Functional capabilities of lower limb amputees
I. C. Narang *
B. P. Mathur *
P. Singh *
V. S. Jape *
Abstract
Five hundred lower limb amputees were evaluated by personal interview at the Artificial Limb Centre, Pune, India. Information thus obtained on activities of daily living and functional capabilities with their prostheses was analysed. The analysis showed that 55% of the amputees were totally independent, 40% had to use a crutch or cane and only 5% were solely dependent on a wheelchair for ambulation. Further, it was also confirmed that as age increased, functional independence decreased, and that below-knee amputees were more independent than above-knee and bilateral amputees. When compared with reports of other workers from the developed countries, the results were equally good, and in some functions, were even better.
Introduction
The aims of the survey were to obtain information directly from the patients on activities generally considered essential for daily living, vocational activities, living arrangements and changes therein. An attempt was made to ascertain the relationship of age and amputation level to the eventual outcome. Information regarding the above capabilities was recorded as supplied by the amputees themselves.
Materials and methods
A questionnaire was prepared and 500 lower limb amputees who had come to the centre in 1980/81 for repair/replacement of their prostheses were interviewed individually and their answers to the questionnaire recorded.
In the interest of simplicity, the level of amputation was divided into three categories—
Below-knee including partial foot, Syme and below-knee amputations.
Above-knee including knee disarticulation, above-knee and hip disarticulation amputations.
Bilateral including combinations of the above.
Primary evaluation consisited of relating the level of functional achievement to the site of amputation. Secondary factors considered were aetiology, age and sex. Relevant data were analysed.
Patient sample
Of the 500 patients interviewed, 298 (60%) were soldiers and 202 (40%) civilians. There were 474 (95%) males and 26 (5%) females. The ages of the patients at the time of amputation ranged from 2 to 65 years (Fig. 1.), and the oldest was now 92 years of age. The majority, 279 (56%), were between 21 and 30 years of age. The marital status of the amputees as found in this series is reflected in Table 1. The majority of the patients (60%) married after becoming amputees.
Duration of disability
The length of time since the amputations varied from 1 to 30 years as shown in Fig. 2. There were 61 patients (12%) of over 30 years duration, of whom 60 were World War II veterans and one was a First World War casualty.
Cause of disability
The majority of cases, 408 (82%), were due to trauma, 86 (17%) due to disease and 6 (1%) congenital. The aetiology for traumatic amputation is depicted in Fig. 3. Among amputees who lost their limbs due to disease, 48 cases (56%) were due to Thromboangiitis obliterans, 18 cases (21%) due to gangrene, 4 (5%) due to diabetes, 6 (7%) due to sarcoma and 10 (12%) due to others.
Type of amputation
There were 308 (61.5%) below-knee, 124 (25%) above-knee and 68 (13.5%) bilateral amputees.
Results
Activities of daily living
There is an extreme paucity of information in the literature relating to activities of daily living (ADL) among amputees.
Dressing
(Including donning and doffing prostheses). All our patients could dress and don their prostheses without any external help, but some took more time than others.
Bathing
Of the total group, 80% could sit on the floor and bathe in the normal manner, 4% took a standing shower and 16% sat on a stool; both latter groups used wall, grab-bars or hand-rails to assist them. Of the bilateral amputees, 25 (37%) sat on the floor and 43 (63%) sat on a stool.
Getting in and out of chairs
Support was not required by 241 (48%) of patients but 238 needed arms on low chairs, while 21 (4%) required arms on all types of chairs. Of the below-knee amputees, 67% did not require any support, while in above-knee about 67% amputees did need support.
Use of aids for ambulation
Table 2 shows that 267 cases (53%) used no assistive devices, 204 cases (41%) used one cane and the remaining 29 cases (6%) used 2 canes or crutches and wheelchairs. Out of 60 bilateral amputees, 12 used wheelchairs exclusively.
