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

Research Outline Chapter I Introduction 1.1 Background of the study 1.2 Statement of the problem 1.3 Significance of the study 1.4 Marketing Practice 1.5 Scope and limitation Chapter II Review of Related Literature 2.1 Synthesis 2.2 Hypotheses 2.3 Definition of terms Chapter III Research Methodology 3.1 Research Design 3.2 Population and Sampling 3.3 Research Locale 3.4 Research instrumentation 3.4 Date Collection Procedures 3.5 Ethical Consideration Chapter IV Presentation, Interpretation, and Analysis of Data Chapter V Summary of Findings, Conclusion, and Recommendation 5.1 Summary of Findings 5.2 Conclusion 5.3 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 ones 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 Roys 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

Assistive Device: Unilateral leg amputees 1. Manual Wheelchair 2. Prosthesis

Physical coping abilities

Roys 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 clients 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 clients 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 Roys 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 patients 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