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299
JRRD
JRRD Volume 47, Number 4, 2010
Pages 299–316
Journal of Rehabilitation Research & Development
Unilateral upper-limb loss: Satisfaction and prosthetic-device use in
veterans and servicemembers from Vietnam and OIF/OEF conflicts
Lynne V. McFarland, PhD;1* Sandra L. Hubbard Winkler, PhD, OTR/L, ATP;2 Allen W. Heinemann, PhD;3
Melissa Jones, PhD, OTR/L, CHT, LTC;4 Alberto Esquenazi, MD5
1Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA; and University of Washington, Seattle,
WA; 2Rehabilitation Outcomes Research Center Research Enhancement Award Program, North Florida/South Georgia
Veterans Health System, Gainesville, FL; and University of Florida, Gainesville, FL; 3Department of Physical Medi-
cine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL; and Center for Rehabili-
tation Outcomes Research, Rehabilitation Institute of Chicago, Chicago, IL; 4U.S. Army, Manhattan, KS; 5Department
of Physical Medicine and Rehabilitation, MossRehab and Albert Einstein Medical Center, Elkins Park, PA
Abstract—Prosthetic use and satisfaction in wounded service-
members and veterans with unilateral upper-limb loss has not
been thoroughly explored. Through a national survey, we
enrolled 47 participants from the Vietnam conflict and 50 from
Operation Iraqi Freedom/Operation Enduring Freedom (OIF/
OEF) with combat-associated major unilateral upper-limb loss.
Upper-limb prosthetic devices were used by 70% of the Viet-
nam group and 76% of the OIF/OEF group. Mechanical/body-
powered upper-limb devices were favored by the Vietnam
group, while a combination of myoelectric/hybrid and mechani-
cal/body-powered devices were favored by the OIF/OEF group.
Upper-limb devices were completely abandoned in 30% of the
Vietnam and 22% of the OIF/OEF groups. Abandonment was
more frequent for transhumeral and more proximal levels (42%
of Vietnam and 40% of OIF/OEF) than more distal limb-loss
levels. Upper-limb prostheses were rejected because of dissatis-
faction with the device by significantly fewer (23%) members
of the Vietnam group than the OIF/OEF group (45%) (p <
0.001). Most common reasons for rejection included pain, poor
comfort, and lack of functionality. A significant paradigm shift
has been noted in the OIF/OEF group, who use a greater num-
ber and diversity of upper-limb prostheses than the Vietnam
group.
Key words: abandonment, activity measure, limb loss, OIF/
OEF, prosthetic device, rehabilitation, satisfaction, upper-limb
loss, veterans, Vietnam conflict.
INTRODUCTION
The National Limb Loss Information Center reported
that in 2007 approximately 1.7 million people were living
with limb loss in the United States [1], and this number is
projected to reach 3.6 million by 2050 [2]. Although
lower-limb loss is more prevalent (80%) than upper-limb
(10%) or multiple-limb (10%) loss, upper-limb loss has
unique challenges and issues [3]. In 2005, 41,000 persons
in the United States were living with major upper-limb
loss, 62 percent of whom had trauma-related injuries [2].
The proportion of trauma-related upper-limb loss
increases during times of warfare: limb loss involved the
Abbreviations: ADL = activities of daily living, aOR =
adjusted odds ratio, CTD = cumulative trauma disorder, DOD =
Department of Defense, OIF/OEF = Operation Iraqi Freedom/
Operation Enduring Freedom, PTSD = posttraumatic stress dis-
order, TBI = traumatic brain injury, VA = Department of Veter-
ans Affairs.
*Address all correspondence to Lynne V. McFarland, PhD;
VA Puget Sound Health Care System, Health Services
Research and Development, 1100 Olive Way, Suite 1400,
Seattle, WA 98101; 206-277-1095; fax: 206-764-2935.
Email: Lynne.McFarland@va.gov
DOI:10.1682/JRRD.2009.03.0027
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JRRD, Volume 47, Number 4, 2010
upper limb in 14 to 15 percent of 5,283 Vietnam service-
members [4–5], 18.5 percent of 89 British World War II
veterans [6], 14 percent of 14 Persian Gulf servicemem-
bers [7], and 12.5 percent of 200 Iraq-Iran conflict ser-
vicemembers during the late 1980s [8–12]. As of January
2009, 161 (22%) of 737 servicemembers in the Operation
Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)
conflict had limb loss involving the upper limb.*
Few studies on combat-related injuries focus on uni-
lateral upper-limb loss. Several reasons upper-limb loss
research trails that of lower-limb loss include (1) upper-
limb loss is less frequent; (2) measurement of upper-limb
activity level is more difficult than measurement of lower-
limb function, which relies on weight-bearing and ambu-
lation; (3) upper-limb prostheses are more challenging to
master than lower-limb prostheses; and (4) trauma is the
primary cause of upper-limb loss, as opposed to dysvas-
cular conditions, so the population is generally more het-
erogeneous and therefore more difficult to study [13].
A recent Department of Defense (DOD) Rehabilita-
tion Directive aims to restore wounded servicemembers
from OIF/OEF to the highest possible functional level so
the loss of a limb does not prevent a return to Active
Duty [14–16]. Factors predicting continued use of and
satisfaction with prosthetic devices in these servicemem-
bers and veterans have not been fully explored [17–18].
Our study explores the effect of this rehabilitation para-
digm shift by comparing the prosthesis use of veterans
with combat-associated unilateral upper-limb loss from
the Vietnam group (predirective) with that of the OIF/
OEF group (postdirective). The purpose of this study was
to describe prosthetic-device use patterns in two large
groups of servicemembers and veterans with combat-
associated upper-limb loss.
METHODS
Study Design
This descriptive, cross-sectional survey collected data
on current prosthetic- and assistive-device use (number
and type of devices and daily frequency of use) and satis-
faction with current prostheses and services from two
distinct groups of veterans and servicemembers with com-
bat-associated major limb loss (digit-only loss excluded).
Survey Participants
Participants in this study were veterans from the
Vietnam conflict and veterans and servicemembers from
the OIF/OEF conflict with at least one major traumatic
amputation (digit-only loss excluded) associated with a
combat-field injury. Veterans and servicemembers with
major limb loss occurring during the Vietnam (1961–
1973) or OIF/OEF (2000–2008) conflicts were sent an
invitation to participate in a survey on prosthesis use. All
servicemembers with major limb loss from OIF/OEF
were invited to participate. A selection of Vietnam veter-
ans were also invited (all unilateral upper-limb loss, all
multiple limb loss, and a subsample of unilateral lower-
limb loss) to match the total number of OIF/OEF invi-
tees. Survey participants included 298 from the Vietnam
conflict (65% response rate) and 283 from the OIF/OEF
conflict (59% response rate). Participants took the survey
by one of three methods: mail, telephone interview, or
Web site. Veterans and servicemembers were surveyed
during 2007 and 2008. A description of the detailed study
methods and the survey are found elsewhere in this issue
[19], and a copy of the Survey for Prosthetic Use can be
found in Appendix 1 (available online only). This study
focuses on servicemembers and veterans with combat-
associated unilateral upper-limb loss occurring during the
Vietnam and OIF/OEF conflicts: unilateral lower-limb
[20] and multiple limb loss [21] are described elsewhere
in this issue.
