent level of upper-limb amputation is transradial, which includes 57% of total upper-limb amputations. Transhumeral amputation with 23% is the second most common upper-limb amputation level.5 In Iran, out of each 200 people with amputation due to the Iran-Iraq war, 25 are persons with upper-limb amputation. Upper-limb amputation leads to serious restrictions in daily activities such as getting dressed, eating, driving, personal cleanliness, and using tools and equipment.6 Also, amputation often leads to a lot of psychosocial difficulties, such as depression, disappointment, reduced self-confidence, stress, and anxiety.7 The faster after amputation the patient receives a prosthesis, training, and body strengthening, along with appropriate psychosocial support, the quicker the individual can return to work and improve performance.8 Thus, using a prosthesis, consistent with each person's abilities and expectations, to a large extent can provide more independence and comfort for the individual with amputation.
Generally, upper-limb prostheses are divided into three groups: cosmetic (passive), mechanical, and powered. Each of these groups has specific characteristics and would be prescribed for special purposes.4,9–11 Nowadays, despite huge developments in upper-limb cosmetic and other prosthetic devices, the patient's satisfaction rate with a prosthesis has not increased, and most patients prefer to not use a prosthesis or to use the passive prosthesis.12–15 The most effective factors to use a prosthesis are sex, age, and the cause and level of amputation.16 The most effective factors in accepting a prosthesis are amputation side, the amputation time passed, the prosthesis consistency with individual abilities, its movement mechanism, and beauty.11–14 Prescription and receipt of a prosthesis at the right time also are factors that can affect prosthesis acceptance and use.11
By reviewing previous literature, it can be found out that some studies have separately examined function and quality of mechanical and cosmetic prostheses.17–19 However, there is not a study using a standard metric tool to compare them. Therefore, the present research was aimed to compare and evaluate the quality of life and function of mechanical and cosmetic prostheses using the Trinity Amputation and Prosthesis Experience Scales (TAPES) questionnaire in subjects with below-elbow amputation with medium limb length.
MATERIALS AND METHODS
Fifty-two individuals with medium-length below-elbow amputation voluntarily participated in this study. Having the ability to read and write, living in Iran, and using a prosthesis for at least 6 months before the test were considered as inclusion criteria of the study. TAPES questionnaire was used in this study. The questionnaire was prepared by Gallagher et al.16 and translated into Persian by Mazaheri et al.20 They investigated the Persian version efficiency on 182 Persian people with lower-limb amputation and proved it.20 The questionnaire has four sections: the first section is related to sociopsychological concerns with artificial limb, and the fourth one deals with studying phantom pain, residual-limb pain, and other medical problems. The TAPES has been translated into many different languages and has been used in many studies. Its scoring method is easy for the researcher, and its time completion by a patient is maximally 15 minutes.16
All the subjects completed and signed the consent form. Information regarding participants' height, weight, sex, and age were recorded. The study was approved by the committee of ethics at the Hamadan University of Medical Sciences. A brief explanation about the questionnaire was given to the subjects. The subjects received the questionnaire and completed it. The Kolmogorov-Smirnov test was used to assess the normality of the data. An independent t-test was used to compare the two groups; α was set at 0.05.The data were analyzed by SPSS statistical software version 16 (USA, Inc, Chicago, IL).
The total number of 52 individuals (including 2 females and 50 males) with medium-length below-elbow amputation participated in this research. There was no significant difference between two groups with regard to demographic data (Table 1). The data regarding mean general adjustment subscale, adjustment with restrictions subscale, social adjustment subscale, and sociopsychological adjustment scale between the two groups are shown in Table 2.
A significant difference for the general adjustment subscale was seen between the two cosmetic and mechanical prostheses (P < 0.05). No significant differences in adjustment with the restrictions subscale between cosmetic and mechanical groups were seen (P > 0.05). The results showed that the social adjustment subscale in subjects with mechanical prosthesis was significantly more than those with cosmetic prosthesis (P < 0.05). The sociopsychological adjustment scale did not have statistical significant difference between the two groups (P > 0.05).