Many more patients between 31 and 60 years used one or more assistive devices compared to those younger than 30 years. When both age and level of amputation are considered, 54% of below-knee under 30 years and 10% of below-knee above 30 years did not need assistive devices. In the above-knee group, 31% of those 30 years of age and under, and 7% of those above 30 years did not need assistive devices. In bilateral amputees, 25% of those under 30 years and 4% of those above 30 years did not need assistive devices.
Daily distance walked
Twelve per cent of the total patient population felt that they walked as much as non-amputees. Most of the patients (84%) walked outdoors daily for approximately 1-2 km, 1.5% walked only in the house, and 2.5% (among bilateral cases) did no walking at all.
Use of stairs
Patients were asked their ability to ascend (Fig. 4.) and descend (Fig. 5.) stairs. Only 27% of the group did not need help, while 3% (all bilateral) could not manage stairs at all. Those needing hand rails or other assistance totalled 70%. Of the total group, 16% descended stairs step over step, while 81% preferred one step at a time. Thirteen bilateral cases could not use stairs either way.
Use of ramps
Most patients (92.8%) had no. trouble using ramps (Fig. 6.), while 4.6% needed help and 2.6% could not manage ramps at all with their prosthesis but could use them with a wheelchair.
Getting up from the floor
Getting up from the floor, a fairly simple task, can be difficult for the individual who lacks proprioception and push off. Thus, 8% of below-knee, 14% of above-knee, and 41% of bilateral amputees needed help, while 30 patients in all, including 15 (22%) bilateral amputees, could not get up from the floor.
Transportation
The ability to drive and use public transport is an important part of today's life style. The majority of patients, 417 (83%) had no previous driving experience. Only 6% could drive a vehicle.
Two hundred and forty patients (48%) could ride a bicycle while 250 (50%) stopped cycling after amputation and 10 (2%) did not know how to cycle even prior to amputation (Fig. 7.).
Concerning the use of public transport, 485 (97%) cases could use taxis, buses and trains; and 15 (3%) could use some forms of public transportation but not all.
Employment
Of all the patients 12% stayed in the same job while 47% had to change occupation; only 3.5% were unable to work and another 4% were able to work but were unemployed.
Living arrangements
The ability to return to and maintain a normal home life is an important aspect of total rehabilitation. The patients were asked three questions (1) Where do you now live? (2) Did you have to change your living arrangements? (3) Did you make modifications in your home?
Ten (2%) lived alone, 177 (35%) lived with their own families and 313 (63%) lived with several families.
Most patients 479 (96%), had not changed their living arrangements. The 21 (4%) who had changed because of amputation, included 9 (3%) below-knee, 2 (2%) above-knee and 10 (15%) bilateral amputees. Two patients had ramps installed in place of steps. Some converted the Indian type latrine to Western commode. Others put a small platform or chair in the bathroom. Some had a railing attached to the adjoining wall.
Sexual relationships
Seventy four per cent of the amputees stated that they had not experienced any change in their sexual relationships since amputation; 18% were unmarried. The 8% who said that they were affected, included 16 below-knee, 15 above-knee, and 10 bilateral amputees.
Other effects of amputation
Of the 500 amputees, 438 (87%) could not walk as before, 299 (60%) could not walk long distances, 319 (64%) could not climb, 286 (57%) could not do heavy lifting, 427 (85%) could not play outdoor games and 394 (79%) could not kneel/squat.
Classification of functional level achieved
To summarize the information given in this section, the patients were classified into five simple categories (Table 3).
Class I — Totally independent.
Class II — Independent with one cane or crutches.
Class III — Independent in home ambulating with prosthesis, but need wheelchair for outdoor activities.
Class IV — Independently ambulant with crutches, but not wearing a prosthesis.
Class V — Non-ambulatory except in wheelchair.
Funtional outcome was compared to level of amputation and age at time of amputation. Data were analysed revealing the following.
Age had a definite effect on the functional outcome of the patient; as age increased, functional independence decreased.
There was also a significant relationship between the level of amputation and functional outcome. The below-knee amputee was more independent than the above-knee and the bilateral amputee.