Survey Measures
The survey collected data on basic demographics,
current military status, and employment. The presence of
self-reported comorbidities, such as arthritis, diabetes,
depression, migraines, phantom pain, residual-limb pain,
posttraumatic stress disorder (PTSD), or traumatic brain
injury (TBI) was also reported. The combat injury impact
rank score was collected and assesses the effect of differ-
ent types of combat injuries on current life. It ranges from
0 (does not affect at all) to 10 (strongly affects). The types
of combat injuries reported were amputated limb, injury
to nonamputated limb, head and eye injuries, hearing loss,
chest injury, abdominal injury, burns, or other injuries.
Self-rated health status was classified into three groups:
(1) very good-to-excellent, (2) good, or (3) fair-to-poor.
*Scoville, Charles R. (Amputee Patient Care Service, Integrated Depart-
ment of Orthopaedics and Rehabilitation, National Naval Medical
Center, Walter Reed Army Medical Center, Washington, DC). Email
to: Gayle E. Reiber (Program Analyst, Department of Prosthetic and
Sensory Aids, VA Puget Sound Health Care System, Seattle, WA).
Email on amputee patient numbers through January 2009. 2009 Jan 31.
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
Cumulative trauma disorder (CTD) (or worn-limb syn-
drome) was also reported; it results from overuse of the
nonamputated limb and may include any one of the fol-
lowing: carpal tunnel syndrome, cubital tunnel syndrome,
tendonitis, arthritis, stiff or painful joints, or ganglion
cysts. The number of surgeries before and after the initial
amputation was also reported. Use of three types of
upper-limb prosthetic devices was recorded: myoelectric/
hybrid, mechanical/body-powered, or cosmetic. Data on
23 activities of daily living (ADL) were collected. These
items included performance of tasks related to eating and
dressing, community activities, housekeeping, automobile
operation, use of tools, and sporting activities.
Prosthetic Devices
Current satisfaction with prostheses was ranked from
0 (not at all satisfied) to 10 (completely satisfied). Survey
participants were also asked which types of prosthetic and
assistive devices they might want to try in the next 3 years.
Retrospective data were also collected on the number
and types of prostheses received in the past (total for the
first year postamputation and then total since that time).
Data were collected on the number of prostheses that wore
out and the average replacement time by type of device.
For prostheses that were discontinued because of dissatis-
faction, the number and types of devices were collected,
as well as the reasons why participants discontinued the
prosthesis. Survey participants self-reported any pros-
thetic-device receipt, regardless of whether received
through military, Department of Veterans Affairs (VA), or
private sources. Survey participants also included whether
they had ever received prototype prosthetic devices.
Due to the complexity of prosthetic systems, we sum-
marized prosthetic-device types into major groups defined
by the degree of technology, device use, and level of limb
loss. Upper-limb prostheses were grouped into three
groups: myoelectric/hybrid (advanced technology),
mechanical/body-powered (no batteries needed), and cos-
metic (nonfunctional). Assistive technology use (walkers,
canes, crutches, car modifications, wheelchairs, terminal
upper-limb devices, etc.) was collected for current use and
predicted use in the next 3 years.
Health Status
Cross-sectional data were collected for current quality
of life, health status, comorbidities, overuse problems
with nonamputated limb(s), social support (marital status,
employment, children, current military status), ability to
perform ADL, current lower-limb function, and the effect
of prior combat injuries on current life. Self-rated health
status was assessed with a validated tool [22]. Retrospec-
tive data were collected on the date and location of all
amputations, number of associated surgeries, level of limb
loss, and types of combat injuries.
Statistical Analysis
Univariate, bivariate, and multivariate findings were
analyzed with Stata 9.2 (StataCorp; College Station,
Texas). For univariate analyses, statistical significance
was based on chi-square (categorical data), Mann-
Whitney U-test (ordinal data), Student t-test (continuous
data), and Fisher exact test if cell sizes <5. The level of
significance was a two-sided p 0.05.
We assessed upper-limb function by using psycho-
metric properties of a 23-item, 4-category rating-scale
instrument for upper-limb activity status using Rasch
analysis and Winsteps software, version 3.64.2 [23].
Rasch analysis provides information about a summed
scale that cannot be obtained using classical test theory
approaches [24–26]. Rasch analysis defines a construct
inferred from a hierarchy of item difficulties and the func-
tioning of response categories. The validity of a measure
is assessed by evaluating the fit of the items to an under-
lying construct. From our survey, 23 ADL were used as
items for the hierarchy of difficulty. Function response
categories on how survey participants performed each
task were collected for each of the ADL. The four possi-
ble response categories were “uses prosthetic device,”
“does with other hand,” “does with assistance,” and “does
not do.” More positive activity-score values indicated
tasks that were typically more difficult and were per-
formed with an upper-limb prosthesis. More negative
activity-score values indicated less difficult tasks that
were typically not done or required the assistance of
another person. We specified a partial-credit model that
allowed the response-category thresholds to vary across
items. The initial Rasch rating-scale analysis of the
23 ADL revealed that the rating-scale categories did not
increase monotonically. For 13 items, the difficulty of cat-
egory 4 (“does not do”) was inverted; that is, “does with
assistance” (category 3) reflected greater dependence. We
rescored responses so that categories 3 and 4 were com-
bined to reflect a maximum level of dependence. Com-
bining these categories eliminated category inversion,
which resulted in improved person reliability (0.89) with-
out lowering the ceiling of the measure. Three items did
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JRRD, Volume 47, Number 4, 2010
not fit well (mean square infit values ranging from 1.42 to
1.69). We removed the most misfitting item (“high aero-
bic sport activities,” mean square infit = 1.69) and the
most overfitting item (“raking,” mean square infit = 0.67).
Our analysis then showed only one item (“drying dishes”)
slightly misfit (mean square infit = 1.42), while preserv-
ing good reliability (0.88). We used the activity-score
measure produced for each person from this 21-item, 3-
category rating-scale analysis for subsequent compari-
sons of upper-limb activity for participant groups.
Multiple linear regression was used to fit a model for
the continuous outcome variable (upper-limb activity) for
each of the groups separately. The outcome for the mod-
els was a continuous upper-limb activity measure derived
using Rasch analysis. Variables significant in univariate
analyses were tested in multivariate models. To avoid
overfitting the model, we added variables significant in
univariate analyses using forward stepwise selection
based on the log-likelihood ratio and the significance of
the coefficient. The new model was compared with the
previous model using the log-likelihood ratio chi-square
test, and the variable was kept in the model if p 0.05.
The variable was removed from the model if p > 0.05 and
it was not a confounding factor. Potential interactions
were assessed using the log-likelihood ratio. Goodness of
fit of the final model was assessed using diagnostic plots
of residual errors, and outliers were investigated [27].
Due to the low frequency of limb loss in the wrist, elbow,
and shoulder levels, only individuals with transfemoral
and transradial limb-loss levels were included in the
models.
