A Comparative Study of Physical Coping Abilities among Knee Amputees using Prosthesis and Manual Wheelchair

Research Outline

Chapter IIntroduction

1.1 Background of the study1.2 Statement of the problem1.3 Significance of the study1.4 Marketing Practice1.5 Scope and limitation

Chapter IIReview of Related Literature

2.1 Synthesis2.2 Hypotheses2.3 Definition of terms

Chapter IIIResearch Methodology

3.1 Research Design3.2 Population and Sampling3.3 Research Locale3.4 Research instrumentation3.4 Date Collection Procedures3.5 Ethical Consideration

Chapter IVPresentation, Interpretation, and Analysis of Data

Chapter VSummary of Findings, Conclusion, and Recommendation

5.1 Summary of Findings5.2 Conclusion5.3 Recommendation

Chapter I

Introduction

Background of the Study

Coping skills or abilities is defined as counteracting disadvantages in their daily life of a

person (Fritscher, 2008) This study focuses on what assistive device to purchase of people with

amputated knees and physical coping abilities wherein people with amputation may use to

overcome the disadvantages of their amputation to their physical performance.

Physical coping exhibits a great challenge for clients with amputation. If one is unable to

cope with physically, it would disrupt their activities of daily living, decrease their independence,

and might even worsen their present condition.

According to the ICF research branch, partner of the WHO Collaborating Center for the

Family of International Classifications (WHO-FIC) in Germany (at DIMDI) (2010), whose

purpose is to seek better understanding of disability through multidisciplinary research, states

that the most common cause of amputation among developed countries is peripheral vascular

disease, whereas, in undeveloped countries, trauma is the most common cause of amputation.

Leg or foot amputation is the removal of a leg, foot or toes from the body. These body

parts are called extremities. Amputations are done either by surgery, or occur by accident or

trauma. (Benjamin, Ma.C., M.D., 2008),

Leg amputations are one of the hardest procedures to recover from. This comes from not

only emotional series of losing a limb but also the physical demands whether the amputation

happened due to injury or disease complications, all those with amputations face many of the

same hurdles. Patients with leg amputations undergo different rehabilitation programs. They tend

to use either prosthesis or wheelchairs as their means of mobility.

As defined by J. Kauzlarich (2010), a wheelchair is a device used for mobility by people

who have difficulty or disability, due to illness or injury. On the other hand, as defined by the

Medical-Dictionary (2010), prostheses are artificial device extensions that replace a missing

body part. Prostheses are typically used to replace extremities damaged by injury (traumatic) or

missing from birth (congenital) or to supplement defective body parts.

Studies have shown that prosthesis and wheelchairs help amputated patients to cope up

physically. In the study conducted by Gunawardena N. et al. (2004) entitled “Prosthetic Outcome

of Unilateral Lower Limb Amputee Soldiers in Two Districts of Sri Lanka,” it was found out that

the use of prosthesis indoors and outdoors helped the patients with most of their mobilization,

especially among below-the-knee amputees, and concluded that prosthetic use was satisfactory

and could be improved. On the other hand, according to the study of Karmarkar et al. (2009,)

majority of the amputees who used wheelchair had less difficulty in doing activities than those

with prosthesis such as traversing a ramp, getting in and out of buses, carrying 10 lb of groceries,

and performing sports and other leisure activities. However, there is difficulty in finding studies

that compare the physical coping abilities of unilateral below the knee amputees using manual

wheelchair and prosthesis in performing activities of daily living which will be researched in the

current study.

The main reason that motivated the researchers to conduct a comparative study of

physical coping abilities among amputees using manual wheelchair and prosthesis is to provide

the amputees with the assistive device that will greatly help them in their physical coping and

also to provide information regarding the level of independence in performing activities of daily

living that other studies did not mention.

Statement of the Problem

The study aims to determine the physical coping abilities or the level of independence in

performing activities of daily living of the unilateral below the knee amputees using manual

wheelchair and prosthesis as their assistive device.

