Comparison of satisfaction with current prosthetic care in veterans and servicemembers from Vietnam and OIF/OEF conflicts with major traumatic limb loss.
Subject: Amputation (Usage)
Amputation (Health aspects)
Disabled veterans (Care and treatment)
Implants, Artificial (Usage)
Implants, Artificial (Health aspects)
Prosthesis (Usage)
Prosthesis (Health aspects)
Authors: Berke, Gary M.
Fergason, John
Milani, John R.
Hattingh, John
McDowell, Martin
Nguyen, Viet
Reiber, Gayle E.
Pub Date: 07/01/2010
Publication: Name: Journal of Rehabilitation Research & Development Publisher: Department of Veterans Affairs Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 Department of Veterans Affairs ISSN: 0748-7711
Issue: Date: July-August, 2010 Source Volume: 47 Source Issue: 4
Product: Product Code: 9105601 Veterans Pensions & Disability NAICS Code: 92314 Administration of Veterans' Affairs SIC Code: 3842 Surgical appliances and supplies
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 241861747
Full Text: INTRODUCTION

One of the highest priorities for the U.S. Department of Defense (DOD) and Department of Veterans Affairs (VA) is provision of expert rehabilitation care, including prosthetic services, for veterans and servicemembers who suffered major traumatic limb loss in combat zones. The goal of prosthetic rehabilitation is to maximize function and quality of life [1]. Servicemembers from recent conflicts in Iraq and Afghanistan (Operation Iraqi Freedom/Operation Enduring Freedom [OIF/OEF]) typically receive state-of-the-art rehabilitation and prosthetic care from three major DOD sources: Walter Reed Army Medical Center, Brooke Army Medical Center, and Naval Medical Center San Diego. Some DOD prosthetic services are also provided by private contractors within DOD facilities. Prosthetic prescriptions for Active Duty servicemembers are developed in a multidisciplinary clinic with input from multiple professional services. Prescriptions are based on demonstrated participation in reaching rehabilitation goals, and specialty limbs are considered to augment participation in activities that can be tied to rehabilitation goals.

Many OIF/OEF servicemembers and all Vietnam veterans have transitioned from DOD to VA. Almost all now receive prosthetic care directly from VA or from private providers under contract with VA. There are 61 large VA medical centers with credentialed VA prosthetists providing in-house prosthetic services [2-3]. In other areas, veterans are first seen within the VA system where they are linked to local credentialed and contracted prosthetic providers with specific prosthetic prescriptions. Veterans retain the right to choose between private VA-funded prosthetic contractors and receiving prosthetic services from a VA laboratory.

Our recent national Survey for Prosthetic Use (Appendix 1, available online only) queried Vietnam and OIF/ OEF veterans and servicemembers with major combat-associated limb loss. One of the goals of the survey was to determine who used prostheses, the location where they received prosthetic care, what services were received, and their satisfaction with prostheses and prosthetic services--an increasingly important healthcare quality measure [1]. While changes in surgical techniques, rehabilitation processes, technology, and new materials may contribute to differences in prosthetic satisfaction between Vietnam and OIF/OEF participants, the extent to which these have improved veterans' and servicemembers' prosthetic-device satisfaction has not been evaluated. Therefore, the purpose of this article was to evaluate the experience and satisfaction with prostheses and prosthetic services for Vietnam and OIF/OEF participants with major traumatic limb loss.

METHODS

Participants in this study were 298 veterans from the Vietnam conflict and 283 servicemembers and veterans from the OIF/OEF conflict with major traumatic limb loss who were surveyed during 2007 and 2008. Veterans and servicemembers with major limb loss occurring during the Vietnam (1961-1973) or OIF/OEF (2001-2008) conflicts were invited to participate in a survey on prosthetic use. All servicemembers with major limb loss from OIF/ OEF, all Vietnam veterans with unilateral upper-limb loss and multiple limb loss, and a sample of Vietnam veterans with unilateral lower-limb loss were invited to participate. Servicemembers from OIF/OEF had to be at least 1 year from limb loss. Participants took the survey by one of three methods (mail, telephone interview, or Web site). Great care was taken to ensure that the method of survey participation did not affect results. A detailed description of the study methods is found in another article in this issue [4], which will further outline the limitations of methodology, number of participants, and nonrespondent rates. A generic version of the Survey for Prosthetic Use, including both upper- and lower-limb loss sections, is available in Appendix 1 (available online only).

Excluded from this analysis were 65 Vietnam and 27 OIF/OEF servicemembers who abandoned or never used prostheses, including individuals using wheeled mobility. The reasons for abandonment are discussed in separate articles in this issue [5-7]. Of the 233 Vietnam and 256 OIF/OEF participants included in this study, 3 Vietnam participants and 5 OIF/OEF participants had incomplete satisfaction data and thus were excluded. This article presents data from 230 Vietnam and 251 OIF/OEF participants.

The Survey for Prosthetic Use was developed to address key issues for veterans and servicemembers with major upper- and lower-limb loss by a group of rehabilitation and surgery clinicians and researchers. Participants answered questions on health, combat injuries, and site and level of limb loss (unilateral upper limb, unilateral lower limb, and multiple limb). Pain questions included phantom and residual-limb pain, chronic back pain, and pain associated with prostheses. Participants self-reported past and current use of prostheses by prosthesis type from the time of their initial limb loss to the present. They also identified their current source(s) of prosthetic care; overall satisfaction with their current prostheses, ranging from 0 (not at all satisfied) to 10 (completely satisfied); experiences with prosthetic services; the timeliness of prosthetic repair and replacement; and issues with prosthetic sockets, prosthetic fit, comfort, pain, and nuisances. Patients with multiple limb loss and prostheses were asked specific questions regarding each limb and the prosthetic devices used for each limb. The survey was reviewed by prosthetic and rehabilitation experts including members of the study Expert Panel for content validity before being piloted on 24 men and women with traumatic or combat-related limb loss. After refinements to the survey questions, the survey was piloted on servicemembers with major traumatic limb loss from the Desert Storm conflict.