RESULTS
Vietnam and OIF/OEF Groups
Forty-seven Vietnam veterans and fifty servicemem-
bers wounded in the OIF/OEF conflict with unilateral
upper-limb loss were enrolled in our study. The mean
(± standard deviation) age of the Vietnam group was 60 ±
2 years, and the mean age of the OIF/OEF group was 30 ±
6 years. Seven (14%) of the OIF/OEF participants
returned to Active Duty after rehabilitation. Surprisingly,
more than half those returning to Active Duty had trans-
humeral limb loss. A comparison of the health status of the
Vietnam and OIF/OEF groups is shown by level of limb
loss in Table 1. The level of limb loss was diverse for both
groups; transradial and transhumeral limb loss being the
most frequent for both the Vietnam (32% and 43%,
respectively) and OIF/OEF groups (40% and 28%, respec-
tively). A detailed description of the demographic charac-
teristics of the Vietnam and OIF/OEF groups with
unilateral upper-limb loss can be found in another article
in this issue [19].
Comorbidity
The Vietnam group reported a mean of 4 ± 3 comor-
bidities, and the OIF/OEF group reported a similar mean
number of comorbidities (5 ± 3), but the type of comor-
bidities differed by group. Arthritis was more frequently
reported by the Vietnam group (55%) than the OIF/OEF
group (26%, p = 0.003). Diabetes was more common in
the Vietnam group (19%) than the OIF/OEF group (4%,
p = 0.02). The OIF/OEF group reported more PTSD
(68% vs 27%, p < 0.001), residual-limb pain (68% vs
32%, p < 0.001), and TBI (32% vs 6%, p = 0.00l) than
the Vietnam group. Phantom pain was reported by 66
percent of the Vietnam group and 82 percent of the OIF/
OEF group (p = 0.07). The frequencies of other comor-
bidities did not significantly differ in the Vietnam versus
OIF/OEF groups: depression (19% and 26%, respec-
tively) and stroke (2% and 6%, respectively).
Combat-Associated Injuries
When survey participants were asked to rank how
their upper-limb loss affected their current quality of life,
the average combat injury impact rank for the Vietnam
group was 7 ± 3 versus 8 ± 2 for the OIF/OEF group (p =
0.04). In the Vietnam group, those with transhumeral
limb loss reported their limb loss had the greatest effect
on their current life, while in the OIF/OEF group,
through-the-hand limb loss had the greatest effect on
quality of life.
In addition to limb loss, other combat-related injuries
were more frequent in the OIF/OEF group: 60 percent of
the Vietnam group reported other combat injuries com-
pared with 90 percent of the OIF/OEF group (p = 0.01).
The mean number of types of combat-related injuries was
significantly higher for the OIF/OEF group (3.9 ± 2.3)
than the Vietnam group (2.9 ± 2.3, p = 0.03). Head injuries
were more frequent in the OIF/OEF group than the Viet-
nam group (44% vs 11%, respectively, p < 0.001); hearing
loss was more frequent in the OIF/OEF group than the
Vietnam group (62% vs 34%, respectively, p < 0.01); and
TBI was more frequently reported by the OIF/OEF group
than the Vietnam group (32% vs 6%, respectively, p <
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
0.001). Other types of combat-related injuries were not
significantly different for the OIF/OEF group compared
with the Vietnam group: injuries to the nonamputated
upper limb (32% vs 28%, respectively), burns (24% vs
13%, respectively), chest injuries (20% vs 11%, respec-
tively), abdominal injuries (18% vs 19%, respectively),
and eye injuries (16% vs 17%, respectively).
General Health
In general, more of the OIF/OEF group self-rated their
health as very good-to-excellent (42%) than the Vietnam
group (30%, p = 0.04). Level of limb loss was not associ-
ated with significant differences in self-rated health
(Table 1). Transhumeral-level limb loss had the lowest
frequency of very good-to-excellent health rating: 20 per-
cent of Vietnam and 14 percent of OIF/OEF groups. For
shoulder-level limb loss, 67 percent of the OIF/OEF group
reported very good-to-excellent health status compared
with only 50 percent of the Vietnam group.
More of the Vietnam group reported CTD problems
with the nonamputated limb than the OIF/OEF group
(60% vs 38%, respectively, p < 0.001). Of the 28 in the
Vietnam group with CTD, the most frequent symptoms
reported for the nonamputated limb were elbow pain and
rotator cuff tendonitis. Of the 19 in the OIF/OEF group
with CTD, the problems reported most frequently were
elbow pain, wrist pain, and tendonitis.
Upper-Limb Activity Measure
The Rasch analysis successfully assigned a mean
activity-measure score to 21 of the 23 ADL. The measure
assigned to each task and other Rasch statistics
are presented in Table 2: the easiest item was driving
(measure = –1.05), while the hardest item was drying
dishes (measure = +1.30). How participants performed the
Table 1.
Comparison of health status and prosthetic use frequency (% of limb-loss level category) for Vietnam (V) and Operation Iraqi Freedom/Operation
Enduring Freedom (OIF/OEF) groups with unilateral upper-limb loss (data presented as percent unless otherwise noted).
Outcome Carpal Wrist Transradial Elbow Transhumeral Shoulder Tot a l
OIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF
No. Persons 3 6 4 15 20 2 3 20 14 4 6 47 50
Active Duty 0 0 25 011 0 0 0 29*0 0 0 14
Comorbidities†
None 0 0 0 7 0 0 0 5 0 50 0 8 0*
Mean ± SD 6 ± 4 4 ± 2 8 ± 3 5 ± 2 5 ± 4 6 ± 2 5 ± 1 5 ± 3 4 ± 2 2 ± 2 4 ± 2 4 ± 3 5 ± 3
Limb-Loss Impact
Score‡ (mean ± SD) 10 ± 0 6 ± 3 7 ± 3 6 ± 3 8 ± 3 8 ± 4 9 ± 1 8 ± 2 9 ± 1 5 ± 4 8 ± 3 7 ± 3 8 ± 2*
Other Combat
Injuries§ 67 67 100 67 85 100 100 50 93 50 100 60 90*
Health Status
Very Good–Excellent 33 33 50 33 55 50 33 20 14 50 67 30 42*
Good 67 33 25 40 30 067 40 57 017 34 40*
Fair–Poor 033 25 27 15 50 040 29 50 17 36 18
CTD¶ 017 50 53 50 100 33 75 36 50 17 60 38*
Activity Measure**
(mean ± SD) 0.5 ± 1.6 2 ± 2 0.9 ± 1.5 2 ± 3 1.6 ± 1.7 0.2 ± 0.5 –0.9 ± 1.6 –0.7 ± 0.9 0.2 ± 1.5 –0.7 ± 0.7 –0.6 ± 0.5 0.6 ± 2 0.7 ± 2
Current Use of Any
Prosthesis
Do Not Use 0 0 50 20 10 50 040 36 50 50 30 22
Current Use 100 100 50 80 90 50 100 60 64 50 50 70 76*
Note: No carpal limb loss in Vietnam group. Data may not add to 100% because of rounding.
*p < 0.05 for frequency by conflict.
†Comorbidities: 1 of 21 categories, such as arthritis, chronic back pain, depression, phantom pain, PTSD, stroke.