There was a significant age and level of amputation interaction indicating that relative to the below-knee amputee, the above-knee amputee's functional independence decreased more rapidly with age. The functional decline of the bilateral amputee in comparison to the below-knee amputee was even more rapid.
Discussion
This study was carried out to document some of the characteristics of the amputee and to compare the results with those of other authors who have done similar studies.
The patient sample was compared with those of other investigators. A sex distribution of 95% males and 5% females in this series differs from that reported by Glattly (1964) and Kegel et al, (1978) which was 77% males and 23% females. An earlier survey done in this centre of 14,400 civilian new patients (Narang and Jape, 1982) showed 88% males and 12% females. The lower incidence of female patients in this study is probably due to the socio-economic structure of a male dominant society. Women also usually stay at home and are thus less exposed to the hazards of trauma.
This study also shows a greater trend towards below-knee amputations. Of this sample 62% had a below-knee amputation as compared to 56% in the Kay and Newman study, 39% in the Glattly study and 65% in the Kegel et al study.
Glattly did not mention bilateral amputee status, but Kegel et al showed it as 15% and Kerstein et al, (1974) as 23%. In this study it was 14% of the total number.
The mean age of 25 years at the time of surgery for this sample was much lower than that of other investigators (Kegel et al — 45 years, Kerstein et al — 57 years, Stern (1976) — 65 years, Silverstein and Kadish (1973) — 66 years, and Bugel and Carlson (1961) — 65 years). The explanation for the difference is that the main cause of amputation in this series is trauma (82%) in a younger age group and not diseases of old age such as arteriosclerosis (Table 4). Amputations occur mostly among younger people exposed to work hazards and also due to the ignorance and lack of observations of safety measures in India.
None of the patients had problems in donning their prostheses, being young individuals. Bathing presented problems to only 20% amputees (Table 5), while Kegel reported 55%. Indians usually bathe in a squatting position on the floor. Some of the above-knee and a large number of bilateral amputees required a stool, or showered and used grab bars.
Of the bilateral amputees evaluated, 68% were independently ambulant with or without cane and 18% used wheelchairs. These figures may be compared with those reported by Kegel et al — 25% and 40%, and Kerstein et al — 40% and 54% respectively. The higher incidence of functional capability in bilateral amputees in this study is because the majority of the patients were younger.
Cycling is the commonest and cheapest mode of transport in India and evaluation showed that of the 98% who could ride a bicycle before amputation, 50% gave up riding, but 60% below-knee, 37% above-knee and 19% bilateral amputees could still ride.
Public transport could be used without much difficulty by 97% of patients. Only 3%, who were all bilateral amputees, experienced difficulty in getting into the bus because of steps, short halts, etc.
Only a small percentage (12%) returned to the same occupation, 47% had to change their professions after amputation. Since 60% of the amputees covered in this study are soldiers, it follows from the nature of their previous work that a majority of them have to change their occupation. Among the civilians, people engaged in physical labour have to seek alternate jobs. This explains the difference in this regard between this study and that of Kegel et al where only 4% changed their jobs and that of Kerstein et al where only 15% changed their jobs.
Those previously engaged in physical labour are unable to find work after amputation because they have a low educational level. They lose their jobs due to physical inability and find difficulty in getting other jobs because of intellectual inability.
The ability of the amputee to return to and maintain a normal home life is extremely important. In this study, most of the amputees did not have to change their homes. This is more due to circumstances than choice. Most Indians live in overcrowded homes. Finding suitable accommodation after amputation is well nigh impossible. Most of them who are used to living in crowded, inconvenient homes with inadequate sanitary facilities continue to do so after amputation because of financial difficulties in finding new homes and scarcity of alternative housing.
It was observed that 85% of amputees could no longer take part in outdoor games.
Patients whose sexual relationships were adveresly affected because of amputation were 5% below-knee, 12% above-knee and 15% bilateral, whereas in the Kegel et al study it was 8% below-knee, 22% above-knee and 35% bilateral, and in Kerstein et al it was 15% all together. The reasons are as follows. First of all, the amputees in this series were much younger. The other reason is that 61% of these amputees who were of a marriageable age, were already married. Of those who were not married before amputation, 60% married later.