The comparison of functional activity, professional activity, social activity subscales, and activity scale mean between the two groups are indicated in Table 3.
Regarding the functional activity subscale, subjects who had mechanical prosthesis were significantly better than those with cosmetic prosthesis (P < 0.05). The two groups in the professional activity subscale did not have statistically significant differences (P > 0.05). Subjects with cosmetic prosthesis had better social activity than those with mechanical prosthesis (P < 0.05). Also, from the activity scale point of view, there was not a significant difference between the two groups (P > 0.05).
The comparison of the mean of cosmetic satisfaction, the satisfaction of weight, functional satisfaction subscales, and satisfaction with prosthesis scale between the two groups are shown in Table 4.
The results showed that cosmetic prosthesis was better for appearance than mechanical prosthesis (P < 0.05). The satisfaction with weight in individuals with cosmetic prosthesis was higher (P < 0.05).
In functional satisfaction, mechanical prosthesis was better than cosmetic prosthesis (P < 0.05). However, the scale of prosthesis satisfaction was not statistically significant (P > 0.05).
The comparison of the mean parameters of residual-limb pain, phantom pain, pain due to other medical problems, and pain scale between the two groups are indicated in Table 5.
The residual-limb pain between the two groups did not have significant difference (P > 0.05). Phantom pain between the two groups also did not have a significant difference (P > 0.05). The pain due to other medical problem variables was not statistically significant between the two groups (P > 0.05). Also, the pain variable between the two groups with cosmetic or mechanical prosthesis was insignificant (P > 0.05).
The comparison mean quality of life parameter between the two groups is shown in Table 6.
Quality of life between the two groups was not significantly different (P > 0.05).
The aim of this study was to evaluate and compare quality of life and function in individuals with one-sided upper-limb amputation using cosmetic and mechanical prostheses.
SOCIOPSYCHOLOGICAL ADJUSTMENT SCALE AND SUBSCALES
The sociopsychological adjustment scale is the sum of three adjustments: adjustment with restrictions subscale, general adjustment subscale, and social adjustment subscale scores. In the present study, the sociopsychological adjustment scale is reported desirable and similar in both groups. This scale includes some statements in the social adjustment subscale section, such as “Having an artificial limb caused me to be dependent to others more than what I want,” “Having artificial limb does not let me do everything,” and “Artificial limb has caused the works rate that I do to be limited,” and emphasizes individual function more, so it seems that it is the reason why these subscale scores are better among other individuals with upper-limb amputation who have used mechanical prostheses. Also, statements such as individual reaction against others' attention to his/her prosthesis and talking about prosthesis have been discussed in adjustment with restrictions subscale section. Most of the participants did not answer one of the questions that relate to adjustment with restriction subscale: “I do not mind seeing somebody pay attention to my walking lame.” The adjustment with restrictions subscale seemed similar between the two groups. However, regarding the general adjustment subscale, individuals more quickly get along with and get used to cosmetic prostheses compared with mechanical ones, because of better appearance and lack of problems with a harness and terminal device. Consequently, these two kinds of prostheses, according to subscales, had superiorities to each other, but regarding the sociopsychological scale, they had no superiority to each other.