‡Limb-loss impact score: defined as values ranging from 0 (limb loss does not affect quality of life at all) to 5 (moderately affects) to 10 (strongly affects).
§Other combat injuries include eye, head, chest, abdominal, and nonamputated-limb injuries; burns; or hearing loss.
¶Cumulative trauma disorder (CTD) defined as any of following symptoms caused by overuse of nonamputated upper limb: carpal or cubital tunnel syndrome, ten-
donitis, epicondylitis, tenosynovitis, ganglion cyst, or osteoarthritis/degenerative joint disease.
**Activity measure: score from Rasch analysis of 21 activities of daily living task difficulties. More positive values indicate more difficult task done using prosthe-
sis, while negative values indicate tasks not done or done with assistance of another person.
Carpal = carpal disarticulation or partial hand, elbow = elbow disarticulation, PTSD = posttraumatic stress disorder, SD = standard deviation, shoulder = shoulder
disarticulation, wrist = wrist disarticulation.
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different ADL differed by limb level. Figure 1 shows the
percentages of these activities performed (using prosthesis,
one-handed techniques, or another person’s assistance) or
not performed. The Vietnam and OIF/OEF groups with
distal limb loss (wrist, transradial, and elbow) used pros-
theses for a similar proportion of ADL (21% vs 25%,
respectively). Of the OIF/OEF group, 21 percent with
transhumeral-level limb loss used a prosthesis for ADL
compared with 4 percent in the Vietnam group. Overall, for
proximal limb loss (higher than the elbow level), 37 per-
cent of the Vietnam group and 26 percent of the OIF/OEF
group performed ADL using their other hand rather than
relying upon their prosthetic devices.
The upper-limb activity scores were also associated
with the level of limb loss, with a trend for activity to
increase the more distal the limb-loss level (Figure 2). In
both groups, higher upper-limb activity scores were found
for the wrist and transradial limb-loss levels (Table 1),
whereas lower activity scores were found in the elbow,
transhumeral, and shoulder limb-loss levels. We did not
find a significant difference in upper-limb activity measure
by group: the mean activity score was 0.6 ± 2 for the Viet-
nam group and 0.7 ± 2 for the OIF/OEF group (p = 0.83).
Prosthetic Devices: Ever Received
The total number of upper-limb prosthetic devices
ever received by type of device and level of limb loss is
provided in Table 3 for the Vietnam and OIF/OEF groups.
As the mean time since limb loss to survey date was sig-
nificantly longer for the Vietnam group (39.1 ± 2.3 years)
than the OIF/OEF group (3.4 ± 1.0 years), the different
time periods at risk were adjusted by using person-years as
the denominator. In the first year after limb loss, the Viet-
nam group received a mean of 1.2 ± 0.5 devices (usually
mechanical/body-powered), while the OIF/OEF group
received a mean of 3.0 ± 1.6 devices (p < 0.001) (typically
one myoelectric/hybrid, one mechanical/body-powered,
and one cosmetic). In subsequent years, the Vietnam
group received significantly fewer upper-limb prostheses
per year (0.1 ± 0.1) than the OIF/OEF group (0.5 ± 0.8, p <
0.001). Rates for the first year after limb loss were higher
than mean annual rates thereafter in both groups, probably
Tab le 2.
Upper-limb activity-measure scores and statistics used for Rasch analysis.
Item*Measure Model SE Infit Mean Square Infit ZItem-Measure
Correlation
Dry Dishes with Towel 1.30 0.20 1.42 2.6 0.62
Peel and Cut Vegetable 0.99 0.19 1.38 2.4 0.63
Hand Wash Dishes 0.67 0.19 1.19 1.4 0.62
Operate Gauges and Dials 0.44 0.26 1.01 0.1 0.62
Use Cell Phone and Take Notes 0.40 0.27 1.04 0.3 0.61
Cut Meat 0.39 0.19 1.07 0.5 0.65
Butter Bread 0.34 0.19 0.93 –0.5 0.68
Open and Close Jar 0.23 0.23 0.95 –0.3 0.66
Low Aerobic Sports (golfing, fishing) 0.14 0.18 1.30 2.1 0.57
Shovel 0.11 0.18 0.77 –1.8 0.69
Fold Laundry 0.04 0.20 0.86 –1.1 0.68
Lace and Tie Shoes 0.01 0.19 0.96 –0.3 0.65
Open Lid of Can –0.02 0.22 0.89 –0.8 0.67
Fold Letter and Seal Envelope –0.11 0.24 0.88 –0.7 0.67
Use Power Tools –0.18 0.19 0.91 –0.7 0.64
Carry Tray –0.47 0.20 0.94 –0.4 0.62
Manage Zippers and Snaps –0.61 0.24 1.01 0.1 0.62
Open and Close Door, Trunk, and Hood –0.62 0.27 0.90 –0.5 0.65
Take Bill from Wallet –0.99 0.26 0.88 –0.7 0.61
Use Toothpaste and Brush Teeth –1.01 0.34 1.04 0.2 0.66
Drive –1.05 0.23 0.78 –1.6 0.66
Mean ± SD 0.00 ± –0.62 0.22 ± 0.04 1.00 ± 0.18 0.0 ± 1.2 —
*Dropped items: raking and high aerobic sports (basketball).
SD = standard deviation, SE = standard error.
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
because of limb adaptation and early rehabilitation adjust-
ments. Overall, the annual mean rate of all prosthetic
devices ever received was significantly higher for the OIF/
OEF group (1.6 ± 1.3 devices/person-year) than the Viet-
nam group (0.13 ± 0.11/person-year, p < 0.001) (Table 3).
Little effect of limb-loss level was noted, except for a
higher annual rate (3.3/person-year) for those with an
elbow disarticulation in the OIF/OEF group.
The patterns for upper-limb devices ever received, cur-
rently used, replaced, and rejected were different depend-
ing upon the type of device and by group (Figure 3). The
Vietnam group has received significantly more mechani-
cal/body-powered devices (89%) to date, and most of these
devices have worn out and been replaced. In contrast, the
OIF/OEF group has received more myoelectric/hybrid
(44%) and cosmetic devices (18%) and fewer mechanical/
body-powered devices (38%). In the OIF/OEF group, more
of the myoelectric/hybrid and mechanical/body-powered
devices were rejected instead of being in current use or
replaced because of daily wear and tear (Figure 3).
Prosthetic Devices: Current Use
The overall frequency of survey participants currently
using any type of prosthetic device was not significantly
different for the pre- and postdirective groups. Of the Viet-
nam group, 33 (70%) were currently using at least one
Figure 1.
Percent of 23 activities of daily living (ADL) performed by one of four methods by Operation Iraqi Freedom/Operation Enduring Freedom (OIF/
OEF) and Vietnam groups overall and according to level of unilateral upper-limb loss. Note: No hand limb loss in Vietnam group.
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upper-limb prosthetic device compared with 38 (76%) of
the OIF/OEF group (Table 1). However, the Vietnam group
used only an average of 0.8 ± 0.8 upper-limb prostheses
compared with 1.4 ± 1.7 in the OIF/OEF group (p = 0.001).
