597

Upper Limb Amputation and Prosthetics Epidemiology, Evidence, and Outcomes

Chapter 22

UPPER LIMB AMPUTATION AND 

PROSTHETICS EPIDEMIOLOGY, 

EVIDENCE, AND OUTCOMES

SANDRA L. HUBBARD WINKLER, PhD*

INTRODUCTION 

Prevalence

Incidence

UPPER LIMB RESEARCH: OUTCOMES

UPPER LIMB RESEARCH: MEASURES

ANALYSIS OF OUTCOMES

SUMMARY

*Research Health Scientist, Rehabilitation Outcome Research Center Research Enhancement Award Program, Malcolm Randall VA Medical Center, 1601 

SW Archer Road, 151-B, Gainesville, Florida 32608, and Assistant Professor, Department of Occupational Therapy, University of Florida, College of 

Public Health and Health Professions, PO Box 100164, Gainesville, Florida 32610; formerly, Research Associate, Predoctoral Fellow, Department of 

Rehabilitation Science and Technology, University of Pittsburgh, 5044 Forbes Tower, Pittsburgh, Pennsylvania 
598

Care of the Combat Amputee

INTRODUCTION

about one in every 200 people. The 1.2 million figure 

was derived from analyses of 1996 NHIS-D data,10 

and the 1.9 million figure is a 2005 estimate based on 

1996 NHIS-D data and US population growth.8,11 One 

limitation of 1996 NHIS-D data is that only amputees 

are counted; the numbers of amputations were not 

considered. Also, upper and lower limb amputees 

were not distinguished from one another. Thus, the 

prevalence of upper limb amputation cannot be found 

in NHIS-D data. A third limitation of 1996 NHIS-D limb 

loss data is that fingers and toes are excluded from 

the count; though loss of a finger or toe may not be as 

disabling as loss of a limb, amputation of a finger can 

be more expensive than amputation of a limb (paid for 

by workers compensation funds).12

Incidence

According to a report published online by the Limb 

Loss Research and Statistics Program, a collaboration 

between the Johns Hopkins Bloomberg School of Public Health and the Amputation Coalition of America, 

185,000 Americans undergo amputation each year.13

Using community hospital discharge data from the 

Healthcare Cost and Utilization Project, Nationwide 

Inpatient Sample, Dillingham et al identified 1,199,111 

hospital discharges that involved amputation or 

congenital limb deficiency from 1988 through 1996, 

averaging 133,235 amputations per year, and a 1996 

annual rate of 52 amputations per 100,000 US population.14 Unlike the NHIS-D data, the data from the 

Healthcare Cost and Utilization Project, Nationwide 

Inpatient Sample are categorized by upper limb amputation versus lower limb amputation. Dillingham et 

al14 identified 166,464 community hospital discharges 

related to upper limb amputations over the 9-year period (14% of all discharges). During this time, there was 

an average of 18,496 upper limb discharges per year.14,15

The 1996 incidence rate for discharges related to upper 

limb amputation was 5 per 100,000 US population, 

as opposed to a rate of 47 per 100,000 US population 

discharges related to lower limb amputations. These 

numbers include hospital discharges and not amputations; however, more than one amputation can occur 

during one hospitalization, and an amputee can be 

hospitalized more than once during a 9-year period. 

Of the upper limb amputation rate, 3.8 in 100,000 were 

trauma related, 1.3 in 100,000 were dysvascular related, 

and less than 1 in 100,000 were cancer related.

Emergency room visits, tracked by the National 

Electronic Injury Surveillance System All Injury Program, are another source of incidence data. According 

The hand has been described as the most individual 

and personal part of the human being.1 However, in 

the civilian sector, research, funding, and access to 

specialized care for upper limb amputees have been 

overshadowed by the substantial increase in lower limb 

amputation because of dysvascular disease.2–5 The prosthetic and rehabilitation needs of injured service members from Operation Enduring Freedom and Operation 

Iraqi Freedom have brought upper limb amputation to 

the forefront of current debate and attention. As of July 

2008, over 800 individuals have sustained major limb 

amputations as a result of military operations in Iraq 

and Afghanistan, 20% of which were upper limb amputations. At the same time, an unprecedented number 

of upper limb amputees are returning to active duty 

military service.6 This has led to a resurgence of research 

to improve the lives of individuals with upper limb loss 

both in the civilian and military communities.

