BODY IMAGE AND PROSTHESIS SATISFACTION

IN THE LOWER LIMB AMPUTEE

Craig D. Muray and Jezz Fox

Address all correspondence to:

Craig D. Murray
Department of Psychology
Liverpool Hope
Hope Park
Liverpool
L16 9JD
UNITED KINGDOM

Tel: +44 +151 291 3883

E-mail: murrayc@hope.ac.uk

1
 BODY IMAGE AND PROSTHESIS SATISFACTION

IN THE LOWER LIMB AMPUTEE

Keywords amputee, body image, pain, prosthesis satisfaction

Abstract

Purpose: This study examines the relationship between prosthesis satisfaction and

body image in lower limb prosthesis users, and the gendered variations within these

relationships.

Method: A total of 44 valid responses were obtained to an Internet survey regarding

prosthesis satisfaction, body image, and phantom pain. Spearman Rho correlations

were calculated for these three domains.

Results: Moderate to high negative correlations were observed between Body Image

Disturbance and Prosthesis Satisfaction. These were consistent across genders. Other

relationships were also revealed, including positive correlations between Prosthesis

Satisfaction with hours of use and negative correlations between Prosthesis

Satisfaction and pain experience, though strong differences between genders were

observed for these. The length of time for which respondents had had their prosthesis

bore little relation to other variables.

Conclusion: The present research is instructive of the close relationship between body

image and prosthesis satisfaction, as well as gender variations in these relationships,

in lower-limb prosthesis users. These findings have implications for targeted service

provision in prosthetic rehabilitation.

2
Introduction

Prosthetic limbs are commonly used by people with limb loss (acquired amputation)

and limb absence (congenital deficiency) to restore or imbue some of the function

and/or cosmesis of an anatomical limb. Both people with acquired amputations and

people with congenital limb absence will be encouraged to use prostheses by a variety

of professionals as part of a rehabilitation process.1-4 However, published research on

the levels of prosthesis use among those with a lower limb amputation varies

considerably.5-7

The incidence of lower-limb amputations is 11 times greater than that for upper-limb

amputation8, and the majority of all amputations occur in older adults9, most

frequently as a complication of diabetes mellitus.10-12 However, amputations are also

carried out for a number of other reasons, including congenital limb deficiency,

vascular insufficiency, cancer, and traumatic injury. Although amputees face major

physical, social, and emotional adjustments, adaptation varies widely between

individuals.13-14

Rybarcyzk, Nyenhuis, Nicholas, Cash and Kaiser15 note that anecdotal reports have

suggested a relationship between a negative body image and psychological

maladjustment to a leg amputation.16-18 An early study19 found that when the

projective Draw-A-Person Test was given to people who were rated as poorly

adjusted to their amputation, they drew the missing limb as either larger or more

exaggerated than individuals who were well adjusted. It has been suggested that

3
amputees who express dissatisfaction with their prostheses may be doing so as a form

of denial or as an excuse for an inability to cope with the prosthesis,20-21 while Ham

and Cotton22 found that fewer emotional problems, and better social integration, were

associated with trouble-free use of a prosthesis.23

The relationship of the body image of people with amputations and psychosocial

adjustment to a leg amputation has previously been explored.15 Rybarcyzk et al.15

examined whether body image and perceived social stigma were important predictors

of psychosocial adjustment to leg amputation, in 112 clients (aged 21-83 years) from

5 prosthetic clinics. Body image was found to be an independent predictor of

depression, quality of life, and prosthesis ratings.

Breakey24 also surveyed people with lower-limb amputations to examine their self-

perception and psychosocial well-being. A significant correlation was found between

body image and life satisfaction, indicating the more negative an amputee feels about

his or her body image, the less satisfied he or she is with his or her life. However,

Fisher and Hanspal25 found that body image disruption, anxiety and depression were

generally not common in established limb wearers, except for young people with

traumatic amputations.

More generally, the relationship between the person with an amputation and

prosthesis tends to be narrowly addressed in the available literature in terms of

‘rejection’ and ‘acceptance’ rates,26 with reference to various contributing factors. For

instance, Millstein, Heger and Hunter27 propose that for any prosthesis to be accepted

and used it must be comfortable, functional and have ‘a pleasing appearance’ (p.31).