We should note that prosthetic satisfaction and overall satisfaction are different measured parameters within this article. Overall satisfaction is a measure of the comprehensive aspects of care: site of service, ability to receive timely appointments, and rehabilitation and prosthetic care. Prosthetic satisfaction is a measure of prosthetic fit, function, comfort, weight, smell, noise, skin problems, and desire to change to a different prosthesis type.

ANALYSIS

We analyzed the findings for veterans and servicemembers by type of limb loss: unilateral upper, unilateral lower, and multiple limb loss. In those with multiple limb loss, we analyzed prosthetic-device data for each involved limb. Prosthetic-device data were analyzed for two time intervals: the first year following limb loss and all subsequent years. This article presents data on participants using prostheses at the time they participated in the survey. Our descriptive analysis examined the source(s) of prosthetic care (DOD, VA, private, or multiple sources) for the Vietnam and OIF/OEF groups. Univariate analyses using Stata 9.2 (StataCorp; College Station, Texas) measured overall satisfaction and 21 specific parameters that influence prosthesis satisfaction. Statistical significance (two-sided test with p < 0.05) was based on chi-square (categorical data), Mann-Whitney U-test (ordinal data), Student t-test (continuous data), and Fisher exact test if cell size [less than or equal to] 5. Wilcoxon rank sum scores were used for variables matched on type of limb loss. We computed correlations between specific satisfaction parameters and the overall prosthetic satisfaction ranking for veterans and servicemembers from both conflicts.

RESULTS

Vietnam participants in our survey averaged 61 years of age, were exclusively male, and were 81 percent Caucasian. The average time since limb loss was 39 years. OIF/OEF participants averaged 29 years of age, 3 percent were female, and 73 percent were Caucasian. No Vietnam veteran participants were on Active Duty. Of the OIF/OEF cohort, 20.5 percent reported being on Active Duty and an additional 8.5 percent were still in rehabilitation more than 1 year after their limb loss. Full- or part-time employment was reported by 79 percent of Vietnam and 54 percent of OIF/OEF participants, with an additional 23 percent of OIF/ OEF participants identified as students. Additional demographic data is reported elsewhere [4]. Overall, 78.2 percent of Vietnam and 90.5 percent of OIF/OEF participants in the survey used their prostheses on a participant-defined "regular basis" (Figure).

Source of Prosthetic Care

Table 1 shows the source of prosthetic care by conflict. A majority of participants from both conflicts receive care from private sources. In the Vietnam group, VA provides the next highest portion of care, whereas in the OIF/OEF group, nearly 40 percent receive care from DOD.

Thus, private providers under contract with VA were the most common source of prosthetic care for participants from both conflicts.

Table 1 also shows participants' overall prosthesis satisfaction by conflict, level of amputation, and source of care. Satisfaction rankings were uniformly higher for participants receiving private-contract care than those receiving VA care for Vietnam veterans and for OIF/OEF participants with unilateral upper- and lower-limb loss, but not multiple limb loss. The cumulative prosthetic satisfaction score was 7.0 for Vietnam and 7.5 for OIF/OEF.

[FIGURE OMITTED]

Table 2 compares survey participants' satisfaction with their prosthetic care by source of care. Participants were generally able to get an appointment with their prosthetist when needed and were largely satisfied with their training regardless of conflict or source of care. Overall, survey participants from OIF/OEF reported higher satisfaction with their prosthetic care providers and services than participants from the Vietnam conflict. Less than half of all participants from both conflicts and all sites of service indicated they receive adequate information on new types of prostheses on a regular basis. Table 2 also shows that significant differences were present among Vietnam veterans in "having a role in choosing my prosthesis," with 73 percent of private-care participants involved and only 54 percent of VA patients involved. A higher percentage of OIF/OEF participants wanted to try a different type of prosthesis on a trial basis and change their current prosthesis to another type. Also, fewer private-care Vietnam participants indicated they wanted to "change their prosthesis to another type" (60% VA vs 36% private, p < 0.05).

Prosthetic Satisfaction by Level of Limb Loss

The following sections discuss the participants' results specific to prosthetic satisfaction by level of limb loss.

Unilateral Upper-Limb Loss

Table 3 shows average overall prosthetic satisfaction scores were similar for veterans and servicemembers with unilateral upper-limb loss from both conflicts. Those with more distal transradial limb loss reported higher satisfaction than those with more proximal transhumeral limb loss. Some participants reported that they cannot routinely wear their prosthesis because of a poorly fitting socket (Vietnam 17%; OIF/OEF 13%). In those with transhumeral limb loss from the Vietnam group, 29 percent reported being unable to wear their prosthesis because of poor fit. A detailed description of unilateral upper-limb loss and prosthesis use is reported elsewhere [6]. Table 3 also shows only 67 percent of Vietnam and 50 percent of OIF/OEF participants with upper-limb loss were able to wear their prosthesis without pain; however, 75 percent of those with transhumeral limb loss from OIF/OEF reported pain with use of their prosthesis (p [less than or equal to] 0.05), up significantly from the 43 percent in Vietnam participants. On average, for both conflicts, approximately 40 percent of participants were bothered by skin problems, more than 20 percent had prostheses that made bothersome noises, approximately 25 percent were bothered by smells related to the prosthesis, and approximately 66 percent were bothered by sweating in the socket. In spite of these difficulties, 77 percent of Vietnam and 88 percent of OIF/OEF survey participants had adjusted to life with a prosthesis and approximately 90 percent stated they could cope with their prosthesis regardless of conflict and level of amputation.