Contrary to the assumption that loss of limbs may cause a psychological barrier to normal sexual behaviour, it was found that none of our amputees experienced such a barrier. On the contrary, most of them confessed to a heightened sexuality. Another thing is that women generally being passive and submissive in India, rejection by wives is rare.
The patients whose sex life is adversely affected are those who could not get married. They have few outlets since sexual permissiveness is still more or less a taboo.
An examination was made of the impression that below-knee amputees do better than above-knee amputees who in turn do better than bilateral amputees. Results confirm that below-knee amputees definitely do need less help than above-knee and above-knee less than bilateral amputees. In total functional outcome 70% below-knee, 36% above-knee and 30% bilateral were found in Class I.
The patients identified the following needs in their suggestions for improvement. Only 153 offered suggestions.
A few wanted a more cosmetic looking foot.
A few wished for a more durable foot.
A few complained of the heavy weight of prosthesis.
Some wanted a manual on the maintenance of prostheses.
Some suggested ventilation holes and others water proofing of the artificial limb.
The majority complained of frequent breaking of locking joints and wished these to be more durable.
FUNCTIONAL CAPABILITIES SURVEY
AMPUTEES
Interview Schedule
Name :
Disability No.
Age:
Sex:
M/S State:
Income :
Source of payment :
Education:
Do you receive pension benefits? Yes/No
Any other benefit/compensation/None.
How long ago was your arm/leg amputated?
Which arm/leg? Rt/Lt/both
If arm, were you right-handed or left-handed before amputation?
Level of amputation :
Phantom feeling
No phantom feeling
Can feel just part of missing limb
Can feel entire missing limb
Phantom is same length as opposite limb
If leg, phantom is used when walking
If arm, there is movement in fingers of phantom
Missing part is painful and requires medicine
Missing part is painful but requires no medicine
Other
Condition of stump
Scar along front/bottom/back of stump
Any other surgical scar on amputated limb? Yes/No
If Yes, reason:
Does the amputation scar adhere to bone? Yes/No
Does fluid ever drain from anywhere on the limb? Yes/No
Do you have any areas that are tender to touch? Yes/No
Is your stump painless/uncomfortable/painful?
Any other condition:
Condition of unamputated limb
Normal
Does not allow me to be very active
Some cramping, but no problems
Open sores present
Painful all the time
Other:
Social adjustment
Do you live alone/with your nuclear family/in a joint family?
How have your family/friends responded to you as an amputee?
Do you feel that people are more reluctant to accept you socially since your amputation? Yes/No/Do not know
Do you feel handicapped or deprived from leading a normal life? Yes/No
If Yes, how:
Has you amputation affected your sexual activities, either physically or emotionally? Yes/No
Do you feel there is a change in your personality as a result of amputation? Yes/No
Do you find the appearance of your prosthesis a social embarrassment? Yes/No. Comments:
Prosthetic history
How long have you had a prosthesis?
Do you still wear your prosthesis? Yes/No
How many prosthesis have you had since your amputation?
Have you ever had a prosthesis from somewhere else? Yes/No
Have you made any modifications to your own prosthesis? Yes/No
If Yes, how?
How many hours per day do you wear your prosthesis?
Do not wear at all
0-2 hours
2-4 hours
4-6 hours
All day
If arm, specify hand/hook
Putting on and removing prosthesis
Can do completely alone
Need some help
Other
How long does your prosthesis last before you need a new one?
Is your prosthesis comfortable when you wear it? Yes/No. Comment:
Do you feel that the prosthesis is as much a part of you, as your other limb? Yes/No
How?
How long did you go for training after you got your first prosthesis?
No training
Less than two weeks
2-4 weeks
1-2 months
2-4 months
Longer than 4 months
Length of time between surgery and completion of prosthetic training:
No training
One month
Two months
Four months
More
FOR LEG AMPUTEES ONLY
Description of prosthesis
How do you keep your prosthesis on?