A prosthesis might only be perceived as useful for particular tasks (e.g. work or

4
recreational activities), meaning it is only worn for part of the day.28 If a prosthesis

often breaks down, requiring regular repairs, it may be considered too much ‘fuss and

bother’ and be rejected.29 Similarly, a high degree of energy expenditure involved in

using a prosthesis often militates against its habitual use.30 Finally, the motivations

and expectations of the would-be user have sometimes been described as lacking or

unrealistic,26 leading to disillusionment and rejection.

Many people who undergo an amputation, and subsequently require a prosthesis,

experience a ‘phantom limb’, which is the experience of feeling as though the

amputated appendage is still there and intact, or resembling the pre-amputated limb.

These phantoms can be painful or non-painful. Burning, cramping, and shooting

pains are characteristic of phantom pain, or a pain similar to pre-operative pain,31-32

whole non-painful phantom sensations have been described as tingling, or itchy.33

Phantom limb pain is an important clinical problem, as it can become intractable,

leading to drastic and often unsuccessful surgeries such as further amputation.33 In

general, phantom limb pain interferes with rehabilitation, prolonging hospital stays

and increasing the number of prosthetic fittings. Correlations between coping with

limb loss, body image, and the occurrence of phantom limb pain have been

examined.34 Patients who coped better with the loss suffered less from phantom limb

pain. A difference was also noted in subjective representation of the body image:

patients suffering from phantom limb pain tended to have an image of their bodies as

a complete and undamaged entity.

Previous research has produced mixed findings regarding the importance of gender in

psychosocial adjustment to amputation and prosthesis use. While one study has found

5
that women were more likely than men to be depressed following an amputation,35

and anoter reported that male gender was linked to greater life satisfaction post-

amputation,36 other research has found that gender does not predict levels of

psychosocial adjustment.37-39 However, gendered patterns of prosthesis satisfaction

and body image disturbance have not yet been examined.

The research discussed above is indicative of the impact that amputation or congenital

limb absence may have on a person’s body image, health and well being. Prosthesis

use is therefore often important for such persons’ rehabilitation. Consequently, it has

been argued that some prostheses can not only restore near normal appearance and

form, but can also substantially ‘repair’ the person’s damaged body image.40

However, such claims have not yet been fully explored. Therefore, the present study

is an investigation into the relationship between prosthesis satisfaction and body

image in lower limb prosthesis users. In addition, the present study seeks to explore

any gendered variations which might arise in these relationships.

Method

RESPONDENTS

Respondents were recruited via postings to four Internet discussion groups. Over a

period of four weeks, 46 responses were obtained via a web-site (see materials section

below for details). Two respondents did not indicate their type of amputation, and

were excluded from the analysis. In total 44 lower-limb prosthesis users (24 males, 17

females, and three people who did not indicate their gender) completed the

6
questionnaire. The mean age of the sample was 42. Respondents reported five

different types of limb loss: below knee (n=22), through knee (n=14), above knee

(n=6), bilateral limb loss (n=1), and partial foot (n=1). The causes of limb loss in our

sample were trauma (n=16), cancer (n=16), congenital limb absence (n=3), peripheral

vascular disease (n=2), and diabetes (n=1). Six respondents indicated ‘other’ causes.

Respondents had used a prosthesis, on average, for 8.1 years, and had an average

daily use of 13 hours.

[Insert Table 1 about here]

MATERIALS

The survey drew upon three established questionnaires: the Trinity Amputation and

Prosthesis Experience Scales (TAPES)41; the Amputee Body Image Scale (ABIS)24;

and the McGill Pain Questionnaire (MPQ).42 The questionnaire was presented in a

single HTML file. Upon submission, responses were recorded into a data file by

means of a Perl CGI-Script. The content of each of the three questionnaires is detailed

below.

The Trinity Amputation and Prosthesis Experience Scales (TAPES): The TAPES is a

multidimensional self-report instrument designed to help understand adjustment to a

lower limb prosthesis. It consists of three sections: psychosocial issues, activity

restriction, and satisfaction with a prosthesis. The present study utilises the third of

these only, which looks at levels of satisfaction with a prosthesis. Respondents were

asked to rate 10 different aspects of their prosthesis by responding to statements (e.g.

‘I am happy with the appearance of my prosthetic limb’) on a 5-point scale ranging

7
from strongly agree (5) to strongly disagree (1). The total from this is referred to as

Total Satisfaction (10 items) and has three subscales: Functional Satisfaction (5

items), Aesthetic Satisfaction (4 items), and Weight Satisfaction (1 item).41

The Amputee Body Image Scale (ABIS): The ABIS24 is comprised of 20 items that

assess how an amputee perceives and feels about his or her body experience. As with

the original format, participants were asked to indicate their responses to the

questions using a scale of 1 (none of the time) to 5 (all of the time). This scale

produces scores that range from 20 to 100, with high scores indicating high body

image disturbance (BID). Three of the questions are reverse-scored.