Of the 37 devices in use by the Vietnam group, 78 percent
were mechanical/body-powered, 14 percent were myoelec-
tric/hybrid, and 8 percent were cosmetic (Table 3). Of the
69 devices in use by the OIF/OEF group, significantly
fewer were mechanical/body-powered (38%, p < 0.001)
and significantly more (46%) were myoelectric/hybrid. Use
of cosmetic devices was similar for both the Vietnam and
OIF/OEF groups. Prosthesis use by type of upper-limb
device is presented in Table 3 by level of limb loss. Myo-
electric/hybrid devices were used more frequently by the
OIF/OEF group for the transradial limb-loss level. In con-
trast, more myoelectric/hybrid devices were used by the
Vietnam group for the transhumeral limb-loss level.
Assistive Devices
We asked participants what upper-limb assistive
devices they currently used (Table 4). The number of
participants who used any type of upper-limb assistive
device was similar in the Vietnam group (30%) and the
OIF/OEF group (44%). A variety of assistive devices was
used, most frequently adaptors for sporting activities
(significantly more in the OIF/OEF group, 36% com-
pared with 2% in the Vietnam group), grasping tools,
computer adaptations, kitchen or cooking devices, and
car steering wheel knobs. No significant differences were
found by type of assistive device by level of limb loss.
Prosthetic Devices: Replaced
Upper-limb prosthetic devices needing replacement
because of wear and tear or breakage are presented in
Table 3 by level of limb loss and group. We have data on
Figure 2.
Mean upper-limb activity measure score by Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) groups. More posi-
tive score indicates combination of more strenuous activities of daily living usually done using prosthesis. More negative values indicate less
strenuous activities usually not done or done with assistance. Note: No hand limb loss in Vietnam group.
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
replaced and rejected devices for 232/250 of the Vietnam
group and 200/228 of the OIF/OEF group. In the Vietnam
group, significantly more (141/232, 60.8%) upper-limb
prosthetic devices were replaced because of wear and
tear than in the OIF/OEF group (41/200, 20.5%, p <
0.001). Not surprisingly, most of the devices replaced in
the Vietnam group were mechanical/body-powered
(95%); in the OIF/OEF group, the distribution by device
types was similar. Most levels of upper-limb loss were
not associated with higher replacement frequency, except
for the transhumeral level, at which significantly more
mechanical/body-powered devices were replaced in the
Vietnam group. More cosmetic devices wore out in the
OIF/OEF group at the transhumeral level.
Table 3.
Frequency of number of prosthetic devices by use for Vietnam and OIF/OEF groups with unilateral upper-limb loss by level of limb loss (data
presented as percent unless otherwise noted).
Outcome Carpal Wrist Transradial Elbow Transhumeral Shoulder Total
OIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF
No. Persons 3 6 4 15 20 2 3 20 14 4 6 47 50
Prosthetic Devices
Ever Received
Rate*1.30 ±
0.76 0.17 ±
0.13 2.02 ±
1.60 0.17 ±
0.12 1.42 ±
0.84 0.06 ±
0.05 3.3 ±
4.04 0.12 ±
0.11 1.5 ±
1.18 0.10 ±
0.07 1.07 ±
0.73 0.13 ±
0.11 1.6 ±
1.3
Range 1–8 2–16 2–15 1–19 1–9 1–4 3–8 1–14 0–15 1–7 2–5 1–19 0–15
Myoelectric 520 15 30 38 0 3 40†28 10 10 434†
Hybrid 0 0 0 25 17 0 9 12 56 62 17 310†
Mechanical/
Body-Powered 615 12 40 45 2 8 39†27 3 2 89†38
Cosmetic 710 15 50 36 010 20 19 20 12 418†
Total (No.) 12 37 28 99 88 515 94 66 15 19 250 228
Prosthetic Devices
Currently Used
Myoelectric/
Hybrid 020 320 44†0 6 40†34 20 12 14 46†
Mechanical/
Body-Powered 821 838 58 3 4 34 23 3 0 78†38
Cosmetic 9 0 9 33 45 018 33 033 18 816
Total (No.) 3 7 4 13 34 1 5 13 17 3 6 37 69
Prosthetic Devices
Replaced‡
Myoelectric/
Hybrid 0 0 46 50 46 0 0 50 8 0 0 1 32†
Mechanical/
Body-Powered 21 18 21 44 36 2 7 34†14 2 0 95†35
Cosmetic 017 750 36 014 736†17 7 4 34†
Total (No.) 325 10 62 16 3 3 47 8 4 1 141 4 1
Prosthetic Devices
Rejected‡
Myoelectric/
Hybrid 912 912 22 0 2 12 41†62 17 15 51†
Mechanical/
Body-Powered 0 4 16 35†28 212 52†38 6 6 85†36
Cosmetic 8 0 8 0 42 0 0 0 25 017 013†
Total (No.) 5 3 10 17 24 1 5 25 34 812 54 90
Note: No carpal limb loss in Vietnam group.
*Annual rate of all upper-limb prosthesis ever received (mean ± SD).
†p 0.05 for frequency by conflict.
‡Nonresponse for 18 in Vietnam group and 28 in OIF/OEF group for replaced and rejected devices.
Carpal = carpal disarticulation or partial hand, elbow = elbow disarticulation, OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, V = Vietnam,
SD = standard deviation, shoulder = shoulder disarticulation, wrist = elbow disarticulation.
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Average replacement times were different by type of
device. The Vietnam group reported a trend for using
myoelectric/hybrid devices longer before replacement
(100% reported 3 years or longer) than the OIF/OEF
group (only 12% reported 3 years or longer, p = 0.08).
The Vietnam group also reported using mechanical/body-
powered devices significantly longer before replacement
(92% reported “replaced every 3 years or longer”) than
the OIF/OEF group (11% “replaced every 3 years or
longer” [p < 0.001]; 89% replaced myoelectric/hybrid
devices in under 2 years). The mean time of replacement
for cosmetic devices averaged 1 to 2 years for both the
Vietnam and OIF/OEF groups.
Prosthetic Devices: Rejected
We also collected data on the number of prosthetic
devices rejected over the lifetime (i.e., no longer used
because of dissatisfaction or problems) and found signifi-
cantly different patterns between the two groups. In the
OIF/OEF group, significantly more (90/200, 45%) of all
prosthetic devices ever received were rejected than in the
Vietnam group (54/232, 23%, p < 0.001). In the Vietnam
group, 85 percent of the rejected upper-limb devices were
mechanical/body-powered, whereas in the OIF/OEF
group 51 percent of the rejected devices were myoelec-
tric/hybrid and 13 percent were cosmetic (Table 3).
Rejection of mechanical/body-powered upper-limb
devices was significantly more frequent in the Vietnam
group for transradial and transhumeral limb-loss levels
(35% and 52%, respectively). In contrast, OIF/OEF
members with transhumeral level limb loss rejected sig-
nificantly more myoelectric/hybrid upper-limb devices
(41%). The most common reasons for rejection are
shown in Figure 4 by group and type of prosthetic
Figure 3.
Fate of upper-limb prosthetic devices by type of prosthesis for Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF)
groups with unilateral upper-limb loss. *p < 0.05 compared with other group in same category and device-type group.