Unilateral Lower-Limb Loss

Table 3 shows average prosthetic satisfaction was significantly higher in OIF/OEF than Vietnam participants with unilateral lower-limb loss (7.1 vs 7.6, p < 0.05). Fewer Vietnam veterans with transfemoral limb loss had difficulty wearing their prostheses because of poor socket fit than OIF/OEF veterans (7% vs 15%, p < 0.05). On average, 87 percent of lower-limb participants in both conflicts reported their prostheses fit well and 95 percent reported a manageable prosthetic weight. Of participants with lower-limb loss, 73 percent reported that they were happy with their socket comfort and fit and about 40 percent remained interested in changing to another prosthetic type, irrespective of previously noted differences by site of service.

Prosthesis-associated pain was reported as a problem in 51 percent of Vietnam veterans and 37 percent of OIF/OEF participants with unilateral lower-limb loss (p < 0.05). Of OIF/OEF respondents, 63 percent reported skin problems on the residual limb compared with 54 percent in the Vietnam group. We should note that a significant increase in skin problems was reported between the OIF/OEF and Vietnam transtibial groups (72% vs 52%,p < 0.05). Noises, smells, and sweating were common at all levels of unilateral lower-limb loss for both conflict groups. In spite of the difficulties expressed, more than 94 percent of unilateral lower-limb loss participants reported good coping and adapting skills and more than 96 percent stated that they had adjusted to life with a lower-limb prosthesis.

Multiple Limb Loss

In Table 4, OIF/OEF survey participants with multiple limb loss reported significantly higher overall prosthesis satisfaction scores (7.9 [+ or -] 1.8) than those in the Vietnam group (6.7 [+ or -] 2.5, p < 0.05). Socket fit was satisfactory for 80 percent of Vietnam and 89 percent of OIF/OEF participants. Prosthesis-associated pain was reported as a problem in more than one-third of OIF/OEF and Vietnam participants. Of OIF/OEF respondents, 52 percent reported skin problems on the residual limb compared with 49 percent in the Vietnam group. Noises, smells, and sweating were common at all levels for both conflict groups, with an average of 70 percent of participants reporting being bothered by sweating. Of the Vietnam and OIF/OEF participants, 95 percent stated they could cope with their prosthesis, and more than 90 percent reported that they were adjusting to life with a prosthesis.

Prosthetic Repair and Replacement

Prosthetic repair and replacement data indicated that approximately 90 percent of participants were able to obtain necessary repairs when needed across all service providers. Slightly lower numbers were reported on getting a prosthetic "replacement" as needed; yet between 67 and 85 percent received replacements when they felt they needed them across all sources of care. Replacement times of [greater than or equal to] 2 months (from prescription to initial prosthesis measurement) were reported by 25 percent of the Vietnam group at VA versus 21 percent cared for in private facilities. In the OIF/OEF group, significantly reduced replacement times were noted: 3 percent reported replacement times of [greater than or equal to] 2 months at DOD, 15 percent at VA, and 9 percent at private facilities.

Factors Associated with Prosthetic-Device Satisfaction

Specific factors were correlated with overall prosthetic-device satisfaction. In both the Vietnam group and the OIF/OEF group, factors that correlated with decreased prosthetic satisfaction included poor socket fit (p < 0.001), poor prosthesis fit (p [less than or equal to] 0.001), difficulty getting repairs or replacements when needed (p [less than or equal to] 0.001), lack of involvement in choosing the type of device (p [less than or equal to] 0.001), desire to change to anther type of prosthetic device (p [less than or equal to] 0.001), lack of satisfaction with training (p [less than or equal to] 0.01 for Vietnam participants and p [less than or equal to] 0.001 for OIF/OEF participants), and skin problems (p [less than or equal to] 0.05 for Vietnam participants and p [less than or equal to] 0.001 for OIF/OEF participants). In addition, in the OIF/OEF group, a high correlation was found between decreased overall prosthesis satisfaction and increased problems with sweat management (p [less than or equal to] 0.001). Conflict-specific findings did not differ after controlling for age in both conflicts and sex in the OIF/OEF conflict.

DISCUSSION

Three important improvements were noted in use of prosthetic devices in comparing OIF/OEF and Vietnam veterans with major traumatic limb loss. First, all OIF/ OEF servicemembers with limb loss received care from the DOD Amputee Patient Care Program, including extensive rehabilitation, prostheses, and training, to restore function to the highest level possible. Second, 92 percent of participants with multiple limb loss from the OIF/OEF conflict use prosthetic devices compared with 69 percent from the Vietnam conflict. And third, greater use of prosthetic devices was also noted for OIF/OEF versus Vietnam groups for unilateral lower-limb loss (94% vs 89%, respectively) and unilateral upper-limb loss (76% vs 70%, respectively).

Private providers under contract with VA deliver 78 percent of prosthetic devices and related services to Vietnam veterans and 42 percent to OIF/OEF servicemembers and veterans.

Table 1 shows decreased prosthetic satisfaction when VA was compared with private and DOD care, except for participants with unilateral upper-limb loss, for whom satisfaction with prosthetic service providers was similar across conflicts.

Participants with transradial loss were more satisfied overall than those with transhumeral level loss. This is likely due to the difficulty of using transhumeral prostheses and the greater loss of function from the higher level of amputation. Changes in technology did not appear to affect the overall satisfaction in the transhumeral group, despite significant advancements in prosthetic-device technology for this group. These changes in technology include advancements in myoelectric terminal devices, conventional elbow systems, and socket design, as well as in materials and socket suspension. Further, current rehabilitation protocols focus on functional performance training and return to independent function. A related article based on this survey population shows that only 50 percent of all upper-limb survey participants who used myoelectric prostheses used them daily (both Vietnam and OIF/OEF), with even significantly lower daily use reported for hybrid devices (partial myoelectric control and partial body-powered control); yet 59 percent of Vietnam and 68 percent of OIF/OEF participants use a mechanical prosthesis daily [6]. These numbers combined with the fact that little difference in satisfaction was found between the Vietnam and OIF/OEF groups suggest that technological differences with the advent of myoelectric prostheses have had minimal impact on use and overall satisfaction for persons with upper-limb loss. This finding is especially important considering that 30 to 50 percent of all those with upper-limb loss (myoelectric and conventional) have minimal daily prosthetic-device use [6]. Further research is needed to improve function and fit in these high-technology devices.