The McGill Pain Questionnaire (MPQ): The McGill Pain Questionnaire (MPQ)42

consists primarily of 3 major classes of word descriptors (sensory, affective and

evaluative) that are used by respondents to indicate their subjective pain experience.

In its original format, respondents are presented with 80 adjectives in groups, and

have to select one from each group that most closely matches their own pain. The

chosen categories are then weighted to produce a level of pain score. For the purposes

of the present study we have modified this procedure. Here, respondents are asked to

pick a maximum of one adjective from each group, and a total pain score is calculated

from the number of adjectives chosen (0-20).

ETHICAL CONSIDERATIONS

Conducting research on sensitive topics requires a full consideration of ethical issues.

Such issues included making appropriate contact with potential participants,

maintaining participants anonymity, and protecting them from harm. These issues

8
were first discussed with members of the researchers’ departmental ethics committee

before agreeing ethical protocols. We provided our personal and a dedicated e-mail

address for respondents to make contact with us, should they wish to discuss any

unresolved issues.

Results

Descriptive statistics for the main variables under investigation are presented in Table

2 in order to provide an idea of the distribution of the data to the reader.

[Insert Table 2 about here]

In order to gain a full representation of the relationships under investigation, three

categories of correlations were undertaken. Firstly, correlations for the whole data-set

were examined. Then the same correlations were considered for males and females

separately. Whilst producing the desired comparisons, breaking down the data in this

manner results in correlations being performed with relatively small samples. These,

in turn, require strong correlations in order to achieve significance. Thus, the use of

p-values in interpreting the data may be misleading as it may, for example, lead to

meaningful relationships being dismissed as unimportant. Therefore, whilst providing

the r & p values in Table 3, the presentation of the results concentrates upon the

magnitude of the correlations.

[Insert Table 3 about here]

9
Body Image Disturbance (BID) for the whole sample was moderately to highly

correlated with levels of Prosthesis Satisfaction (Total Satisfaction, r = -.52;

Functional Satisfaction, r = -.43; Aesthetic Satisfaction, r = -.40; Weight Satisfaction,

r = -.34). A similar pattern of results was also seen for males (Total Satisfaction, r =

-.51; Functional Satisfaction, r = -.47; Aesthetic Satisfaction, r = -.18; Weight

Satisfaction, r = -.30) and females (Total Satisfaction, r = -.60; Functional

Satisfaction, r = -.41; Aesthetic Satisfaction, r = -.57; Weight Satisfaction, r = -.55).

The largest discrepancy being between the male and female correlations on Aesthetic

Satisfaction and Body Image Disturbance.

For the whole population the number of hours use per day was related to Total

Satisfaction (r = .39), Functional Satisfaction (r = .48), Weight Satisfaction (r = .21),

and Body Image Disturbance (r = -.39), but not Aesthetic Satisfaction (r = .04) nor

pain (r = -.09). Caution needs to be exercised in the interpretation as these overall

figures for level of use appear to result from stark differences between genders: for

comparison r-values are presented for males vs. females, Total Satisfaction r = .15 vs.

r = .70, Functional Satisfaction r = .37 vs. r = .74, Aesthetic Satisfaction r = -.29 vs. r

= .37, Weight Satisfaction r = -.04 vs. r = .47. For Body Image Disturbance (r = -.46

vs. r = -.29) and pain (r = -.14 vs. r = .07) these gender differences are not apparent.

The length of time with a prosthesis shows little correlation with the other variables

except Functional Satisfaction for females (r = .25) and Aesthetic Satisfaction for the

whole population (r = -.28) though for the latter there is a large difference between

genders (males r = -.44 vs. females r = -.07).

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Finally, when considering the relationships between the total pain and the other

variables we see low to moderate correlations for the whole population (Total

Satisfaction, r = -.19, Functional Satisfaction, r = -.27, Aesthetic Satisfaction, r = .12,

Weight Satisfaction, r = -.16, and Body Image Disturbance, r = .21). However,

gender differences are apparent for all variables (male r-values vs. female r-values,

Total Satisfaction, r = -.35 vs. r = .16, Functional Satisfaction, r = -.43 vs. r = -.13,

Aesthetic Satisfaction, r = .05 vs. r = .51, Weight Satisfaction, r = -.35 vs. r = .14, and

Body Image Disturbance, r = .27 vs. r = –.09).