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
device. Myoelectric/hybrid devices were most frequently
rejected because of pain (23% in Vietnam group and 11%
in OIF/OEF group), whereas mechanical/body-powered
upper-limb devices were rejected because of poor com-
fort (11% in Vietnam group and 8% in OIF/OEF group).
Cosmetic devices were rejected because of a lack of
functionality (22% in OIF/OEF group). The reasons for
device rejection did not differ significantly by amputa-
tion level (data not shown).
Prosthetic Devices: Abandoned
Some members of the Vietnam and OIF/OEF groups
with unilateral upper-limb loss completely discontinued
use of any type of upper-limb prosthetic device. Of the
Vietnam group, 14/47 (30%) of participants completely
abandoned the use of all prosthetic devices for their upper
limb (Table 1). Of the Vietnam group, shoulder- and
elbow-level limb loss had the highest frequency of aban-
donment (50%). The Vietnam group used prosthetic
devices for a mean of 4 ± 8.2 years before abandoning
them (range = 2 months to 30 years of use). The most fre-
quent reason for abandoning all devices was “too much
fuss” (57%); other reasons included pain, weight of the
device, short residual limbs (could not support device), and
the need to use residual limbs. All but one had comorbid
conditions including CTD (65%) and other combat injury
problems (14%) or chronic back pain (data not shown).
Of the OIF/OEF group, 11/49 (22%) of participants
completely abandoned the use of all prosthetic devices
for their upper limb (one person never received any pros-
theses). Shoulder, elbow, and wrist levels had the highest
frequency of abandonment (Table 1). Most tried a variety
of prosthetic types before abandoning the use of all pros-
thetics: 9 (82%) tried myoelectric/hybrid, mechanical/
body-powered, and/or cosmetic devices, while 2 had
tried only myoelectric/hybrid devices. The OIF/OEF
group used prosthetic devices for a mean of 8 ± 7 months
before abandoning them (range = 1 month to 1 year of
use). The most frequent reasons for abandoning all
devices were “residual limbs were too short” (30%), pain
(20%), weight of the device (20%), too much fuss (10%),
or inability to control the device (10%). Fewer in the
OIF/OEF group had CTD (30%) or other combat injury
problems (10%) than in the Vietnam group, but the dif-
ference was not significant (data not shown).
Multivariate Models Predicting Activity
Separate multivariate linear regression models were
evaluated for each group (Table 5). In the Vietnam
group, higher upper-limb activity was associated with the
Table 4.
Survey participants’ use of upper-limb assistive devices in Vietnam and OIF/OEF groups with unilateral upper-limb loss (data presented as per-
cent unless otherwise noted).
Outcome Carpal Wrist Transradial Elbow Transhumeral Shoulder Total
OIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF VOIF/
OEF
No. Persons 3 6 4 15 20 2 3 20 14 4 6 47 50
None 67 67 0 67 65 50 67 70 50 100 67 70 56
Any Assistive Device 33 33 100 33 35 50 33 30 50 0 33 30 44
Kitchen or Cooking Device 0 17 50 13 15 0 0 20 7 0 17 15 14
Dressing Attachment 33 17 0 7 10 50 0 0 7 0 0 6 8
Eating Attachment 0 17 25 7 5 50 0 10 7 0 17 11 8
Household Device 0 0 25 0 5 0 0 10 0 0 0 4 4
Car Modifications*0 17 25 13 10 50 0 5 14 0 33 11 14
Grasping Tool Device 0 0 50 13 20 0 0 5 21 0 0 6 18
Computer Modifications 0 0 25 7 10 0 33 10 21 0 17 6 16
Telephone Attachment 0 0 0 7 0 0 0 0 0 0 0 2 0
Sports Device†67 0 50 0 40 0 0 5 43 0 0 2 36‡
Other Work Devices 0 0 50 13 15 0 33 5 14 0 17 6 18
Note: No carpal limb loss in Vietnam group.
*Car modifications for unilateral upper limbs included steering wheel knob (100%).
†Sports terminal devices included gloves and adaptors for sports such as golfing, fishing, skiing, bicycling, archery, and bowling.
‡p 0.05 for frequency by conflict.
Carpal = carpal disarticulation or partial hand, elbow = elbow disarticulation, OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, V = Vietnam,
shoulder = shoulder disarticulation, wrist = elbow disarticulation.
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use of mechanical/body-powered prosthetic devices
(adjusted odds ratio [aOR] = 2.66). Four variables were
associated with significantly lower upper-limb activity
level: a higher number of comorbidities (aOR = 0.73),
rotator-cuff tendonitis in the opposite shoulder of the
limb loss (aOR = 0.30), arthritis (aOR = 0.25), and trans-
humeral-level limb loss (aOR = 0.15). In contrast, in the
OIF/OEF group, one variable was significantly associ-
ated with higher upper-limb activity: current use of
mechanical/body-powered prosthesis (aOR = 3.39) and
one was associated with lower activity: transhumeral-
level limb loss (aOR = 0.50). No significant interactions
were found for either model, and other variables investi-
gated in the univariate analysis were not significant in the
multivariate analysis (age, sex, race, number or type of
combat injuries, PTSD, TBI, self-rated health, prosthetic-
device satisfaction factors, pain, or mental-health scores).
DISCUSSION
Our survey offered a unique opportunity to determine
upper-limb prosthetic-device use patterns for two distinct
groups of servicemembers with combat-associated unilat-
eral upper-limb loss. The Vietnam group has the benefit
of long experience with prostheses, while the OIF/OEF
group benefits from the availability of more advanced
technologies and improvements in treatments for injuries
in the combat field. These improvements include changes
in body armor; improvements in combat casualty care,
Figure 4.
Reasons for upper-limb prosthetic-device rejection by device type for Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/
OEF) groups. Myo = myoelectric/hybrid, Mech = mechanical/body-powered, Cosm = cosmetic.
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
including the use of artificial blood and rapid evacuation
to combat field hospitals; newer myoelectric/hybrid pros-
thetic-device technologies; and state-of-the-art rehabilita-
tion techniques [9,28–30]. Improved body armor and
protective vests have increased survival rates after blast
injuries, resulting in an increase in the survival of more
severely injured servicemembers. The DOD rehabilitation
programs at Walter Reed Army Medical Center, Brooke
Army Medical Center, and the Naval Medical Center San
Diego have also implemented a paradigm shift, increasing
the duration and complexity of rehabilitation programs,
including the availability of technologically advanced
prostheses. Special programs are also in place for
wounded servicemembers with upper-limb loss, including
the Defense Advanced Research Projects Agency [31–33]
and the Occupational Therapy Section at Fort Indepen-
dence, which is developing competencies for the perfor-
mance of ADL [34].
Unilateral upper-limb loss accounts for 16 percent of
our Vietnam survey study cohort and 18 percent of our
OIF/OEF survey study cohort [19]. An important outcome
of the DOD rehabilitation paradigm shift is the provision
of three technologically advanced upper-limb prostheses:
myoelectric/hybrid, mechanical/body-powered, and cos-
metic or passive devices. Unique to this shift is that the
myoelectric/hybrid prostheses are typically provided first,
followed by the mechanical/body-powered, and then cos-
metic prostheses. Traditionally (in the Vietnam war era),
mechanical/body-powered prostheses were provided ini-
tially, which was problematic because use of a mechani-
cal/body-powered prosthesis requires the surgical site to
be healed and the residual limb shaped and desensitized.