Specifically, this study seeks to answer the following questions:

1. What is the profile of the respondents in terms of:

a. age

b. reason for amputation

c. sex

2. What are the physical coping abilities in performing activities of daily living of

a. amputees using manual wheelchair

b. amputees using prosthesis

3. What are the physical coping abilities in performing activities of daily living as rated

by the caregivers of:

a. amputees using manual wheelchair

b. amputees using prosthesis

4. Is there a significant difference in the self-rating of respondents and ratings of the

caregivers?

5. Is there a significant relationship in the physical coping abilities of amputees using

manual wheelchair and prosthesis with demographic variables such as age, reason for

amputation and sex?

6. Is there a significant difference in the physical coping abilities between amputees using

wheelchair and amputees using prosthesis?

Significance of the Study

The study provides information on the physical coping abilities of unilateral below the

knee amputees. This study aids to determine the physical coping abilities based on the level of

independence of patients who underwent unilateral below the knee amputation that uses manual

wheelchair and prosthesis.

Marketing Practice

Medical supplies business may use this study to increase their sales on which assistive

device, whether wheelchair or prosthesis to recommend to the market. They can also focus on

what device to sell to their clients with unilateral below the knee amputees in performing

activities of daily living and therefore provide the needed care or assistance to those who are less

independent.

Scope & Limitation

This study primarily deals with the physical coping abilities of unilateral below the knee

amputees using manual wheelchair or prosthesis and aids in determining their level of

independence in performing activities of daily living.

The study participants involved were 10 amputees using wheelchair and 10 amputees

using prosthesis, 18 to 65 years old, regardless of their sex, who underwent unilateral below the

knee amputation, whose cause of amputation is only due to diabetes and trauma, and use manual

wheelchair or prosthesis for a minimum of five months and a maximum of 12 months.

Clients younger than 18 years old and older than 65 years old, have bilateral or above the

knee amputation, and have been using these assistive devices less than five months and more

than a year are excluded from the study. In addition to that, only ten areas from the activities of

daily living were assessed.

Chapter II

Review of Related Literature

As we all know, wheelchairs and prosthesis are very helpful to people who desire some

physical mobility. By using wheelchair and prosthesis, they can continue their function in a

normal way. These devices can answer their needs as a person, and can give them more freedom

and independence. This study determines if which of the two devices (manual wheelchair or

prosthesis) provides a greater physical independence for clients with unilateral below the knee

amputation. 

There are also certain factors that affect the physical coping abilities of amputees,

According to the systematic literature review of Sansam et al. (2009) about the factors that affect

walking abilities among people with amputation, it states that a great number of studies say that

amputees were able to walk better if the level of their amputation was below the knee and

unilateral, had fewer problems related to their stump, and had better cognitive abilities. Those

who were using wheelchairs were also able to get a better balance in sitting if their level of

amputation was below the knee as the remaining leg on the affected side was still enough to act

as a lever. The review also stated that those who were employed at the time of their amputation

also learned faster in using their prosthesis and were able to walk longer using the device.

Participation in sports prior to the amputation also led to better walking ability. Other studies

also included that those who were older found it harder to walk, however, other studies found no

relationship between age and the ability to walk. It was anticipated that older age affected

walking ability because of the number of medical conditions the patient had experienced and not

the age itself. Another factor was sex. Most studies claimed that it had no significant effect and

only a few stated otherwise. Social support was also another factor associated with better

mobility among these clients.

The Profile of the Respondents in Terms of Age, Reason for Amputation and Sex

According to Lento (2007), those older than 65 years of age usually get their amputation

due to vascular diseases like diabetes while the younger age groups are more likely due to

trauma. On the other hand,according to the amputation statistics of the Smith (2008), a hospital

of the Columbia University College of Physicians and Surgeons, the peak age for amputations is

between 41 and 70 years of age, with 75 percent of all amputations occurring in people over the

age of 65.