Relying on the prevalence of upper limb amputation 

in the general US population to plan rehabilitation for 

all upper limb amputees is problematic for three reasons. First, most amputation epidemiological research 

in the general population has been funded by diabetes 

research dollars, and thus focuses on dysvascular-disease–related (and primarily lower limb) amputations. 

Second, results vary depending whether amputees, 

amputations, or amputation-related hospitalizations 

are counted.7 Finally, most disability survey data are 

more than 10 years old. “Prevalence” is determined 

by the number of people living with amputations 

and looks at how many people are affected, and most 

estimates of amputation prevalence are derived from 

the 1996 National Health Interview Survey–Disability 

(NHIS-D).8 “Incidence” refers to the number of new 

cases, usually per year, per population at risk. Sources 

of incidence data include community hospital and 

hospital emergency room discharge data and employment-related data. When interpreting incidence data, 

it is important to consider whether amputations or 

amputees are being counted and to identify the population at risk. For example, incidence rates of lower limb 

amputation for a population of individuals with dysvascular disease will be different than incidence rates 

for the US population. Frequently, statistical techniques 

are used to standardize the incidence rates to the US 

population by age, sex, and geographical region.9 

Prevalence

According to analyses of the NHIS-D, there are 1.2 to 

1.9 million people in the United States living with limb 

loss (data excludes finger tip and toe amputations), or 
599

Upper Limb Amputation and Prosthetics Epidemiology, Evidence, and Outcomes

to analysis of 2001–2002 National Electronic Injury 

Surveillance System data, approximately 30,000 people 

with non-work–related amputations were treated in 

emergency rooms each year, an annual rate of 10 per 

100,000 US population.16 Most (91%) were treated for 

finger amputation. Work-related amputation data is 

tracked both at the national and state levels.16 The 

Bureau of Labor Statistics reported a 1999 work-related 

amputation rate of 15 per 100,000 population (the 

results did not differentiate upper from lower limb 

amputations).17 For example, in Kentucky between 

1994 and 2003, 96% of the Kentucky worker’s compensation amputation claims were for upper limb 

amputation.12

UPPER LIMB RESEARCH: OUTCOMES

When designing any effective research program, it 

is imperative to reach some consensus on the best way 

to measure outcomes in various domains, such as functional performance, independence, quality of life, and 

cost. Research focused on upper limb amputation presents its own unique challenges. Recently, the Limb Loss 

Research and Statistics Program performed a survey 

to understand how both upper limb and lower limb 

amputation impact the outcomes of daily living and 

quality of life. Although the sample included 109 upper limb amputees (11% of the sample), results did not 

distinguish between upper and lower limb amputees. 

The results indicated 30% of the sample experienced 

difficulty with bathing and 7% required help with activities of daily living. It is possible that an upper limb 

amputee could have more difficulty with activities of 

daily living than a lower limb amputee because of the 

fine motor component of activities of daily living. Additionally, 81% of the sample used assistive technology 

(AT) other than prosthetic devices; for example, canes, 

walkers, and wheelchairs. AT needs of upper limb 

amputees remain unknown, though understanding an 

amputee’s need for AT is an important consideration 

for reimbursement policy and best practice guidelines 

(ie, what type of equipment should be made available 

to amputees to maximize function when they are not 

able to use their prostheses). For example, 41% of 

lower limb amputees have dermatologic conditions associated with the amputation, regardless of prosthetic 

use.18–20 Frequently, lower limb amputees are unable 

to use their prostheses during dermatologic episodes 

and must rely on mobility-related AT. No studies were 

found that addressed dermatologic conditions and AT 

needs for upper limb amputees. 