Subsequent studies have shown a positive relationship
between early fitting, satisfaction, and use [3,6,31,35–40].
An additional benefit of myoelectric/hybrid prosthesis use
has been the reduction in phantom limb pain [41]. How
these shifts in medical care and availability of advanced
technologies may improve upper-limb function is not
known.
Returning to pre-limb-loss activities may indicate
restoration of normal functioning. In the case of OIF/
OEF servicemembers wounded in combat, return to
Active Duty is encouraged. In the Vietnam conflict, only
3 percent of servicemembers with upper- or lower-limb
amputations returned to duty after rehabilitation [30]. We
found 14 percent of our OIF/OEF study group with
upper-limb loss returned to Active Duty, which demon-
strates a positive effect of the DOD paradigm shift in
rehabilitation goals.
Age-related or combat-associated comorbidities may
complicate the recovery process. The Vietnam group had a
mean of 4 ± 3 comorbidities, and the OIF/OEF group,
though younger, had a mean of 5 ± 3 comorbidities. In the
civilian population with upper- or lower-limb loss, Pezzin
et al. reported a mean of 5 ± 2 comorbidities for people
with dysvascular-related limb loss and 2 ± 2 comorbidities
for trauma-related limb loss [3]. The mean number of
comorbidities of individuals with military-service-
connected limb loss is more similar to an older, dysvascular
disease group than a non-service-connected, trauma-related
limb loss group. CTD, or worn-limb syndrome, is fre-
quently found in people with unilateral upper-limb loss
[12,42]. Black et al. found that 53 percent of unilateral
upper-limb patients using a prosthetic device had pain in
their remaining arm, most of which was associated with
CTD [43]. CTD and overuse injuries are also estimated to
be three times more likely in people with unilateral upper-
limb loss than in the general workforce, in which CTD is
also frequently reported [43–47]. In our study’s two groups,
CTD was significantly higher (60%) in the Vietnam group,
who are 40 years from their limb loss, than in the OIF/OEF
group (38%), who are 3 to 4 years from their limb loss. As
CTD takes time to develop, we may see an increase in
CTD in the OIF/OEF group as they age, or perhaps CTD
will occur less frequently in this group because the use of
Table 5.
Multivariate regression models assessing variables associated with
upper-limb activity for Vietnam and OIF/OEF groups with unilateral
upper-limb loss.
Variable aOR 95% CI p-Value
Vietnam Group
No. Currently Used
Mechanical/Body-Powered
Prostheses
2.66 1.14–6.21 0.02
No. of Comorbidities 0.73 0.57–0.93 0.01
Rotator Cuff Tendonitis on
Contralateral Arm 0.30 0.08–1.02 0.05
Arthritis 0.25 0.06–0.99 0.05
Transhumeral Level 0.15 0.05–0.48 0.002
OIF/OEF Group
No. Currently Used
Mechanical/Body-Powered
Prostheses
3.39 1.98–5.80 0.001
Transhumeral Level 0.50 0.16–1.11 0.08*
Note: Goodness of fit: Vietnam model, F statistic = 11.6, p < 0.001; OIF/OEF
model, F statistic = 16.0, p < 0.001.
*Inclusion resulted in better fitting model.
aOR = adjusted odds ratio, CI = confidence interval, OIF/OEF = Operation
Iraqi Freedom/Operation Enduring Freedom.
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multiple types of prosthetic devices has a protective effect.
Efforts that spare overuse on the nonamputated upper limb
need to be more thoroughly researched to limit the develop-
ment of this complication.
The ability to perform routine ADL largely depends
upon the upper limbs. Unlike instruments for lower-limb
loss functional levels, which measure function by ambu-
latory ability, no standard tool has been recognized for
upper-limb loss functional levels. Upper-limb function
instruments are being developed for children [48] and
adults [49] with limb loss but have not been fully vali-
dated. We measured upper-limb activity using Rasch
analysis with ADL. A national survey of adults with
upper- and lower-limb loss (37% due to vascular condi-
tions and 39% due to trauma), of whom only 11 percent
had upper-limb loss, indicated that 30 percent of the sam-
ple experienced difficulty with bathing and 7 percent
required help with ADL [42]. In our survey, an even
higher percentage of both Vietnam and OIF/OEF groups
with upper-limb loss reported they required assistance
with ADL (34% and 36%, respectively). A surprisingly
large proportion of our survey participants with upper-
limb loss did not use an upper-limb prosthetic device;
rather, they switched to the other hand to perform routine
activities.
Ours is the first known study to use multivariate
adjusted methods to investigate the relationship between
factors associated with upper-limb activity in combat-
associated upper-limb loss. Mechanical/body-powered
upper-limb prostheses were associated with higher upper-
limb activity measures, but myoelectric/hybrid or cos-
metic prostheses were not. Transhumeral-level limb loss
was negatively related to higher activity measure in both
groups, suggesting servicemembers and veterans with
limb loss at high levels have more difficulty performing
ADL. Lower upper-limb activity scores were associated
with more comorbid conditions (total number, CTD, and
arthritis) but only for the older Vietnam group. When
these factors are examined to plan areas for improving
upper-limb activity, little can be done about the site of the
limb loss, but efforts may be focused on other types of
upper-limb prostheses to improve use and to reduce the
development of CTD in the nonamputated upper limb
(especially since this limb is used for routine activities
rather than the limb with the amputation).
One challenge in comparing research investigating
use of prosthetic devices is inconsistency in the defini-
tions of prosthetic-device “use” [50]. Prosthetic-device
use has been measured with both continuous scales
(counting days/week and hours/day the prosthesis is
worn) and categorical scales (regularly, a lot of the time,
all the time, occasionally, not at all, never) [12,42,51–52].
In our study, we collected both the number of each type of
upper-limb prosthesis used and the frequency used (daily,
weekly, monthly, yearly). Most participants reported use
of an upper-limb prosthesis (70% of Vietnam and 76% of
OIF/OEF groups), but differences were found by group
according to the type of upper-limb device. Confounding
investigation of prosthetic use is the type of prosthesis
used. A person with upper-limb loss may have more than
one type of prosthesis, each with different use patterns.
Early research did not mention type of prosthesis, pre-
sumably because mechanical/body-powered prostheses
were all that were available [12]. Biddiss et al. collected
data from 242 people with non-combat-associated limb
loss from the United States, Canada, and the Netherlands,
asking about devices tried, devices currently used, and the
primary device [53]. In this study, 81 percent were using
myoelectric/hybrid prostheses, 58 percent were using
mechanical/body-powered, and 33 percent were using a
passive hand. In our study, we did document a shift in the
type of upper-limb prostheses used. While most of the
Vietnam group used mechanical/body-powered upper-
limb prostheses (78%), the OIF/OEF group used signifi-
cantly more myoelectric/hybrid prostheses (46%),
supporting the effect of the DOD paradigm shift.