Do not wear
Cuff suspension
Waist belt
Leather corset
Pelvic band
Cuff suspension with waist belt
Shoulder harness
Muscle contraction (for BK)
Total suction
Any other
How many stump socks do you wear?
Do not wear prosthesis
One 3 ply
Two 3 ply
More
None
Use of prosthesis
How do you get in and out of chairs?
Do not need chair arms
Need arms on low, sunken chairs
Need to use arms on all chairs
Other
Do you have a wheelchair? Yes/No
If yes, for which activities?
Use no crutches, canes etc
Use one cane
Use two canes
Use one crutch
Use two crutches
Use walker
Do not walk at all
Use wheelchair
Other
How do you manage kerbs?
Without help
Need help
Cannot manage at all
Other
Going down stairs
Step over step
One step at a time
Other
Ramps
Do not need help
Need help
Can only go up ramp
Cannot go up or down ramp
Other
Getting up from the floor
Do not need help
Need help
Other
Dressing
Can dress and undress completely alone
Need help in getting dressed and undressed
Other
Bathing
Sit on floor
Take standing shower
Other
Amount of walking
As much as anyone
Walk in house + 6 Km.
Walk in house + 5 Km.
Walk in house + 4 Km.
Walk in house + 3 Km.
Walk in house + 2 Km.
Walk in house + 1 Km.
Walk in house + 1/2 Km.
Walk only in house
Do not walk
Driving/motor cycle riding/cycling
Public transportation
Can use taxi
Can use bus
Can use airplane
Can use train
Can use all above
Other
Extra activities
Swimming
Running
Track games
Basketball
Football
Other
Work situation
Retired and stay at home
Part time work
Full time work
Able to work, but unemployed
Unable to work for reasons other than amputation
Unable to work because of amputation
Doing different type of work because of amputation
Child, do not work yet
Other
Type of work
Do not work
Sedentary (sit most of the day)
Stand most of the day
Heavy lifting involved
Great deal of walking involved
Other
Any other medical complication since amputation, how long?
Blindness
Stroke
Heart attack
Diabetes
Other
What do you do now that you are an amputee that you could not do before?
What could you do before that you cannot do now because of amputation?
Have you had to change your living place because of amputation? Yes/No
Have you had any modification done to your home because of amputation? Yes/No
If yes, what?
Do you have any suggestions to improve either the function or appearance of your prosthesis? Yes/No
If Yes, what?
Remarks:
Place:
Date:
Name of person taking interview
References:
- Bugel, H. J., Carlson. R. I. (1961). A study of the lower extremity. Am. J. Phys. Med. 40, 93-95.
- Davies, E. J., Fritz, B. R., Clippinger, F. W. (1970). Amputees and their prostheses. Artif. Limbs. 14 (2), 19-48.
- Glattly, H. W. (1964). Statistical study of 12,000 new amputees. South. Med. J. 57, 1373-1378.
- Kay, H. W., Newman, J. D. (1974). Amputee survey, 1973-74: preliminary findings and comparisons. Orthot. Prosthet. 28 (2), 27-32.
- Kegel, B., Carpenter, M. L., Burgess, E. M. (1978). Functional capabilities of lower extremity amputees. Arch. Phys. Med. Rehabil. 59, 109-120.
- Kerstein, M. D., Zimmer, H., Dugdale, F. E., Lerner, E. (1974). Amputations of lower extremity: a study of 194 cases. Arch. Phys. Med. Rehabil. 55, 454-459.
- Narang, I. C, Jape, V. S. (1982). Retrospective study of 14,000 civilian disabled (new) treated over 25 years at an Artificial Limb Centre. Prosthet. Orthot. Int. 6, 10-16.
- Silverstein, M. J., Kadish, L. (1973). A study of amputations at lower extremity. Surg. Gynecol. Obstet. 137, 579-580.
- Stern, P. H. (1976). Assessment of amputee rehabilitation using a text generating data processing system. Orthot. Prosthet. 30 (2), 31-42.
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