An amputee’s access to care is another important 

ideological factor to consider. The Limb Loss Research 

and Statistics Program study found 10% of amputees 

surveyed did not receive medical care when needed, 

and 20% did not receive rehabilitation when needed.13

An earlier study (1979–1993) of acute inpatient data 

found the mean acute length of hospital stay was 

nearly double for lower limb versus upper limb 

amputees.21 This is likely because most lower limb 

amputations are for dysvascular disease, a condition 

that may have associated comorbidities that may also 

require inpatient care. Another finding of the Dillingham et al21 study was that only 3% to 4% of upper 

limb amputees were discharged from acute care to 

rehabilitation, as opposed to 20% to 23% of lower limb 

amputees. It remains unknown if upper limb amputees 

fail to undergo inpatient rehabilitation because they do 

not use prostheses.21

Cost of care is another important consideration 

when designing a research program. In a 2004 study 

of both upper limb and lower limb amputees, Pezzin et al found the mean out-of-pocket expense for 

trauma-related amputation was $890, versus $485 

for dysvascular-disease–related amputations.22 Other 

important cost-related factors to consider include the 

costs of amputation in the United States (including the 

cost of hospitalization and the cost of a prosthetic device) and whether or not the cost is considered over the 

continuum of care. When considered across the entire 

continuum of care, the cost of a prosthetic device may 

appear more reasonable to third-party payers. 

As technology becomes more sophisticated and 

prostheses become more expensive, the decision as to 

who is eligible for which technology becomes more 

complicated. The US military provides service members with upper limb amputations with a myoelectric 

prosthesis, a body-powered prosthesis, and a cosmetic 

prosthesis. This level of care is rare in the civilian community, where third-party payers typically fund only 

one prosthesis unless there is evidence that additional 

devices will increase function. The Limb Loss Research 

and Statistics Program study found most amputees 

wore their prostheses all day if satisfaction with the fit 

was high, and associated the highest level of satisfaction with ease of use. These results, however, include 

satisfaction with both upper limb and lower limb 

prostheses, so they do not accurately describe patient 

happiness with upper limb prosthetics, alone. One of 

the main problems in research investigating satisfaction with and use of prosthetic devices is inconsistency 

in the definitions of “use” and “satisfaction.” Use has 

been measured with both continuous scales (ie, counting days per week and hours per day the prosthesis 

is worn) and categorical scales (ie, whether the pros-
600

Care of the Combat Amputee

thesis is worn regularly, a lot of the time, all the time, 

occasionally, not at all, or never).13, 22–25 The Limb Loss 

Research and Statistics Program study found 95% of 

participants used their prostheses regularly; however, 

only 21% of the participants were upper limb amputees. Studies of upper limb amputees performed in 

England found 72% of participants used their prostheses “regularly.”23 A study performed in Australia found 

18% of participants used their prostheses “all the time,” 

and 13% used their prostheses “a lot of the time.”26

Additionally, Davidson measured the extent to which 

upper limb amputees used the grasp feature of their 

prostheses; 7% used the grasp feature “all the time” 

and 29% “never” used the grasp feature. A limitation 

of the satisfaction and use studies is that measurement 

has not been standardized. Additionally, the type of 

prosthesis used was not typically mentioned. In order 

to determine what factors account for variability in use 

of devices, future studies need to use consistent, standardized scales to evaluate “use” per type of device. 

For example, a study performed in Ireland by Graham 

et al found 56% of upper limb amputee participants 

used their prostheses functionally, and 34% used their 

prostheses cosmetically (however, participants could 

only select one of the two use responses).24 Future 

studies should consider that participants may have 

more than one prosthesis, each used for a different 

purpose. In addition, studies should also account for 

other comorbidities that may affect outcomes. The 

Graham study was the only study found to include 

posttraumatic stress disorder (PTSD) as a factor related 

to use; 69% of the participants reported having PTSD. 

Most studies of upper limb amputation, including 

the Graham study, provide only descriptive analyses. 

Future studies could use PTSD as a variable in a regression model to more robustly determine the relationship 

between PTSD and use of a prosthesis. 

A study published in 1989 used descriptive statistics to find an association between successful use of a 

prosthetic device and having a high school diploma, 

being employed or rapidly returning to work, accepting the amputation, perceiving that the prosthesis 

was expensive, and exhibiting less than two comorbidities.27 Factors cited as unrelated to successful use 

of a prosthesis included age, hand dominance, rehabilitation, training in use of the prosthesis, and use of 

a temporary prosthesis. Forty participants with upper 

limb amputations were classified as successful users if 

they used a prosthesis every day, partially successful 

if they used a prosthesis for certain tasks, and unsuccessful if they did not use a prosthesis or did not use 

it functionally (ie, wore it only for cosmetic purposes). 