In terms of cause of amputation, Mosquera (2011) stated that Diabetes is one of the

leading cause of amputation because it causes insufficient blood supply to different parts of the

body which results to hardening of the arteries and 30-40% of diabetic patient requires

amputation. Atherosclerosis is commonly seen among older men who smoke making them to be

the topmost candidate for amputation. Furthermore, according to the National Limb Loss

Information Center in the United States in 2008 there are around 1.7 million people who were

amputated. It was stated that the major cause was due to trauma caused by accidents like

vehicular accidents, slip and fall accidents on dangerous premises, and Hazardous defective

products.

While in terms of sex, Mostafa et al, (2010), four (4) of every five (5) traumatic

amputation victims are male, and most of them are between ages 15 and 30 years old.

Furthermore,Congdon (2011) stated that males are at a significantly higher risk for trauma

related amputations than females. The leading causes of trauma-related amputations have been

reported to be injuries involving machinery (40.1%), powered tools and appliances (27.8%),

firearms (8.5%), and motor vehicle crashes (8%).

On the other hand, Uwin (2009) said that factors such as age, sex and cause of

amputations do not contribute to the physical coping of patients. According to the study social

support is the one that usually contributes to the patients coping abilities.

The Physical Coping Abilities in Performing Activities of Daily Living of Amputees Using

Wheelchair

Torres (2009), Simons (2006) and Wang (2010) stated that despite the disabilities of

patients using wheelchairs, they are still able to perform different kinds of sports. The most

common sports that they can execute are basketball, tennis, hockey and the like. Sooner or later,

these patients are able to adapt to their condition and to the use of their wheelchair and are

therefore, able to become physically active.

These researchers mentioned the different sports and activities that can be done outdoors

by the amputees using wheelchair, however, they did not mention any of the activities the

researchers want to evaluate.

Gailey, R.S. (2006) stated in his book, that the primary means of mobility for a majority

of amputees, either temporarily or permanently, is the wheelchair. The energy conserved using

wheelchair is lower than prosthetic ambulation. Therefore, the proper use of wheelchair should

be taught to all amputees during their rehabilitation program in order to efficiently make use of

energy. These patients have the decision on how far they can go and the only thing that limits

them is their decision of stopping. Sometimes they tend to keep on pushing so that they can meet

their goals or their destination.

According to Lin et.al (2003), activities such as doing laundry, washing dishes,

vacuuming, fixing the bed and other types of cleaning are not that accessible for patients who are

using wheelchair and prosthesis because of the energy required and the reach and grasp involved

in accomplishing the task.

Washing dishes is considerably easier for patients using wheelchair because they are

sitting next to the sink while performing the task. Taller patients may have more advantages

because they have longer reach. Tools may also be modified and equipped with handles to assist

patients to adapt to their household works.

Whitehead (2006) stated that there are different ways in order to transfer one’s self to

bed using wheelchair and vice versa. To make it possible for those who use wheelchair to

transfer themselves to bed, they use different assistive devices to make it even more possible for

them such as crutches, cane and walkers.

Furthermore, according to Hsu (2008) a person using wheelchair can do some household

chores like mopping and sweeping the floor or even vacuuming.

According to Grunert (2011), if clients using wheelchair are able to acquire tips, ideas

and ways to dress up themselves in their wheelchair, these patients may be able to dress up and

carry it out independently. They may need help at the beginning but in the long run they will be

able to cope up with their conditions and performs according to their needs.

Regarding exercise, Hecker(2008), mentioned that wheelchair exercise helps clients

increase their strength, flexibility, improve their mobility, strengthen the heart and lungs, and

help control weight.The benefits of exercise mentioned were the ability to better perform daily

activities such as pushing the wheelchair and holding or carrying items and transferring in and

out of the wheelchair.

Moreover,Falk et.al. (2009), talked about how wheelchair users might be able to feed

themselves and states that most of these clients utilize assistive devices such as wheelchair tray

to help them in eating.

