Clinical Survey of Upper Extremity Amputees in India
Brig. I.C. Narang, MS, FICS *
Lt. Col. B.P. Mathur, MS, M.Phil. (UK) *
Lt. Col. Pal Singh, MS *
Mrs. V.S. Jape, MA, MA(SW) *
A survey of upper limb amputees has been carried out at the Defense Services Artificial Limb Centre, Poona, India. The aim of the survey was primarily to gather information directly from the patients about the utility of upper limb prostheses which are being provided at present, and also analyze factors like etiology, age, sex, and others.
Initially it was planned to send out questionnaires to the patients in order to collect information from a larger number of upper limb amputees. However, since the information collected in this manner might not have been very accurate, it was decided to interview the patients who reported directly to the Centre.
MATERIALS & METHODS
A questionnaire was prepared and 100 unilateral and 30 bilateral upper limb amputees were interviewed individually, and their answers to the questionnaire were recorded.
Age & Sex Differences
The maximum number of amputations were found to have occurred in the age group 21-50 years as shown in Table 1; i.e. 39 (30 percent) occurring at 21-30 years, 47 (36 percent) at 31-40 years, and 21 (16 percent) in the 41-50 year old age group. It is seen that the maximum number of amputations occurred during the productive years of the individuals, as it is this age group which is more exposed to a hazardous nature of work.
Out of 130 patients surveyed, 124 (95 percent) were males, and there were six (five percent) females.
Status of Patients (Military or Civilians)
Out of 130 patients interviewed, 82 (63 percent) were civilian and 48 (37 percent) were military patients.
Cause of Injury
Table 1 and 2(2) shows the various causative agents leading to amputations among patients in this series.
Trauma was the most prevalent causative agent, with 122 out of 130 patients having lost limbs due to injuries, predominantly as a result of crush injuries, vehicle accidents, blast injuries, and train accidents. Diseases and congenital causes accounted for six and two cases, respectively.
It was observed that the 28 cases of crush injuries, the largest number of cases among the trauma group, were predominantly due to agricultural accidents. In India, such injuries, mostly due to thresher machines, are becoming very common—due to rapid mechanization without proper instructions and lack of safety guards in the equipment.
The most common cause of amputation in vehicle accidents, 25 cases, was a result of sustaining injury by another vehicle while resting the elbow on the open window of the patient's own vehicle.
Blast injuries, 24 cases, occurred mostly in military patients who had to handle dangerous explosives. Only a few civilian patients were encountered who had lost a limb as a result of blast injuries.
Level of Amputation
The levels of amputation in unilateral and bilateral cases are shown in Table 3-A. and Table 3-B.. Out of 130 cases, 100 (77 percent) were unilateral, and 30 (23 percent) were bilateral amputees. Among unilateral amputees, the majority of cases were below elbow amputees, i.e. 55, followed by 32 above elbow amputees.
Among 30 bilateral amputees, 23 patients had at least one below elbow residual limb, i.e., 14 had bilateral below-elbow residual limbs (including one with bilateral wrist disarticulations) and nine patients had below elbow amputations on one side.
The various other combinations of amputations at identical or unidentical sites are shown in Table 3-B. .
Out of 130 patients, 127 (98 percent) were right-handed, whereas only three (two percent) were left handed. No ambidextrous person was encountered. Loss of dominant hand was encountered in 90 patients.
Time lag in prosthetic fitting
Table 4 . shows the time lag from the date of injury to prosthetic fitting. It was observed that only 16 (12 percent) were able to get a prosthesis fitted within six months from the date of injury.
For the majority of the patients it took more than six months to get a prosthesis.
The cause for this unusual delay was primarily due to the time taken by the Centre to call up patients, because of its long waiting list.
Distribution of Prostheses Provided
All the patients had body powered conventional upper limb prostheses with hook or hand terminal devices. No patients were using an externally powered prosthesis, due to its non-availability in India.
The distribution of types of prostheses in use was as follows:
Distribution of Terminal Devices
The various terminal devices that the patients had taken at a time of fitting of the prostheses were as follows (Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. 6,and Fig. 7):
Duration of Disability
The duration of disability at the time of interview of the individual patients is shown in Table 5.. It is evident from the table that the survey results represent patients who had been disabled recently and also those who had been amputees for a long time.
Duration of Prosthetic Fitting
Table 6. shows the duration since patients had been fitted with prostheses.
Out of 130 patients, 13 (ten percent) discarded their prostheses altogether. They reported to the Centre not for repair or renewal of their prostheses, but for treatment. Such patients were mostly those who had lost their lower limbs, in addition to upper limbs, due to Thromboangitis Obliterans.
117 (90 percent) were using their prostheses at the time of interview. The majority of these patients, i.e. 77 (59 percent), were using the devices solely for cosmetic reasons. They hardly made any use of the functions of the prostheses. Such patients were mostly unilateral amputees, who could perform most of the activities single-handedly. On interrogation about bimanual activities, it came to light that they avoided it, since help was available in their homes as well as places of work, from relatives and colleagues, respectively. Five bilateral amputees were also found not using their prostheses for functional purposes since they had undergone bilateral Krukenberg operations and were functioning with their residual limbs; however, for cosmetic purposes they wore their limbs.
For functional purposes, only 40 patients (34 percent) were using the prostheses. The majority of these patients were bilateral amputees, and their very survival depended upon how well they could make use of their prostheses.
Out of 40 patients who were using their prostheses, 15 were unilateral cases, whereas 25 were bilaterals. The functional gain following prosthetic fitting was found quite satisfactory in the majority of cases. Of the 30 bilateral cases, 23 had at least one below elbow prosthesis (14 bilateral below elbow prostheses and nine unilateral below elbow wearers).