The average prosthesis-satisfaction score across all lower-limb levels was significantly higher in OIF/OEF participants with unilateral lower-limb loss than Vietnam participants. While most respondents with unilateral lower-limb loss stated they were satisfied with the fit and comfort of their prostheses, we would hope that changes in materials and technology would positively affect satisfaction for participants at each limb-loss level (i.e., moving the average satisfaction scores into the 8.0 or 9.0 range on a scale of 10). However, this did not appear to be the case. Unilateral lower-limb prosthesis-satisfaction averages were only between 7.0 and 7.8 on a scale of 10, with no significant differences between participants' level of amputation for both Vietnam and OIF/OEF participants.

In those with multiple limb loss, the OIF/OEF group reported higher overall satisfaction than the Vietnam group, although pain in the residual limbs, skin problems, sweating, and nuisances continued to be frequently reported by all combat-related veterans and servicemembers.

Vietnam veterans receiving care in the private sector were significantly less likely to want to try different prostheses and components than participants from OIF/OEF receiving private-sector care. It has been reported that as the number of prosthetic-device options increases, the expectation for finding the "perfect" components also increases, leading to ultimate disappointment [8]. This may explain the desire to try new components or prostheses, even in cases in which multiple prostheses and components have been used.

A number of possible reasons exist for the higher overall satisfaction ratings in participants from the OIF/OEF conflict. At the outset is the structure of the initial care and rehabilitation process from the battlefield to rehabilitation care at DOD facilities [9-10]. Also, expansion to multidisciplinary care may affect overall rehabilitation and prosthetic satisfaction. Our survey included OIF/OEF participants who were at least 1 year from limb loss. The factors identified by study participants included their involvement in prosthetic selection, training, and maintenance. A number of advancements to prosthetic materials and components are available to OIF/OEF servicemembers/veterans that were not initially available following the Vietnam era. These may not have been uniformly offered to Vietnam veterans. Additionally, it appears that providing multiple prostheses with different components and allowing each servicemember to meet his or her rehabilitation potential further stimulates involvement in former and new physical activities [5-6,11]. The participants' ages and being greater than 1 year from amputation to survey may affect study findings.

Dillingham et al. studied use and satisfaction with prosthetic devices in people with trauma-related limb loss [12]. They found that prosthetic devices were worn approximately 80 hours per week; yet 57 percent of participants were not satisfied with prosthetic comfort or fit.

In a retrospective cohort study of community participants with limb loss, 25 percent of participants were not satisfied with overall performance of their prostheses and 33 percent were not satisfied with the comfort and fit [13].

Lower-limb prosthetic maintenance, repair, and replacement were reported for individuals in the United Kingdom with more than 10 years of limb-loss experience. Younger participants (age <60) with transfemoral limb loss needed 1.1 new prostheses, 3.15 new sockets, 4.23 component changes, and 20.49 minor repairs in 10 years. Transtibial participants needed 1.4 new prostheses, 2.9 new sockets, 3.2 major repairs, and 14.1 minor repairs. The authors suggest that prescription of modular prostheses rather than conventional limbs allows easy replacement of components, thus reducing the need for new limbs [14].

In our study, between 25 and 68 percent of participants reported pain-free use of their prostheses (upper and lower limb). The survey did not ask participants to differentiate the frequency, type, and levels of pain. Pain is so prevalent among those with limb loss that it is often underevaluated. According to Kooijman et al., long after surgical wounds have healed, as many as 80 percent of all those with limb loss still experience phantom and residual-limb pain [15]. Since few standardized guidelines exist for evaluating the fit of a prosthesis as it relates to discomfort, the expectation may be that pain, even on an occasional basis, is "normal or acceptable." Therefore, not only is pain within the residual limb tolerated but also pain associated with use of the prosthetic device is often "tolerated" by the person with limb loss. Pain is a prominent issue for up to half of those who bear weight on a residual limb. One positive finding from this study is that among those with unilateral lower-limb loss, reports of pain with prosthetic use were significantly less in the OIF/OEF group than the Vietnam group. This could be due to overall improved prosthetic fit or surgical techniques.

Findings from other studies report similar pain prevalence. Several of these studies were able to quantify pain to a greater extent than we were able to do in this national survey [16-18]. In Hoaglund et al.'s study, more than 50 percent of those studied with lower-limb amputation had pain in their residual limb with use of their prosthesis [19].

Raichle et al. administered a questionnaire to 752 people with lower-limb loss (average age 54) and 107 with upper-limb loss (average age 47) [20]. Limb-loss etiology was injury for 54 percent of those with lower-limb loss and for 83 percent of those with upper-limb loss. The impact of the prostheses on phantom pain was mixed. Among those with lower-limb loss and phantom pain, pain intensity on a numeric rating scale (0 = no pain, 10 = worst imaginable pain) was between 4.3 and 5.8. About half the participants indicated their prostheses had no effect on phantom pain, 21 percent indicated their prostheses made phantom pain worse, 16 percent reported prostheses lessened phantom pain, and 13 percent did not know if there was an impact. In those with residual-limb pain, 42 percent reported an effect from the prosthesis. In participants with upper-limb loss, pain intensity ranged from 4.4 to 5.8. In these participants, 26 percent indicated their prostheses worsened their phantom pain, 12 percent indicated their prostheses made phantom pain better, 30 percent reported no effect on phantom pain, and 32 percent did not know if there was an impact. The survey did not attempt to investigate the methods that participants had used to address their pain issues. Future prospective studies are needed to address the actual and perceived impact of prosthetic use on phantom and residual-limb pain.