The literatures cited here talk about the activities such as sports, transferring, and

activities of daily living that can be done by patients using wheelchair, and also mention that

these patients are able to perform tasks like dressing, and eating independently. However, the

other activities of daily living stated in the literature do not mention the level of independence of

patients with below the knee amputation with regards to the performance of these tasks.

The Physical Coping Abilities in Performing Activities of Daily Living of Amputees Using

Prosthesis

According to Legro et al (2001) and Carol and Eldestein (2006) through the use of

prosthesis, patients are able to walk, perform daily activities and engage in recreational activities

such as sports. Furthermore, Edelstein (2002) stated that some of the skills of patient with

unilateral lower-limb amputations can perform are dressing, clothing and bathing. According to

her book “Prosthetics And Patient Management: A Comprehensive Clinical Approach Chapter 3

p.27,2006” she stated that the first functional activity that should be accomplished by patients

with amputation two weeks after the operation should be sitting upright, moving abilities in bed

and transferring from one place to another to prevent complications such as pressure sores and

others. When the client is able to master sitting upright the client is able to dress upthemselves

independently.

Moreover, Shin et al (2006), conducted a study regarding the activities of daily living that

can be done by amputees using prosthesis. One of the activities mentioned was preparing a meal

under the household level of their tool described by Wade (1985). Based on the results, 11 out of

43 prosthetic users can do the household chores described in the tool including preparing meals.

Schafer (2007) also stated that prosthesis is used to replace a missing body part and

because of this prosthesis users should be able to perform the activities like eating, walking and

dressing up independently and comfortably. And Skoski (2009) a doctor with a hemipelvectomy

amputation, mentioned in her website that she is still able to go around shopping in malls, trying

clothes and carrying bags while shopping.

While according to Wolff-Burke and Cole (2004), exercise is also important among

amputees using prosthesis as aid in each leg, arms, stomach and back muscles and plays a crucial

role in assisting the body for movement and standing. Without muscle strength the body is

unable to meet the demands of mobility.

The literature discusses the activities that can be done by patients using prosthesis and

most of the daily activities mentioned above can be done independently. Activities like shopping,

dressing up, and preparing meals can only be done after they adapted to their prosthesis.

However, other activities of daily living which the researchers want to evaluate are not

mentioned in the literatures above.

Significant Difference in the Physical Coping Abilities Based on the Level of Independence

of Unilateral Below-the-Knee Amputees Using Manual Wheelchair and Prosthesis

The study conducted by Hoenig,H., Taylor, D. & Sloan, F.(2003) stated that

technological assistance refers to the use of equipment (wheelchairs, canes, walkers, raised toilet

seats, prosthesis) to allow performance of daily activities. Equipment is provided to enable

persons with difficulty in performing their activities to function more independently.

According to Hewitt (2009), there are different physical adaptations especially in the use

of a prosthetic leg; there are different factors that may affect them like their age and weight.

However, some amputees prefer the comfort of wheelchair but still choose to use their prosthetic

leg since they have a greater degree of independence. Climbing the stairs is one of the difficulties

in using the wheelchair, however, there are some other areas available for patients with disability

using wheelchair.

In contrast, Tan (2006) stated using a wheelchair can actually avoid pressure ulcers and

promote increase in sitting comfort and tolerance. It is also advisable for long distance mobility.

According to the study of Chin et.al (2009), elderly patients with hip disarticulation

amputation using prosthesis consume much oxygen than those using wheelchair while walking

are asked to walk for a distance. The distance covered by patients using wheelchair is doubled

compared to the distance of those using prosthesis. These results show that the efficiency of the

use of prosthesis for walking is lower than the use of wheelchair.

In the study conducted by Shin et al. (2006), Prosthesis use was evaluated by standing up,

walking indoors and outdoors, walking across stairs, and requiring for external support. While in

the manual wheelchair users, the transferring and propelling activities are evaluated. During the

study, the prosthesis group showed great improvement in doing such activities. Most of the

prosthesis users could do daily activities independently and they got higher scores than the

wheelchair group. On the other hand, the wheelchair users could do some activities both

independently and dependently on others. As a result, overall independence in activities of daily

living was significantly higher in prosthesis group compared to the wheelchair group.

