INTRODUCTION
According to a study of the medical records of Korean amputees published in 1996 in Korea on the frequency of occurrence of amputation for each area of amputation, the ratio of upper extremity amputation to lower extremity amputation was approximately 1 : 2.2 with upper extremity amputation accounting for the relatively lower proportion.
1 Since prosthetic limbs for the upper extremities have technical difficulties in reproducing delicate and complex movements and the tactile and proprioceptive sensory functions of the hand and upper extremities, upper extremity amputees experience an enormous sense of frustration and problems in the rehabilitation process.
2 Although prosthetic limbs have been developed and recently used in combination with electronic technologies such as myoelectric prostheses, the prosthetic limbs themselves still remain heavy, fail to reproduce precision movement functions and have a slow movement speed. Clearly, there are continuing substantial problems in the prosthetic replacement of hands.
3,
4
In the case of those with unilateral upper limb amputation, unlike the lower limb amputees, a relatively large number of the amputees do not use their prosthetic limb because they can compensate adequately for the in conveniences in carrying out daily activities by use of their remaining upper limb. Moreover, the majority of amputees only use their prosthesis for cosmetic reasons. They have a low level of satisfaction with its functional use and are therefore poorly motivated and reluctant to use it for this purpose and undergo rehabilitation training.
5
Accordingly, this study carried out a questionnaire survey of patients, who had been prescribed upper extremity prosthetic limbs by the Center of Prosthetics and Orthotics. The purpose of this survey was to assess the actual usage of a prosthetic limb by upper extremity amputees and to determine the impacts of its use on the performance of daily living activities and levels of satisfaction. Issues related to occupation and driving after injury were also explored. Our objective was to identify changes which might be occurring over time by comparing our results with those of previous studies. An additional purpose was to provide data, which can form the basis for helping in the future development of prosthetic limbs and the rehabilitation treatment of upper extremity amputees.
DISCUSSION
The severing of a part of the human body not only causes functional and psychological disability but also induces social isolation.
2 Although enormous efforts have been made in an attempt to overcome these difficulties, the majority of these attempts have been focused on lower extremity amputation.
7 Moreover, in the case of unilateral upper limb amputees, most consider a prosthetic limb has an only supplementary role since most of the activities of daily living are conducted by using the upper extremity on the intact side.
8,
9 Since the level of expectations about prosthetic limbs differs widely and the frequency of upper extremity amputation is lower than that of lower extremity amputation, reports on the actual status of prosthesis usage of upper extremity amputees in Korea remain inadequate.
In the previous research by Song and Park,
5 the frequency of amputation level was highest for transradial amputation at 51.9%, followed by 32.8% for transhumeral amputation and 8.2% for shoulder disarticulation. In assessing the cause of amputation, they found high proportions of shrapnel and gunshot injuries (67.9% and 16.8%, respectively). In this study, although the frequency of transradial amputation was the highest, accounting for 48.4% of the unilateral upper limb amputees, the frequencies of transhumeral amputation and shoulder disarticulation (19.4% and 6.6%, respectively) were less than those previously reported, and the frequencies of partial hand and fingers amputation and wrist disarticulation (17.9% and 6.6%, respectively in the two studies) were, higher. Although it is not possible to perform accurate analysis since no assessment of the causes of amputation was made in the present study, these results, when compared with those of the earlier research findings, indicate causes such as shrapnel injury, gunshot injury and damage from explosions, which damage proximal sites of the upper extremity, are decreasing, and that mechanical and electrical causes arising from industrialization, which bring about damage to the distal sites, are increasing.
1
In the research reported by Wright et al.
10 and Durance and O'Shea,
11 the frequencies of the use of functional prosthetic limbs were quite high (84% and 77%, respectively in the two studies). However, previous reports in Korea, which studied the types of prosthetic limb used for the upper extremities, found lower frequencies of functional prosthetic and cosmetic prosthetic limbs (62.5% and 55.5%, respectively, of all the prosthetic limbs for upper extremities.
2,
8 Moreover, the frequency of cosmetic prosthetic limbs accounted for 79.8% of the total, which is substantially higher than that of functional prosthetic limbs at 1.5%, even in the research by Song and Park.
5 In the present study, although the usage of a functional prosthetic limb increased to 15.0%, it was found that 80.2% of the unilateral upper limb amputees are using a cosmetic prosthetic limb. Such findings are believed to be the results of the very low frequency of those receiving rehabilitation training in the usage of a prosthetic limb (7.3%), the majority of the questionnaire respondents being old and familiar only with the prosthetic limb, which was prescribed for them in the past (40.15 years was the mean time since the of amputation) and therefore not having attempted to try a new functional prosthetic limb, and the substantially significant burden of manipulation and adaptation to a functional prosthetic limb.