In our study, an average of 50 percent of all participants reported skin problems. Persons with lower-limb loss reported higher rates of skin issues than the persons with upper-limb loss. Dillingham et al. reported only 25 percent of all patients with traumatic amputation had problems with wounds, skin irritation, or pain [12]. Dillingham et al. further hypothesized that the skin problems in his study population may have been related to the excessive and repetitive stresses placed on the prostheses by an active population. Other studies find similar incidence of skin problems with prosthetic use [21]. Further investigation of prevention of skin problems is warranted.

This study adds to a growing series of works investigating the satisfaction of people with limb loss as an indicator of quality of care. In this study, survey participants demonstrating lower overall satisfaction also had significant issues with other aspects of their prostheses, further demonstrating that fit and function of the device have a significant impact on overall satisfaction. However, problems with fit are not the only reason for overall participant dissatisfaction. The same people who were less satisfied overall were also more likely to have wanted to change their type of prosthesis, felt they did not have a role in choosing their prosthesis, and had difficulty getting a repair or replacement within a reasonable amount of time. In this study, strong correlations were found between overall satisfaction and issues surrounding fit and delivery systems; however, with no standouts among them, the reasons for overall dissatisfaction appear to be multifactorial.

Several issues were noted surrounding prosthetic selection, training, and information dissemination on new types of prostheses [22]. Research indicates that people who feel well educated about their prosthesis care are more likely to adhere to treatment recommendations and have improved health outcomes [23]. Most individuals receiving care in DOD Amputee Patient Care Centers had multiple opportunities during rehabilitation to trial multiple prosthetic devices. However, a concern across all survey participants was the dearth of information available to individuals with limb loss on new prosthetic devices. The cause for these findings is multifactorial and not entirely clear, especially in light of modern information flow and direct patient component marketing. Agencies caring for these individuals need to identify ways to disseminate appropriate information.

The importance of interdisciplinary rehabilitation teams is increasing [23], and expansion of interdisciplinary care may affect overall rehabilitation and prosthetic use. Work with the newest generation of servicemembers from Iraq and Afghanistan (OIF/OEF) includes those with limb loss in addition to other traumatic injuries, such as fractures, soft tissue and neurological injuries, emerging fragments, thermal burns, heterotopic ossification, and traumatic brain injury [1]. This diverse patient population necessitates improved communication and a multidisciplinary approach to achieve good patient outcomes. Future research addressing age at limb loss and time since limb loss in these settings is needed.

One of the significant limitations of this survey is its inability to differentiate patterns of use. Full-time use may be perceived differently than use of a prosthetic device only for specific tasks or activities. This may require further exploration into a more suitable measure to assess daily patterns of use and the impact of prosthetic satisfaction on daily use patterns. Another limitation is that we were unable to differentiate the cause of participants' pain. While pain may be due to a poorly fitting prosthesis or a perceived poorly fitting prosthesis, it may also be due to a prosthesis in need of a minor adjustment or physiologic pathology, such as a neuroma or scar tissue. Further study of the issues surrounding pain with prosthesis use is required.

Several additional areas require further study. In the upper-limb group, multiple problems were noted with prosthetic fit and function; yet 90 percent reported ability to cope with a prosthesis and 80 percent reported they had adjusted to life with a prosthesis. Similarly, in the lower-limb group, between 96 and 98 percent reported that they had adjusted to life with a prosthesis; yet up to 15 percent reported their socket fits poorly. Issues of coping and adjustment are complex and warrant further investigation.

Abbreviations: DOD = Department of Defense, OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, VA = Department of Veterans Affairs.

JRRD at a Glance

[GRAPHIC OMITTED]

Veterans and servicemembers from Vietnam and Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) conflicts with major traumatic limb loss were surveyed about their satisfaction with current prosthetic devices and prosthetic services. Reports of pain, sweating, skin irritation, and problems with socket fit continue to be significant issues for survey participants. In those with upper-limb loss using myoelectric prostheses, minimal impact was found on prosthetic use and prosthesis satisfaction. Among lower-limb loss participants from both conflicts, notable differences exist in prosthetic satisfaction when comparing source of care. Prosthetic technology, surgical changes, and changes in rehabilitation procedures appear to have had little effect on the overall prosthetic satisfaction across those with unilateral upperlimb and multiple-limb loss in the Vietnam and OIF/OEF conflicts. Areas of significant concern continue to be socket fit, pain, skin problems, sweating, and nuisances. There are also important differences in the overall satisfaction between sources of prosthetic care, but these differences are more profound when compared across conflict than between sources within the same conflict group. Differences in prosthetic satisfaction between sources of care suggest a need for continued practitioner education and system evaluation.

CONCLUSIONS

Prosthetic technology, surgical changes (myodesis, use of wound vac, etc.), and changes in rehabilitation procedures appear to have had little impact on the overall prosthesis satisfaction across those with unilateral upper-limb and multiple-limb loss in the Vietnam and OIF/OEF conflicts. Areas of significant concern continue to be socket fit, pain, skin problems, sweating, and nuisances. Formulating appropriate prosthetic prescriptions based on clinical findings and the patient's goals and desires is critical to successful outcomes for servicemembers and veterans with major traumatic limb loss. Important differences were found in the overall satisfaction between sources of prosthetic care; however, these differences appear to be more profound when compared across conflict than between sources within the same conflict group. Differences in prosthetic satisfaction between sources of care suggest a need for continued practitioner education and system evaluation. Multiple opportunities exist for prosthetic providers in all settings to improve care.

ACKNOWLEDGMENTS

Author Contributions:

Study concept and design: G. M. Berke, J. Fergason, J. R. Milani, J. Hattingh, M. McDowell, V. Nguyen, G. E. Reiber.

Data analysis and interpretation: G. M. Berke, J. Fergason, J. R. Milani, J. Hattingh, M. McDowell, V. Nguyen, G. E. Reiber.