An article by Armstrong et.al (2008), stated that wheelchair use can enable people with

disabilities to become mobile, remain healthy and participate fully in community. The use of

wheelchair is proven to increase physical function and motor activity, and thus, using wheelchair

reduces dependence on others.

In contrast, another study conducted by Karmarkar et al (2009), veterans with lower-limb

amputation ages 18 years or older with lower limb amputation and made use of a prosthesis or

wheelchair for mobility were asked to perform functional activities such as traversing a ramp,

getting in and out of cars and buses, carrying 10 lb of groceries and participating in sports and

leisure activities. They were asked to categorize the activity as easy, difficult, or cannot perform.

The results of the study showed that patients using wheelchair and prosthesis had almost similar

scores. However, those in the prosthesis group with higher level amputation had more difficulty

in performing the said activities.

There are a lot of differences mentioned in the literatures above; some state that

prosthesis users cope better than those using wheelchairs, and others stated otherwise. One

mentioned literature, on the other hand, says that there is no difference in the performance of

activities between prosthesis and wheelchair users. However, no study is yet conducted regarding

the differences in the level of independence in carrying out activities of daily living among

unilateral below the knee amputees using manual wheelchair and prosthesis.

Significant Relationship of the Physical Coping Abilities of Amputees Using Wheelchair

and Prosthesis with Demographic Variables such as Age, Reason for Amputation and Sex

Bodeau et al (2005) stated that after losing a limb, physical adaptation greatly depended

on age. They stated that younger individuals usually cope well with their prosthetic legs and lead

active lives and may return to their work or continue to participate in their sports if they have

any, while the result for geriatric individuals may be more sedentary in nature.

In addition, in the study conducted by Tanneke Schoppen, MD, PhD, et.al (2003), it was

said that level of amputation, older age and presence of other diseases play a big role in

determining the functional outcome after the amputation. Healing problem is a problem in older

amputees; their skin is not elastic and flexible as compared to younger ones making the residual

limb more restricted in mobility. For prosthetic users, the characteristic of the stump predicts the

success in prosthesis fitting.

Furthermore, according to Mosquera (2002), the elderly find more difficulties during the

rehabilitation process than the younger people where the major goal is to regain the ability to

walk. All amputees have greater oxygen requirements when walking which is one of the reasons

for difficulties among the elderly.

Sousa et al (2009), stated women are greatly concerned with how they look in losing a

limb which has a huge impact on their physical appearance. It was stated that most women only

use their prosthetic legs for cosmetic purposes unlike the men who are more concerned with the

effective restoration of function in order to perform the activities they used to do before their

amputation.

According to Randall (2011), written in one of his journals “Behavioural Medicine”, the

reason of amputation affects how a person in coping with losing a limb. It was stated that those

individuals who lost their limb due to trauma found it harder to accept their condition showing

the denials which could delay their coping compared to those who lost their limb as the result of

long term disease and were able to accept their condition easier because they were able toprepare

for the amputation.

Synthesis

Assistive devices such as wheelchairs and prosthetics provide great assistance to knee

amputation. Studies have shown that there are lots of benefits that can be gained with the use of

the said devices with regards to doing basic tasks, such as moving from one place to another,

performing simple activities with independence, and actively participating in sports. Research

shows that most of the clients using wheelchairs are able to cope better than those using

prosthesis.

Studies also show that the age, sex, and reason of amputation are factors that affect the

physical coping of unilateral amputees using wheelchair and prosthesis. They state that elderly

have more difficulties in achieving the goal of rehabilitation which is to regain walking because

of their limitations unlike the younger individuals who have more energy in performing

activities. Studies also mention that men use their prosthesis for the restoration of function to

perform tasks they used to do, while women were only concerned on how they could improve

their appearance. They also stated that patients who received their amputation due to trauma

found more difficult in coping as compared to those who had more time to prepare for it, like

those who had long term illnesses such as diabetes.