The evidence that the level of limb loss is associated
with prosthetic-device use is conflicting; however, the
majority of findings support a positive relationship. Peo-
ple with more proximal and below-wrist-level loss are
less likely to use their prostheses than those with transra-
dial disarticulations [11]. Reasons may include a longer
prosthesis that is heavier and requires more energy expen-
diture or shorter residual limbs that provide less sensory
information important for function [40]. In a survey of
people with upper-limb loss (non-combat-associated),
those with more proximal limb loss were more likely to
use mechanical/body-powered prostheses [53]. In our
study, in both the Vietnam and OIF/OEF groups, a lower
percentage of participants with upper-limb loss with more
proximal amputations (transhumeral and shoulder) cur-
rently used prostheses.
The reasons why different types of upper-limb prosthe-
ses are rejected are beginning to be understood. In one
study, 39 percent of myoelectric/hybrid, 50 percent of
mechanical/body-powered, and 53 percent of cosmetic
devices were rejected [53]. Datta et al. found in 80 partici-
pants that 34 percent rejected their upper-limb prosthetic
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MCFARLAND et al. Unilateral upper-limb loss: Satisfaction and prosthetic-device use
devices [12]. Reasons given for rejection were pain, no
functional benefit, poor cosmesis, and weight of the pros-
thesis. In our study, rejection or dissatisfaction with the
upper-limb prosthesis was associated with the type of pros-
thetic device and the level of limb loss. Myoelectric/hybrid
upper-limb devices were often rejected because of their
heavy weight, pain, and lack of comfort. Mechanical/body-
powered upper-limb devices were rejected because of their
heavy weight, lack of comfort, pain, and poor fit. Cosmetic
upper-limb devices were rejected mainly because of lack of
functionality. More proximal limb-loss levels had a higher
proportion of device rejection (transhumeral and shoulder)
than more distal levels (transradial, wrist, and partial hand).
Advances in lighter upper-limb prosthetic devices for
higher limb-loss levels are needed to improve comfort,
lighten weight, and increase use of upper-limb prostheses.
Dealing with limb loss is difficult in and of itself
without having to deal with the complications and routine
of using a prosthetic device. In contrast to people with
lower-limb loss, a significant proportion of people with
upper-limb loss completely abandon use of all prostheses
and rely upon their nonamputated upper limb to perform
daily tasks. Unfortunately, reliance upon the uninjured
arm often results in CTD or fatigue due to overuse. Of
60 people with upper-limb loss surveyed in the United
Kingdom, 45 percent developed shoulder pain in the con-
tralateral upper limb and 35 percent abandoned using
their prosthetic devices [12]. In another study of 242 peo-
ple with upper-limb loss, 20 percent abandoned pros-
thetic devices [11]. In our study, 30 percent of the
Vietnam group and 22 percent of the OIF/OEF group
completely abandoned upper-limb prostheses. Although
the Vietnam group used prosthetic devices for a longer
time (average 4 years) before abandonment than the OIF/
OEF group (average 8 months), the reasons were similar
(pain, weight, fuss), and most of those who abandoned
prosthetic devices had other comorbid complications.
More research is needed to elucidate preventable reasons
for upper-limb prostheses abandonment and policies to
correct deficiencies.
One limitation to our survey is the concern over gen-
eralizability. All of our study participants were active ser-
vicemembers in combat-field operations at the time of
their limb loss. Several things can cause upper-limb loss:
congenital conditions [10–11,54–55], non-combat-
related trauma [10,12,56–57], complications from infec-
tions [10,58], dysvascular conditions [3,10], or combat-
associated injuries [9]. Surveys from non-combat-associ-
ated upper-limb loss populations show similar trends for
prosthetic-device use as our population. Recruiting sub-
jects with trauma or congenital upper-limb loss from the
National Amputee Statistical Database for the United
Kingdom, Datta et al. studied 60 upper-limb loss subjects
who had a mean age of 58 years and were 24 years from
their limb loss [12]. Most (73%) had returned to work,
45 percent developed CTD, and 29 percent no longer
used a prosthesis regularly. Biddiss and Chau recruited
242 Canadian subjects with upper-limb loss from health-
care providers, support organizations, and a prosthesis
manufacturer [11]. Most (79%) of them had lost the
upper limb because of congenital conditions, 20 percent
abandoned upper-limb prostheses, but 64 percent
reported frequent prosthetic-device use. Pezzin et al.
recruited 935 subjects in the United States with upper- or
lower-limb loss from the Amputee Coalition of America
registry; 362 of the participants had trauma-related limb
loss, and 10 percent had upper-limb loss [3]. Although
detailed upper-limb data were not specifically presented,
few differences were noted for current use, whether the
cause was dysvascular, trauma, or cancer. Comparison of
our two combat-associated groups to population-based
surveys that encompass all origins of upper-limb loss
shows more diversity in the levels of limb loss in combat-
related limb loss.
CONCLUSIONS
The soldiers from Vietnam and those returning from
OIF/OEF with upper-limb loss are in a position to influ-
ence current clinical care practice and research focuses.
Clinical implications and limitations of these two groups
are different. The Vietnam group is dealing with the
effects of aging, reliance upon the contralateral arm that
may have CTD, and the presence of other comorbidities,
but their advantage is they have usually adjusted to life
with upper-limb loss and have done well. The OIF/OEF
group faces challenges that include balancing the reha-
bilitation of the lost limb in conjunction with other com-
bat injuries and combat-related comorbidities with the
wish to return to an active lifestyle.
ACKNOWLEDGMENTS
Author Contributions:
Study concept and design: L. V. McFarland.
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Acquisition of data: L. V. McFarland, M. Jones.
Analysis and interpretation of data: L. V. McFarland, S. L. Hubbard
Winkler, A. W. Heinemann, M. Jones, A. Esquenazi.
Drafting of manuscript: L. V. McFarland, S. L. Hubbard Winkler,
A. W. Heinemann.
Critical revision of manuscript for important intellectual content:
L. V. McFarland, S. L. Hubbard Winkler, A. W. Heinemann,
A. Esquenazi.
Statistical Analysis: L. V. McFarland, A. W. Heinemann.
Financial Disclosures: The authors have declared that no competing
interests exist.
Funding/Support: This material was based on work supported by VA
Health Services Research and Development Service (grant IIR 05-
244) and a Career Scientist Award to Dr. Reiber (grant RCS 98-353).
The views expressed in this article are those of the authors and do not
necessarily reflect the position or policy of the VA or DOD.
Additional Contributions: Special thanks to Jane Emens for admin-
istrative support on this project, Juliana Bondzie and Koriann Brous-
seau for recruitment, and all the Vietnam and OIF/OEF survey
participants. Melissa Jones, PhD, OTR/L, CHT, LTC, U.S. Army
(retired), is now at Landstuhl Regional Medical Center, Germany.
Institutional Review: Institutional and human subjects approvals
were received from VA and DOD.
Participant Follow-Up: The authors do plan to notify study subjects
of the publication of this article.
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Submitted for publication March 16, 2009. Accepted in
revised form June 10, 2009.