Discussion

PROSTHESIS SATISFACTION AND BODY IMAGE DISTURBANCE

For the whole sample, and males and females separately, higher levels of overall

satisfaction with their prosthesis were correlated with lower levels of body image

disturbance. However, of the three subscales, only higher levels of Functional

Satisfaction with a prosthesis were appreciably correlated with lower levels of body

image disturbance for men, while for females higher levels of all three sub-scales

were appreciably correlated with lower levels of body image disturbance. Previous

research has produced mixed findings regarding the importance of gender in

psychosocial adjustment to amputation and prosthesis use.37-39 However, the present

research has examined the relationship between body image disturbance and

prosthesis satisfaction in men and women and found interesting variations.

11
The findings reported here are in line with recent qualitative research carried out by

one of the authors,43 where it was found that for male participants the importance of

the ‘Functional’ aspects of a prosthesis were related to the ability to continue

providing financially for their family, and enabling strenuous activities. However, for

female participants in particular, the ‘Aesthetic’ or cosmetic aspects of a prosthesis

were important in sustaining a sense of femininity, where being able to continue

wearing feminine clothes (e.g. skirts and high heels), and having a prosthesis which

looked ‘realistic’ were important. However, in the present research, ‘Functional

Satisfaction’ with a prosthesis was also related to a positive body image in females.

However, further research is needed in order to ascertain whether the functional

requirements of men and women differ in important ways, and hence whether

prosthetic rehabilitation has to take place in a gendered fashion.

NUMBER OF HOURS OF PROSTHESIS USE PER DAY

For the whole sample, higher levels of Overall Satisfaction and Functional

Satisfaction with a prosthesis, and lower levels of Body Image Disturbance, showed

appreciable correlations with higher levels of hourly use per day. However, when the

data for males and females was separated, females demonstrated higher, and

appreciable correlations between all levels of satisfaction with a prosthesis and

number of hours of use per day. Only Functional Satisfaction with a prosthesis was

appreciably correlated in this manner for males. These findings contradict those of

Gallagher and MacLachlan,41 who found a correlation between Functional Satisfaction

and the number of hours per day that a prosthesis was used, but who argued that

because of the concealability of an artificial limb, Aesthetic Satisfaction can not be

expected to predict prosthetic usage. However, Gallagher and MacLachlan41 did not

12
separate their data to look at gender, and so may have overlooked similar

relationships.

A final finding in regards to the number of hours a day that a prosthesis was used is

its appreciable relationship with a positive body image for males. Taken together,

these findings would appear to highlight the importance, for men, of having a positive

body image in prosthetic rehabilitation, while, for females, this reinforces the view

that a prosthesis must be more than purely cosmetic but, rather must afford real

functional benefits if they are going to be able to use and value them.

PHANTOM PAIN AND PROSTHESIS SATISFACTION

For males, higher levels of Total Satisfaction, Functional Satisfaction, and Weight

Satisfaction, were appreciably correlated with fewer chosen pain categories, while for

females, higher levels of satisfaction with the Aesthetic aspects of a prosthesis were

correlated to a higher number of chosen pain categories. If we treat higher number of

chosen pain categories as an indicator of higher levels of experienced phantom pain,

it is perhaps unsurprising to find that, for males, the less pain experienced the more

they were satisfied with the Functional and Weight aspects of their prosthesis.

However, it is perhaps surprising that the above pattern was not found for females

also. One possible explanation, in line with Pucher et al.,34 is that females did not

‘cope’ as well as men with limb loss, and hence experience more phantom pain. The

heightened importance given to the Aesthetic aspects of a prosthesis by females could

be seen as evidence of this, and a failure to accept an altered body. However, it must

be emphasised that the adapted MPQ used here was not intended to provide a

13
‘measure’ of experienced phantom pain, but, rather, an index of the broad range of

descriptors of phantom pain that applied to our participants. Therefore, any

relationship between levels of experienced phantom pain and satisfaction with a

prosthesis needs to be explored with an alternative approach. However, the present

research does suggest a possible, and interesting, gender difference in relation to

phantom pain and satisfaction with a prosthesis.

LENGTH OF TIME WITH A PROSTHESIS

Finally, for males Aesthetic Satisfaction showed an appreciable negative correlation

with Time With a Prosthesis. This seems to suggest that the needs of users may

change over time, and so requirements that were satisfactory at time of fitting will not

be later on. The implication of this is that if this need is not monitored and met,

prosthesis use may decline and lead to the social isolation and depression described

by Williamson et al.14 in people who do not use their prostheses.