Theoretical Framework

Adaptation Theory of Sister Callista Roy

According to Callista Roy, humans are viewed as biopsychosocial adaptive systems that

cope with environmental change through the process of adaptation (Polit and Beck, 2008). She

also stated that humans strive to live within a band where we can cope adequately. Responses to

amputation include adaptation, over a long period of time unilateral amputees use devices like

manual wheelchairs and prosthesis to cope physically.

Physiological function is one of the adaptive models in Roy’s theory. It refers to the way

humans interact with the environment through physiological processes to meet their basic needs.

In this study, unilateral below the knee amputees adapt through the use of prosthesis or manual

wheelchair and are therefore able to meet their physiological needs.

Conceptual Framework

Unilateral leg amputees

Assistive Device:

1. Manual Wheelchair2. Prosthesis Physical coping

abilities

Roy’s Adaptation

Model

The study focuses on the physical coping abilities of unilateral below the knee amputees.

The subjects of the study are males and females aging from 18 to 65 years of age who have been

using manual wheelchair and prosthesis for a minimum of 5 months and a maximum of 12

months. The conceptual framework shows the relationship between the use of manual wheelchair

and prosthesis to the physical coping abilities of the said patients. The figure shows the

relationship between the variables. There are two independent variables used in the study, which

are the use of manual wheelchair and prosthesis, whereas, the dependent variable is physical

coping abilities.

The triangle for unilateral below the knee amputation has its relationship with the circle

of assistive devices of manual wheelchair and prosthesis. This shows that the assistive devices is

based on the client’s preference and condition. In order for the client to perform his daily and

desired activities, he or she uses an assistive device such as manual wheelchair and prosthesis,

and if the client is able to use one of these devices with minimal pain or difficulty, the client is be

able to cope physically.

The physical coping ability is related to the assistive devices because without the use of

such devices the physical coping abilities would not be possible, while the assistive devices are

affected by the client’s condition and preference.

In this study, the independent variable (wheelchair and prosthesis) affects the dependent

variable (physical coping abilities) through the adaptation model of Sister Callista Roy.

According to Roy’s adaptation model, before a person can cope with his condition he

should first adapt to his environment. With regards to this study, amputees should first adapt to

their present condition using a manual wheelchair or prosthesis before they can physically cope.

Sister Roy mentioned three types of stimuli that affect the environment, namely, focal,

contextual and residual stimuli.

The focal stimulus will include factor such as the preference of amputees in their assistive

device.

The contextual stimulus will have a great impact in the physical coping abilities of the

amputees, since this refers to the reason for amputation that will come in hand after the focal

stimulus.

Attitude and the patient’s culture were not included since their effects were unclear and

these are referred as the residual stimuli.

Adaptive modes of a person include physiologic-physical, self-concept, role-function

and interdependence. Physiologic-physical adaptation will play a great role in adaptation since in

the five needs of an individual includes activity as a need. Furthermore, adaptation to changes in

needs will influence the degree of wholeness of a person.

Hypotheses

Null Hypotheses:

There is no significant difference between the rating of the amputees and the rating of the

caregivers.

There is no significant relationship between the physical coping abilities among amputees

using manual wheelchair and prosthesis with demographic variables (age, reason for amputation,

and sex).

There is no significant difference between the physical coping abilities among amputees

using manual wheelchair and prosthesis.

Definition of Terms:

1. Physical coping abilities: is the amputees’ level of independence in performing

activities of daily living as measured by the modified standardized tool.

Level of independence:

a. High independence-performs >70% of task to complete independence or 100%

b. Moderate independence- performs 35%-70% of the task with moderate assistance

c. Low independence- performs <35% of the task with maximal assistance

2. Wheelchair: A chair mounted on wheels. The type of wheelchair used in the study is a

manual wheelchair.

3. Prosthesis: the artificial leg used by unilateral leg amputees to substitute the

amputated leg