On the question of the level of satisfaction with a prosthetic limb, the frequency of those reporting it as 'satisfactory' was 30.0%, which is slightly higher than the proportion found in the research by Song and Park,
5 but proportion of those who were found to be 'dissatisfied' was still very high at 28.6%. However, 44.7% of unilateral upper limb amputees in the present study reported wearing their prosthetic limbs for an average of 8-16 hours per day. Gaine et al,
12 considered that the wearing of prosthetic limb for a daily average of eight hours or more indicated success in the usage of a prosthetic limb and devised a prosthetic success score for which the duration of wearing of prosthetic limb was one of the component scores. The results of the present study demon strate an increase in the daily duration of wearing a prosthesis when compared with the 39.2%, who stated that they always wore their prosthesis, in the study by Song and Park.
5 Nevertheless, the present study found that the level of amputation and types of prosthetic limb made no difference to levels of satisfaction or durations of wearing a prosthesis. Moreover, the extent of usage also appeared to be unaffected by the level of amputation and types of prosthetic limb. Most (76.9%) of the unilateral upper limb amputees reported using their prosthetic limb always or occasionally for cosmetic purposes, and this group's the level of satisfaction with their prosthetic was lower than that of the group using their prostheses for functional purposes.
On the questions about 17 detailed activities of daily living, tasks such as tying shoe laces, opening and drinking a bottled beverage with a bottle opener, using scissors and buttoning shirts were found to be more difficult than other activities. In general, there was a tendency for activities to be more difficult to perform, if they required delicate movements and substantial force of the distal extremities. In particular, for those with amputation of the hand or fingers, activities which required delicate movements of the terminal ends of the upper extremities, such as buttoning shirts and using scissors, tended to be more difficult. By adding and examining detailed tasks to the basic activities of daily living, it is thought that the results of the present study will provide information to assist in the development of rehabilitation training programs for upper extremity amputees.
Most of the respondents in the present survey stated that after amputation they were either unemployed or performed different tasks at different workplaces (39.7% and 29.3%, respectively), and only 8.8% returned to the same task at the same workplace. While this is an increase from the 5.5% reported by Chang et al.
8, it is still substantially lower than the occupation return rate of 30.4% reported in the research by Gaine et al.
12 In addition, it was confirmed that there was no case of a return to the original workplace amongst the bilateral upper limb amputees. Considering the fact that amputation occurred at the average age of 25.70 years and that this age represents a productive stage in people's lives when they have substantial socio-economic capabilities, the socio-economic losses arising from amputation are believed to be enormous. As was the case in the previous researches,
13 the results of the present study showed that the extent of return to an occupation was unrelated either to whether the dominant upper extremity was amputated or to the educational background of the amputee. Office workers experience less demand on the functioning of their upper extremities and the extent of their return to their previous occupation was found to be better than for military personnel, skilled manual workers and common laborers. In addition, farmers, skilled manual workers and common laborers, who face greater demands on the functioning of their upper extremities, see rehabilitation training more as more important than others do. On the question of the reasons for failure to return to ones' previous occupation, although an inability to perform as in the past accounted for 51.6% of the answers, many gave reasons such as insufficient functions of a prosthetic limb (16.2%) and lack of social awareness about disabled persons (11.6%). This illustrates that the social awareness about amputees or systems related to occupation rehabilitation is still insufficient. The development of prosthetic limb with faster and more accurate movement functions is also needed.
According to Davidson,
6 68% of upper extremity amputees drove vehicles after amputation, with 73% of drivers using handle rotation knobs and 23% having extended winker levers. In the present study, 41.0% of all the amputees stated that they drove after amputation, with 26.9% of them using remodeled automobiles. The subjects were not asked to provide details of types of remodeling, and this makes accurate comparisons difficult, but the proportions of the drivers and the remodeling of automobiles were found to be relatively lower. Moreover, although there were no differences in the side of amputation and types of prosthetic limb between those who did and did not drive after amputation, the drivers and non-drivers were found to differ in terms of the level of the amputation. A statistically larger number of amputees drove if the level of amputation was closer to the distal site. Under the current domestic road and traffic laws of Korea, those, who have lost both arms above the elbow, or those, who are unable to use both arms at all, are not allowed to drive. However, there is exception for the cases in which such people are able to drive normally by using automobiles, which have been designed and built to suitably accommodate for the extent of the physical disabilities of the amputee driver. If rehabilitation services for driving, such as the development and supply of assistive devices appropriate for driving, are improved and if there is an expansion of rehabilitation centers for driving, then the proportion of upper limb amputees who drive will increase. This should improve their activities of daily living and also increase their satisfaction levels with their prosthetic limbs.
This study is limited in the extent to which the results can be generalized to everyone with upper extremity amputations, since subjects included only the patients who were prescribed prosthetic limbs for their upper extremities at a single hospital; furthermore, all the subjects were male and elderly. A second limitation is the study relied upon a postal questionnaire survey for the collection of data, and more detailed and useful information could have been obtained from the amputees by the use of personal interviews.
However, this study is meaningful in comparison to the previous researches in that it investigated a range of issues, including levels of satisfaction, the actual status of usage of a prosthetic limb for the upper extremities, activities of daily living, and the impacts on occupations and driving. It is believed that the findings of this study could be used in the future as basic information for the prescription and training for use of upper extremity prosthetic limbs and for rehabilitation training in relation to returning to employment.