Summary and Conclusions

The present research is instructive of the close relationship between body image and

prosthesis satisfaction, as well as gender variations in these relationships, in lower-

limb prosthesis users. These findings, such as the heightened importance of the

aesthetic components of an artificial limb for females, and the functional aspects for

males, have implications for targeted service provision in prosthetic rehabilitation.

However, further research is required to identify other influencing aspects in

successful prosthesis use, such as the importance of site of amputation (e.g. below

knee and above knee), and whether these too have gendered variations. Finally, the

14
finding that males found their prosthesis to be less aesthetically pleasing with the

passage of time is indicative that user’s needs and expectations may change and

therefore need assessing at frequent intervals.

ACKNOWLEDGEMENTS

The authors would like to thank all the respondents of the survey, as well as Ian

Gregson and Wayne Renardson for posting the call for participants on the Listservs

they moderate.

15
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21
TABLE 1: SAMPLE CHARACTERISTICS

Characteristic n % M SD Range

Gender
Male 24 54.5
Female 17 38.6
Unknown 3 6.8
Age (years) 41.6 12.9 18-75

Cause of amputation
Accident 16 36.4
Cancer 16 36.4
Congenital 3 6.8
Peripheral vascular 2 4.5
disorder
Diabetes 1 2.3
‘Other’ 6 13.6

Type of amputation
Below knee 22 50.0
Through knee 14 31.8
Above knee 6 13.6
Bilateral 1 2.3
Partial foot 1 2.3

Length of time with prosthesis 8.1 9.4 0.1-40.0

(years)

Daily prosthesis use (hours) 13.0 4.5 0.0-19.0

22
TABLE 2: DESCRIPTIVE STATISTICS FOR PROSTHESIS SATISFACTION,
BODY IMAGE, AND PAIN

Possible Valid Mean Median Minimum Maximum Lower Upper Std.Dev.

Range N Quartile Quartil
e
Total 10-50 44 36.8 35.0 19.0 100.0 32.0 40.0 11.8
Satisfactio
n
Functional 5-25 44 20.9 20.0 7.0 100.0 17.0 22.0 12.8
Satisfactio
n
Aesthetic 4-20 44 13.4 14.0 4.0 20.0 11.0 16.0 3.6
Satisfactio
n
and Weight 1-5 44 2.9 3.0 1.0 5.0 2.0 4.0 1.1
Satisfactio
n
ABIS Total 20-100 44 57.0 57.5 23.0 100.0 42.0 67.0 20.9
MPQ Total 0-20 44 11.5 11.5 0.0 20.0 6.5 18.5 7.1

23
TABLE 3. SPEARMAN RANK ORDER CORRELATIONS
ALL (valid n=44, MALE (valid FEMALE (valid
except †=43) n=24) n=17, except
††=16)
Prosthesis Body Image -.52 **** -.51 *** -.60 ***
Satisfaction Total Disturbance
Pain -.19 * -.35 * .16 *
Hours Of Use .39 *** .15 * .70 ***
Time With A -.14 † * -.18 * .04 †† *
Prosthesis
Functional Body Image -.43 *** -.47 ** -.41 *
Satisfaction Score Disturbance
Pain -.27 * -.43 ** -.13 *
Hours Of Use .48 **** .37 * .74 ****
Time With A .05 † * .06 * .25 †† *
Prosthesis
Aesthetic Body Image -.40 *** -.18 * -.57 **
Satisfaction Score Disturbance
Pain .12 * .05 * .51 **
Hours Of Use .04 * -.29 * .37 *
Time With A -.28 † * -.44 ** -.07 †† *
Prosthesis
Weight Body Image -.34 ** -.30 * -.55 **
Satisfaction Score Disturbance
Pain -.16 * -.35 * .14 *
Hours Of Use .21 * -.04 * .47 *
Time With A -.06 † * -.09 * .14 †† *
Prosthesis
Body Image Pain .21 * .27 * -.09 *
Disturbance
Hours Of Use -.39 *** -.46 ** -.29 *
Time With a .10 † * .01 * .09 †† *
Prosthesis
Pain Hours Of Use -.09 * -.14 * .07 *
Time With -.07 † * -.10 * .04 †† *
Prosthesis

* p>0.05 ** p<0.05 *** p<0.01 **** p<0.001 (Two-tailed)

24