Drafting of manuscript: G. M. Berke, J. Fergason, J. R. Milani, J. Hattingh, M. McDowell, V. Nguyen, G. E. Reiber.

Critical revision of manuscript for important intellectual content: G. M. Berke.

Statistical analysis: G. M. Berke, G. E. Reiber.

Administrative support: G. E. Reiber.

Funding/study supervision: G. E. Reiber.

Financial Disclosures: The authors have declared that no competing interests exist.

Funding/Support: This material was based on work supported by the VA Health Services Research and Development Service (grant IIR 05244) 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 VA or DOD.

Additional Contributions: We sincerely thank the veterans and servicemembers who participated in our survey.

Institutional Review: Institutional and human subjects' approvals were received from VA and DOD. A waiver of consent was obtained for survey participants.

Participant Follow-Up: Each study participant will receive a copy of this single-topic issue of JRRD.

Submitted for publication December 3, 2009. Accepted in revised form April 7, 2010.

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[11.] Dougherty PJ, McFarland LV, Smith DG, Esquenazi A, Blake DJ, Reiber GE. Multiple traumatic limb loss: A comparison of Vietnam veterans to OIF/OEF servicemembers. J Rehabil Res Dev. 2010;47(4):333-48.

[12.] Dillingham TR, Pezzin LE, MacKenzie EJ, Burgess AR. Use and satisfaction with prosthetic devices among persons with trauma-related amputations: A long-term outcome study. Am J Phys Med Rehabil. 2001;80(8):563-71. [PMID: 11475475] DOI:10.1097/00002060-200108000-00003

[13.] Pezzin LE, Dillingham TR, Mackenzie EJ, Ephraim P, Rossbach P. Use and satisfaction with prosthetic limb devices and related services. Arch Phys Med Rehabil. 2004;85(5):723-29. [PMID: 15129395] DOI:10.1016/j.apmr.2003.06.002

[14.] Nair A, Hanspal RS, Zahedi MS, Saif M, Fisher K. Analyses of prosthetic episodes in lower limb amputees. Prosthet Orthot Int. 2008;32(1):42-49. [PMID: 17943622] DOI:10.1080/03093640701610615

[15.] Kooijman CM, Dijkstra PU, Geertzen JH, Elzinga A, Van der Schans CP. Phantom pain and phantom sensations in upper limb amputees: An epidemiological study. Pain. 2000;87(1): 33-41. [PMID: 10863043] DOI: 10.1016/S0304-3959(00)00264-5

[16.] Czerniecki JM, Ehde DM. Chronic pain after lower extremity amputation. Crit Rev Phys Med Rehabil. 2003; 5(3-4):70.

[17.] Ketz AK. The experience of phantom limb pain in patients with combat-related traumatic amputations. Arch Phys Med Rehabil. 2008;89(6):1127-32. [PMID: 18503810] DOI:10.1016/j.apmr.2007.11.037

[18.] Jensen MP, Smith DG, Ehde DM, Robinsin LR. Pain site and the effects of amputation pain: Further clarification of the meaning of mild, moderate, and severe pain. Pain. 2001; 91(3):317-22. [PMID: 11275389] DOI: 10.1016/S0304-3959(00)00459-0

[19.] Hoaglund FT, Jergesen HE, Wilson L, Lamoreux LW, Roberts R. Evaluation of problems and needs of veteran lower-limb amputees in the San Francisco Bay Area during the period 1977-1980. J Rehabil Res Dev. 1983;20(1):57-71. [PMID: 6887067]

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[21.] Koc E, Tunca M, Akar A, Erbil AH, Demiralp B, Arca E. Skin problems in amputees: A descriptive study. Int J Dermatol. 2008;47(5):463-66. [PMID: 18412862] DOI:10.1111/j.1365-4632.2008.03604.x

[22.] Van der Linde H, Hofstad CJ, Geertzen JH, Postema K, Van Limbeek J. From satisfaction to expectation: The patient's perspective in lower limb prosthetic care. Disabil Rehabil. 2007;29(13):1049-55. [PMID: 17612990] DOI:10.1080/09638280600948375

[23.] Nielsen CC. A survey of amputees: Functional level and life satisfaction, information needs, and the prosthetist's role. J Prosthet Orthot. 1991;3(3):125-29.

* Eckrich, Neal. (National Program Director, Prosthetic and Sensory Aids Service, VA Central Office, Washington, DC). Personal communication to: Gayle E. Reiber (Program Analyst, Department of Prosthetic and Sensory Aids, VA Puget Sound Health Care System, Seattle, WA). 2009 Mar 16.

* Address all correspondence to Gary M. Berke, MS, CP, FAAOP; 801 Brewster Ave, Suite 270, Redwood City, CA 94063; 650-365-5861; fax: 650-365-5896.

DOI:10.1682/JRRD.2009.12.0193

Gary M. Berke, MS, CP, FAAOP; (1) * John Fergason, CPO; (2) John R. Milani, CPO; (3) John Hattingh, L-CPO; (4) Martin McDowell, CPO; (5) Viet Nguyen, MD; (6) Gayle E. Reiber, PhD, MPH (6-7)

(1) Private Practice, Adjunct Clinical Instructor, Stanford University, Redwood City, CA; (2) Prosthetics-Orthotics Clinic, Brooke Army Medical Center, Fort Sam Houston, TX; (3) Clinical Manager, Department of Veterans Affairs (VA) Central Office, Prosthetics and Clinical Logistics Office, Washington, DC; (4) Northwest Prosthetic and Orthotic Clinic, Seattle, WA; (5) Prosthetic/Orthotic Laboratory, VA Puget Sound Health Care System, Seattle, WA; (6) University of Washington School of Medicine, Seattle, WA; (7) Health Services Research and Development Service, VA Puget Sound Health Care System, Seattle, WA

Email: gmberke@gmail.com
Table 1.
Participants' overall mean prosthesis satisfaction ranking * by
conflict, level of amputation, and source of care.