ACTIVITY SCALE AND SUBSCALES
Neither of the two groups was superior to the other in the activity scale. To do miscellaneous activities, some literature articles have reported cosmetic prostheses as more useful and others have reported mechanical prostheses as more useful.12,17–19,21–26 The activity scale is the sum of the three activities: functional activity, professional activity, and social activity subscales scores. It has been observed that mechanical prostheses created fewer restrictions for functional activity subscale, and most of the previous literature confirms this result. For example, Millstein et al.12 reported that individuals with below-elbow amputation only used a mechanical prosthesis to do their daily activities, and other types were reported to be less useful and inefficient. Burger and Marinček18 in a research on individuals with upper-limb amputation expressed that, in Slovenia, most of the individuals used a mechanical prosthesis to do their activities such as personal health affairs, driving, and other daily duties. Also, in the Crandall and Tomhave23 and Davidson et al.24 studies, mechanical prosthesis was reported more efficient.12,18 However, Østlie et al.26 in a study indicated that, despite the fact that most persons with upper-limb amputation were satisfied with their prosthesis skills, they did not use their prosthesis for their activities, and it was said that lack of enough training in using the prosthesis was the problem. Maybe the other cause of the difference in results is using a different questionnaire in the present study compared with the study of Østlie et al. Most of the participants in both groups achieved lower scores in the professional activity subscale. Low scores were due to the fact that most of the participants did not answer to the questions in this section; therefore, their scores were 0. Also, individuals who answered the questions related to the professional activity subscale including the prosthesis impact on walking and going up stairs have chosen “no, it did not limit them.” Regarding the social activity subscale in individuals using cosmetic prosthesis, fewer restrictions have been reported. The results reported in the Burger and Marinček18 and Crandall and Tomhave23 studies are supported by the present article for social activities and recreational activities. Due to better appearance, people using cosmetic prostheses had more self-confidence in participating in society and preserving social relationships.
PROSTHESIS SATISFACTION SCALE AND SUBSCALES
The prosthesis satisfaction scale is the sum of the following three satisfaction subscale scores: cosmetic satisfaction, weight satisfaction, and functional satisfaction. The results of this study showed that prosthesis general satisfaction rate between the two groups was similar. Burger and Marinček,18 Østlie et al.,26 and Jang et al.27 suggested that the kind of prosthesis does not affect the prosthesis satisfaction rate of persons with amputation. In fact, their results support the present study. However, there were some superiorities to each other in subscales. The cosmetic satisfaction was higher in individuals who used cosmetic prosthesis. Crandall also reported more acceptance of a cosmetic prosthesis among women, which was due to the importance of beauty to them.23 From color, shape, and appearance, point of view cosmetic prosthesis users were more satisfied than mechanical users with their prosthesis. The results from the cosmetic satisfaction subscale showed that it is required that prosthetists should pay more attention to the color, shape, and appearance of mechanical prostheses. Compared with mechanical prosthesis users, the cosmetic prosthesis users were more satisfied with their prosthesis weight. It is logical that mechanical prostheses with components added for providing a particular function are heavier than cosmetic prostheses. Regarding the satisfaction subscale, the mechanical prosthesis users reported more desirable results of this subscale, and they were more satisfied with their prosthesis. The result of this study were consistent with that of the Crandall and Tomhave23 and Jang et al.27 studies.
Unlike the present study, Crandall's and Jang's studies showed that mechanical prostheses provide participants with more functional satisfaction than cosmetic prostheses. Also, Burger and Marinček18 reported that although persons with upper-limb amputation used mechanical prostheses more, from the functional point of view, this prosthesis has been reported as weak and unreliable. Maybe this contradiction between Burger's and the present study is due to the level of the participant amputation. In Burger's study, participants had transhumeral, transradial, or partial-hand amputation, whereas the participants in this study had below-elbow amputation. According to the findings of the present research and the previous literature, a cosmetic prosthesis provides more satisfaction regarding appearance and weight, and the mechanical one makes persons with amputation more satisfied with regard to function. Thus, it can be said that both have some superiorities over the other.
PAIN SCALE AND SUBSCALES
Many individuals with upper-limb amputation have experienced different kinds of pain including residual-limb pain, phantom pain, neck pain, back pain, and pain due to other medical problems.28–33 All of these types of pains cause weaknesses and restrictions for individuals with amputation and affect their health and function.28,30 Pain could potentially lead to many problems for persons with amputation, such as job loss and social problems. Also, pain may hinder use of the prosthesis.28–30 Pain after amputation has a huge effect on stress rate and disability of individuals with amputation and can influence their quality of life directly.34–36 A total of 23.07% of participants in the present research did not report any pain, whereas in a similar study, only 10% of the participants did not report pain.33 Although residual-limb pain, along with phantom-limb pain, is the most prevalent type of pain among individuals with amputation (in the present article, 55.76% of the participants reported this kind of pain), both groups of participants reported similar rates of this type of pain. Therefore, it has become clear that the type of prosthesis does not affect residual-limb pain in persons with upper-limb amputation.