The majority of the bilateral amputees (25) had right sided dominant longer residual limbs available to use the prostheses as dominant prostheses. In two cases, however, they had to change dominance to the left side, since they had below elbow amputations on the left and above elbow amputations on the right side.
Among unilateral cases, the whole limb, irrespective of previous dominance, was used as a dominant hand, and the prosthesis was used as a support.
Out of 40 patients, all were using their prostheses for some activities of daily living, 25 for their professional work as well, and 31 for avocational purposes, too.
Use of Terminal Devices
Though every patient was given a large number of terminal devices at the initial fitting, it was observed that of the 130 cases, only 15 unilateral and 25 bilateral patients made use of them. The majority were concerned about cosmesis, and thus rejected unattractive terminal devices for the expense of function, by wearing a passive hand only. Among bilateral cases, however, the acceptance rate was very high, since for functional gain they had to use the terminal devices. They also expressed the view that they would be much happier if the hands could be made more functional.
All 15 unilateral amputees made use of hooks. In addition to a hook, 10 patients used grass cutters (being farmers by profession) and two made use of driving devices.
Among the 25 bilateral amputees, the acceptance of terminal devices was better. The majority of them, in addition to hooks, made use of two to three more terminal devices, mostly for eating and dressing purposes. Though initially bilaterals also took a large number of terminal devices to perform various activities, a number of such devices were rejected due to the difficulties in interchanging the devices. Maximum use was made of hooks to perform most of the activities.
The educational level of upper extremity amputees has been found much higher than expected, and is shown in Table 7..
Profession Before Amputation
Table 8. indicates patients' profession before amputation.
The largest group of amputees belonged to the technician class (34), followed by students (23), white collar workers (20), and soldiers (19).
Professional and Financial Status Following Prosthetic Fitting
Out of 130 upper limb amputees, 70 had to change their jobs, 34 were offered the same job, and 26 lost their jobs.
The majority of patients in this survey had to change jobs or lose them since their job involved use of both hands, e.g. technicians, drivers, soldiers, labourers.
Due to the changes of jobs, 68 had to accept jobs with less income, but 29 had better jobs financially. Thirty-three patients had no effect on their earning capacity following amputation.
Change of Personality
As far as personality changes are concerned, the proportion of those who professed personality changes in themselves were found more or less equal to those who did not, i.e., 60:70 ratio.
Among 60 patients who felt some change in their personality following amputation, 40 were more anxious, worried, and depressed, whereas 20 felt that now they were more mature and responsible.
Feeling of Being Handicapped
On interrogation, 54 patients out of 130 complained that they felt handicapped and also had personality changes.
Seventy-six patients did not feel handicapped (subjectively).
The above feelings were purely personal feelings and had no relevance with functional gain or other factors following prosthetic fitting.
Acceptance by Society
Out of 130 patients interviewed, the majority, i.e. 109, said that they were well accepted by society, whereas 21 felt that they were not.
Out of 130 patients, 87 belonged to joint family groups, 33 to nuclear families, and only 10 lived alone.
Since the majority were living with others, they did not feel an urge to be totally independent, as help was always available. This attitude of the patient is supported by the prevalence of the joint family system, culture, and customs of Indian society, and the number of relatives and friends who go out of their way to help such unfortunate members of society. This in turn makes the patient more dependent on others.
Out of 130 patients, at the time of the interview, 92 were married and 38 unmarried.
Of the 92 married ones, 47 were married before amputation, and 45 got married after amputation. This suggests that being handicapped probably does not impede marriage plans.
Marriage prospects of bilateral upper limb amputees in this survey were not encouraging. Out of 30 bilateral amputees, 14 were already married before amputation and were quite acceptable to their spouses. However, the remaining 16 who were unmarried found it difficult to get a partner.
Marriage seemed to affect female patients the most. All the female patients (six) in this series were unmarried, though they were between the ages of 16 and 37.
The survey revealed that the sex life of married amputees was normal and satisfactory. None of the married amputees had complained of any problems like sexual inadequacy or maladjustment towards their partners.
The above may be due to Indian culture and traditions in a male dominated society. Females have to play a submissive role, accept male superiority and stay with their husband, once married, for life.
A survey of 130 upper extremity amputees has been carried out by collecting information directly from the patients.
Out of 130 cases, 100 were unilateral and 30 were bilateral amputees.
There were only six female patients. The maximum incidence of amputations was encountered in the 20-50 year old age group.
Trauma was the most prevalent cause of amputations, i.e., 94 percent.
Only a very few cases could be fitted with prostheses within six months from time of injury (12 percent). The majority received their initial prosthetic fitting after six months.
The majority of the unilateral amputees did not use their prosthesis for functional purposes. They wore it solely for cosmetic purposes.
In contrast, among bilateral amputees, the use of prostheses for functional purposes was very high, as their very existence depended on their functional gain following prosthetic fitting.
Though initially a large number of terminal devices were taken, the majority were later rejected. For functional purposes the prosthetic hook was used most often.
The functional gain among bilateral amputees in this series was found quite satisfactory since the majority of them (23 out of 30) had at least one below elbow prosthesis.
All expressed a desire to have a hand, rather than a hook, with more function.
Following amputation, the majority of the patients had to either change their jobs or lost their gainful employment.
Roughly 50 percent of the patients had personality changes following amputation, and felt handicapped.
Acceptance by society and the families of such patients, following amputation, has been of a high order.
There has been no problem for male unilateral amputees to marry following amputation. However, the majority of unmarried bilateral amputees and all female amputees found it difficult to get a partner.
There have not been any psychological problems leading to marital imbalance or break-down in their relationships.