Prosthesis                                     Private
Satisfaction          DOD Only     VA Only       Only

Vietnam

n                         2          37          180
Unilateral Upper         1.0         6.2          6.9
Limb (n = 32)

Unilateral Lower         --          6.5     7.3 ([double
Limb (n = 149)                                 dagger])

Multiple Limb (n        10.0         5.3     6.8 ([double
= 49)                                          dagger])

Total (n = 230)          5.5         6.2     7.1 ([double
                                               dagger])
OIF/OEF

n                        98          22          106

Unilateral Upper         6.6         4.7          6.1
Limb (n = 38)

Unilateral Lower         7.7         6.8     7.7 ([double
Limb (n = 158)                                 dagger])

Multiple Limb (n    7.9 ([double     8.9          8.4
= 55)                 dagger])

Total (n = 251)          7.5         7.0          7.6

                     Multiple
Prosthesis           Sources
Satisfaction        ([dagger])    Total

Vietnam

n                       11         230
Unilateral Upper        10          6.7
Limb (n = 32)

Unilateral Lower        7.5         7.2
Limb (n = 149)

Multiple Limb (n        9.5         6.8
= 49)

Total (n = 230)         8.1         7.0

OIF/OEF

n                       25         251

Unilateral Upper        6.0         6.2
Limb (n = 38)

Unilateral Lower        8.1         7.7
Limb (n = 158)

Multiple Limb (n        6.8         7.9
= 55)

Total (n = 251)         7.5         7.5

* Satisfaction ranking from 0 (low) to 10 (high).

([dagger]) Servicemembers may receive prosthetic care from more
than one provider source (multiple).

([double dagger]) p [less than or equal to] 0.05 compared with
VA source of service.

DOD = Department of Defense, OIF/OEF = Operation Iraqi Freedom/
Operation Enduring Freedom, VA = Department of Veterans Affairs.

Table 2.
Overall mean satisfaction ranking of prosthetic services by care
source and conflict (reported as percent agreement).

                                                 Vietnam

                                                             Private
                                      DOD Only   VA Only       Only
Care Satisfaction                     (n = 2)    (n = 35)   (n = 178)

Usually receive appointment with        100         79          88
prosthetist within reasonable
amount of time (initial or repeat
visits)

Satisfied with training initially       100         83          82
received on how to use prosthesis

Satisfied with training initially        50         89          82
received on how to maintain
prosthesis

Fully informed about prosthetic          50         51          58
equipment choices

Received adequate information on         50         29          31
new types of prostheses on regular
basis

Had role in choosing prosthesis          50         54          73
                                                            ([dagger])

Interested in trying different type      50         80          70
of prosthesis on trial basis

Want to change current prosthesis        50         60          36
to another type                                             ([dagger])

                                      Vietnam

                                      Multiple
                                      Sources *     Total
Care Satisfaction                     (n = 11)    (n = 226)

Usually receive appointment with         91          87
prosthetist within reasonable
amount of time (initial or repeat
visits)

Satisfied with training initially        100         83
received on how to use prosthesis

Satisfied with training initially        100         83
received on how to maintain
prosthesis

Fully informed about prosthetic          46          56
equipment choices

Received adequate information on         27          31
new types of prostheses on regular
basis

Had role in choosing prosthesis          73          70

Interested in trying different type      82          72
of prosthesis on trial basis

Want to change current prosthesis        46          40
to another type

                                                 OIF/OEF

                                                             Private
                                      DOD Only   VA Only      Only
Care Satisfaction                     (n = 95)   (n = 21)   (n = 104)

Usually receive appointment with         89         91         90
prosthetist within reasonable
amount of time (initial or repeat
visits)

Satisfied with training initially        97         95         93
received on how to use prosthesis

Satisfied with training initially        92         81         92
received on how to maintain
prosthesis

Fully informed about prosthetic          78         76         77
equipment choices

Received adequate information on         47         38         48
new types of prostheses on regular
basis

Had role in choosing prosthesis          86         71         86

Interested in trying different type      90         80         93
of prosthesis on trial basis

Want to change current prosthesis        41         48         48
to another type

                                              OIF/OEF

                                      Multiple
                                      Sources *    Total
Care Satisfaction                     (n = 25)    (n = 245)

Usually receive appointment with         84          89
prosthetist within reasonable
amount of time (initial or repeat
visits)

Satisfied with training initially        92          95
received on how to use prosthesis

Satisfied with training initially        76          89
received on how to maintain
prosthesis

Fully informed about prosthetic          80          78
equipment choices

Received adequate information on         40          46
new types of prostheses on regular
basis

Had role in choosing prosthesis          80          84

Interested in trying different type      88          90
of prosthesis on trial basis

Want to change current prosthesis        52          46
to another type

* Servicemembers may receive prosthetic care from more than one
provider source (multiple).

([dagger]) p [less than or equal to] 0.05 compared with VA
source of service.

DOD = Department of Defense, OIF/OEF = Operation Iraqi Freedom/
Operation Enduring Freedom, VA = Department of Veterans
Affairs.

Table 3.
Satisfaction issues (reported as percent agreement) with
currently used prostheses in Vietnam and OIF-OEF participants
with unilateral upper-and lower-limb loss by level.