Phantom-limb pain, which is the most prevalent type of pain among persons with upper-limb amputation, included 48.07% of the participants in the present study. The rate of this kind of pain was similar between the two groups. These results showed that the kind of prosthesis does not affect the phantom pain rate of individuals with upper-limb amputation. Pain due to other medical problems was reported in 40.38% of participants, and with due attention to the similarity of this parameter between the two groups, it was determined that the kind of prosthesis does not have an effect on pain due to medical problems. Similarly, Hanley et al.33 and Davidson et al.37 showed that pain can affect using prosthesis. However, the kind of prosthesis does not affect the residual-limb pain rate and medical problems rate.36,37
Regarding quality of life, neither of the two groups was superior to the other. According to the sum of the scores from four TAPES questionnaire scales that shows the quality of life of the individual with amputation, there was a negligible difference between the two groups. Although in subscales each group reported more desirable results than other group, the two groups were not superior to each other in any of four scales including sociopsychological adjustment, activity, prosthetic satisfaction, and pain. With due attention to average scores related to each group's quality of life, it is distinguished that both prostheses affected the quality of life of persons with one-sided medium-length below-elbow amputation for the better. A few studies have investigated the influence of upper-limb prostheses on the quality of life of persons with amputation. However, none of them has studied the effect of the type of prosthesis on individuals' quality of life.3,25,33,38
According to the result of this study, it is can be concluded that, regarding quality of life in individuals with medium-length below-elbow amputation, neither type of prosthesis has superiority over the other. Also, it was found that each of these two types of prosthesis is suitable for special activities and tasks, and each has a specific function that potentially could improve the individual's quality of life. Because both cosmetic and mechanical prostheses have their own strengths and weaknesses, they can be both together be used by a person with amputation, complement each other, and fulfill the individual's needs. However, persons with amputation, despite consultations and experts' prescriptions, according to their requirements, can choose more suitable prosthesis themselves.
Finally, performing similar studies on individuals with other levels of upper-limb amputation or with bilateral upper-limb amputation is suggested.
1. Hagberg K, Branemark R, Hagg O. Questionnaire for Persons with a Transfemoral Amputation (Q-TFA): initial validity and reliability of a new outcome measure. J Rehabil Res Dev
2. Dudkiewicz I, Gabrielov R, Seiv-Ner I, et al. Evaluation of prosthetic usage in upper limb amputees. Disabil Rehabil
3. Alireza S. The causes of amputation in teaching hospitals in Kerman in 1380 to 1388. 2012;19(3):260–267.
4. Smith DG. Atlas of amputations and limb deficiencies: surgical, prosthetic, and rehabilitation principles. Vol. 3. Rosemont: American Academy of Orthopaedic Surgeons; 2004.
5. Esquenazi A. rehabilitation Upper limb amputee and restoration prosthetic. In Braddom RL, editor. Physical Medicine and Rehabilitation
. 2nd ed. Philadelphia: WB Saunders Co; 2000:263–278.