                                              Upper Limb

Prosthesis Satisfaction              Vietnam

                                        TR       TH     Total *

No./Group                               18       15       33

Average Satisfaction (0-10)            7.6       5.1      6.5

Satisfaction with prosthesis

Prosthesis fits well                    94       50       74

Weight of prosthesis is manageable      94       64       81

Want to change current prosthesis       19       29       23

to another type

Satisfaction with socket

Happy with comfort and fit of           87       50       69
socket                               ([double
                                     dagger])

Cannot wear prosthesis because          7        29       17
socket fits poorly

Problems with prosthesis and
socket

Prosthesis is pain-free to wear         75       57       67

Bothered with skin problems             35       46       40

Bothered by noises from prosthesis      24       23       23

Bothered with smells from               29       15       23
prosthesis

Bothered with sweating inside           53       71       62
socket

Coping and adapting

Can cope with prosthesis                94       79       87

Have adjusted to life with              94       57       77
prosthesis

Prosthesis Satisfaction                   OIF/OEF

                                      Hand        TR

No./Group                               3         20

Average Satisfaction (0-10)            5.0       7.1

Satisfaction with prosthesis

Prosthesis fits well                   100       100

Weight of prosthesis is manageable     100        84

Want to change current prosthesis      33         42
                                               ([double
                                               dagger])
to another type

Satisfaction with socket

Happy with comfort and fit of          100        74
socket

Cannot wear prosthesis because          0         11
socket fits poorly

Problems with prosthesis and
socket

Prosthesis is pain-free to wear        33         68

Bothered with skin problems            33         47

Bothered by noises from prosthesis      0         26

Bothered with smells from              33         32
prosthesis

Bothered with sweating inside          100        68
socket

Coping and adapting

Can cope with prosthesis               100       100

Have adjusted to life with             100        89
prosthesis

Prosthesis Satisfaction              OIF/OEF

                                        TH      Total *

No./Group                               15        38

Average Satisfaction (0-10)            5.5        6.3

Satisfaction with prosthesis

Prosthesis fits well                    92        97
                                     ([double
                                     dagger])

Weight of prosthesis is manageable      83        85

Want to change current prosthesis       50        44
                                     ([double
                                     dagger])
to another type

Satisfaction with socket

Happy with comfort and fit of           75        76
socket

Cannot wear prosthesis because          18        13
socket fits poorly

Problems with prosthesis and
socket

Prosthesis is pain-free to wear         25        50
                                     ([double
                                     dagger])

Bothered with skin problems             42        44

Bothered by noises from prosthesis      17        21

Bothered with smells from               25        29
prosthesis

Bothered with sweating inside           67        70
socket

Coping and adapting

Can cope with prosthesis                83        94

Have adjusted to life with              83        88
prosthesis

                                                Lower Limb

Prosthesis Satisfaction              Vietnam

                                     Foot    TT      TF     Total *

No./Group                             1      112     45       150

Average Satisfaction (0-10)           0      7.3     7.0      7.1

Satisfaction with prosthesis

Prosthesis fits well                  0      91      78       87

Weight of prosthesis is manageable   100     95      93       95

Want to change current prosthesis    100     38      47       41

to another type

Satisfaction with socket

Happy with comfort and fit of         0      76      69       73
socket

Cannot wear prosthesis because       100      7       7        8
socket fits poorly

Problems with prosthesis and
socket

Prosthesis is pain-free to wear       0      50      47       49

Bothered with skin problems           0      52      60       54

Bothered by noises from prosthesis    0      40      27       37

Bothered with smells from             0      33      31       33
prosthesis

Bothered with sweating inside         0      70      67       68
socket

Coping and adapting

Can cope with prosthesis              0      94      98       94

Have adjusted to life with           100     97      100      98
prosthesis

Prosthesis Satisfaction                          OIF/OEF

                                     Foot      TT       TF    Total *

No./Group                             6        91       65      162

Average Satisfaction (0-10)          7.8      7.5      7.8      7.6
                                                              ([double
                                                              dagger])

Satisfaction with prosthesis

Prosthesis fits well                 100       82       89       86

Weight of prosthesis is manageable    83       94       97       95

Want to change current prosthesis     33       43       43       43

to another type

Satisfaction with socket

Happy with comfort and fit of        100       73       71       73
socket

Cannot wear prosthesis because        0        11      15 *      13
socket fits poorly

Problems with prosthesis and
socket

Prosthesis is pain-free to wear      100       61       63       63
                                                              ([double
                                                              dagger])

Bothered with skin problems           50       72       52       63
                                            ([double
                                            dagger])

Bothered by noises from prosthesis    33       48       22       37

Bothered with smells from             50       39       31       36
prosthesis

Bothered with sweating inside         33       57       58       57
socket

Coping and adapting

Can cope with prosthesis             100       99       97       98

Have adjusted to life with            80       98       94       96
prosthesis

* Total includes all levels of upper-limb loss from hand to
shoulder.

([dagger]) Total includes all levels of lower-limb loss.

([double dagger]) p [less than or equal to] 0.05.

OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom, TF
= transfemoral, TH = transhumeral, TR = transradial,
TT = transtibial.

Table 4.
Satisfaction (reported as percent agreement) with currently used
prostheses in Vietnam and OIF/OEF participants with multiple limb
loss.

Prosthesis Satisfaction              Vietnam             OIF/OEF
                                     (n = 50)            (n = 56)

Prosthetic satisfaction (0-      6.7 [+ or -] 2.5   7.9 [+ or -] 1.8 *
10) (mean [+ or -] SD)

Satisfaction with prostheses

Prostheses fit well                     86                  89

Weight of prostheses is                 90                  98
manageable

Want to change current                  49                  50
prostheses to another type

Satisfaction with socket

Happy with comfort and fit of           80                  89
sockets

Cannot wear prostheses because          14                  11
sockets fit poorly

Problems with prostheses and
socket

Prostheses are pain-free to             65                  61
wear

Bothered with skin problems             49                  52

Bothered by noises from                 41                  32
prostheses

Bothered with smells from               37                  43
prostheses

Bothered with sweating inside           69                  71
sockets

Coping and adapting

Can cope with prostheses                95                  95

Have adjusted to life with              94                  91
prostheses

* p [less than or equal to] 0.05 compared with Vietnam group.

OIF/OEF = Operation Iraqi Freedom/Operation Enduring Freedom,
SD = standard deviation.
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