6. Araghizadeh H, Soroush M. Cut bilateral upper limb due to mines and unexploded remnants of war. Teb Janbaz
7. Desmond D, MacLachlan M. Psychological issues in prosthetic and orthotic practice: a 25 year review of psychology in Prosthetics and Orthotics International. Prosthet Orthot Int
8. Freeland AE, Psonak R. Traumatic below-elbow amputations. Orthopedics
9. Mazet R, Taylor CL, Bechtol CO. Upper-extremity amputation surgery and prosthetic prescription. J Bone Joint Surg Am
10. Atkins DJ, Heard DC, Donovan WH. Epidemiologic overview of individuals with upper-limb loss and their reported research priorities. J Prosthet Orthot
11. Biddiss E, Chau T. Upper-limb prosthetics: critical factors in device abandonment. Am J Phys Med Rehabil
12. Millstein S, Heger H, Hunter G. Prosthetic use in adult upper limb amputees: a comparison of the body powered and electrically powered prostheses. Prosthet Orthot Int
13. Roeschlein R, Domholdt E. Factors related to successful upper extremity prosthetic use. Prosthet Orthot Int
14. Drummey J. Enhancing the functional envelope: a review of upper-limb prosthetic treatment modalities. Academy Today
15. McFarland LV, Hubbard Winkler SL, Heinemann AW, et al. Unilateral upper-limb loss: satisfaction and prosthetic-device use in veterans and service members from Vietnam and OIF/OEF conflicts. J Rehabil Res Dev
16. Gallagher P, MacLachlan M. Development and psychometric evaluation of the Trinity Amputation and Prosthesis Experience Scales (TAPES). Rehabil Psychol
17. Durance J, O'shea B. Upper limb amputees: a clinic profile. Int Disabil Stud
18. Burger H, Marinček Č. Upper limb prosthetic use in Slovenia. Prosthet Orthot Int
19. Jones L, Davidson J. The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, Australia. Disabil Rehabil
20. Mazaheri M, Fardipour S, Salavati M, et al. The Persian version of Trinity Amputation and Prosthetics Experience Scale: translation, factor structure, reliability and validity. Disabil Rehabil
21. Kay HW, Peizer E. Studies of the Upper-Extremity Amputee
. Washington: National Academy of Sciences; 1958.
22. Fraser C. An evaluation of the use made of cosmetic and functional prostheses by unilateral upper limb amputees. Prosthet Orthot Int
23. Crandall RC, Tomhave W. Pediatric unilateral below-elbow amputees: retrospective analysis of 34 patients given multiple prosthetic options. J Pediatr Orthop
24. Davidson J. A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther
25. James MA, Bagley AM, Brasington K, et al. Impact of prostheses on function and quality of life for children with unilateral congenital below-the-elbow deficiency. J Bone Joint Surg Am
26. Østlie K, Lesjø IM, Franklin RJ, et al. Prosthesis use in adult acquired major upper-limb amputees: patterns of wear, prosthetic skills and the actual use of prostheses in activities of daily life. Disabil Rehabil Assist Technol
27. Jang CH, Yang HS, Yang HE, et al. A survey on activities of daily living and occupations of upper extremity amputees. Ann Rehabil Med
28. Parkes CM. Factors determining the persistence of phantom pain in the amputee. J Psychosom Res
29. Carabelli R, Kellerman W. Phantom limb pain: relief by application of TENS to contralateral extremity. Arch Phys Med Rehabil
30. Millstein S, Bain D, Hunter G. A review of employment patterns of industrial amputees—factors influencing rehabilitation. Prosthet Orthot Int
31. Datta D, Selvarajah K, Davey N. Functional outcome of patients with proximal upper limb deficiency—acquired and congenital. Clin Rehabil
32. Ephraim PL, Wegener ST, MacKenzie EJ, et al. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil
33. Hanley MA, Ehde DM, Jensen M, et al. Chronic pain associated with upper-limb loss. Am J Phys Med Rehabil
34. Marshall M, Helmes E, Deathe AB. A comparison of psychosocial functioning and personality in amputee and chronic pain populations. Clin J Pain
35. van der Schans CP, Geertzen JH, Schoppen T, et al. Phantom pain and health-related quality of life in lower limb amputees. J Pain Symptom Manage
36. Desmond DM, MacLachlan M. Affective distress and amputation-related pain among older men with long-term, traumatic limb amputations. J Pain Symptom Manage
37. Davidson JH, Khor KE, Jones LE. A cross-sectional study of post-amputation pain in upper and lower limb amputees, experience of a tertiary referral amputee clinic. Disabil Rehabil
38. Deans SA, McFadyen AK, Rowe PJ. Physical activity and quality of life: a study of a lower-limb amputee population. Prosthet Orthot Int