Forty-six percent of the successful users (n=12), 70% 

of the partially successful users (n=7), and 57% of the 

unsuccessful users (n=3) had received rehabilitation.27

Whether or not a participant had access to rehabilitation was not considered. One problem with this study 

is that descriptive statistics were used to explain multivariate relationships. However, this study could be 

helpful if it was repeated using a regression model 

design and current technology.

Time and error have been employed to measure 

successful prosthetic use with a motor learning approach. For example, in a 1993 study by Edelstein and 

Berger, children with traumatic upper limb amputation 

randomized to either a body-powered or myoelectric 

prosthesis were able to perform some tasks faster with 

a myoelectric prosthesis (donning socks, cutting paper, 

applying bandage) and other tasks faster with a bodypowered prosthesis (playing cards, using form board) 

following a 3-month training period.28

Satisfaction with prostheses has also been inconsistently defined. In Australia, Davidson used a survey 

to measure the following: satisfaction with the ability 

to perform specific activities (ie, unsatisfied, just satisfied, or very satisfied), overall satisfaction with the 

prosthesis (ie, very satisfied, quite satisfied, okay, quite 

unsatisfied, or very unsatisfied), and satisfaction with 

the characteristics of the prosthesis (ie, not acceptable, 

fair, good, very good, or excellent).26

In 2004 Pezzin et al22 used multivariate regression 

to examine use and satisfaction of prosthetic devices. 

Seventy-six percent of respondents were satisfied with 

the overall performance of their prostheses; however, 

data were not presented separately for upper limb and 

lower limb amputees. Other outcomes investigated 

by Pezzin et al included the relationship between 

satisfaction and use with time interval between amputation and receipt of prosthesis, level of amputation, 

geographic location, gender, race, ethnicity, insurance 

coverage, comorbidity, and age.22

Studies by Pezzin et al22 and Pinzur et al29 have 

shown a positive relationship between early fitting 

of a prosthesis and satisfaction and use. Early fitting 

is problematic for many service member amputees 

injured in Operations Enduring Freedom and Iraqi 

Freedom because of the extent of upper limb damage. 

Multiple surgeries may be necessary before a temporary 

prosthesis can be fitted. The Otto Bock MyoBoy (Otto 

Bock HealthCare, Minneapolis, Minn) computer-based 

technology enables upper limb amputees to train to use 

myoelectric prosthetic devices while waiting to be fitted 

for prostheses. This allows early muscle strengthening 

and retraining. A second reported benefit of myoelectric 

prosthetic use is reduced phantom limb pain.30

In a 1988 study by Melendez and LeBlanc,31 upper 

limb amputees who did not use prostheses attributed 

their choice to lack of education and information on 
601

Upper Limb Amputation and Prosthetics Epidemiology, Evidence, and Outcomes

prosthetic devices.31 Providing consistent delivery of 

prosthetic information and resources to both rural and 

urban populations remains a challenge. 

Research on the effect of upper limb amputation 

on the outcomes of employment, driving, and participation in society is sparse. In a study of upper 

limb amputees in England, Datta et al found that 

73% of upper limb amputees became employed or 

reemployed following their amputations, although 

67% had to change jobs.23 The study descriptively 

characterized the sample according to amputation 

level and type of prosthetic device used. Similarly, 

Pinzur et al found 72% of upper limb amputees in the 

United States were employed following amputation.29

Future studies could use multivariate methods to associate amputation site and type of prosthetic device 

with employment-related factors. Predictors of return 

to work have been identified for lower limb amputees, 

but not for upper limb amputees.32

Jones and Davidson investigated the driving patterns and vehicle modifications of upper limb amputees in Australia.25,26 The only US study of driving 

involved lower limb amputees. Boulias et al found 81% 

of lower limb amputee participants returned to driving 

an average of 4 months after their amputations. However, in the United States, the percentage of drivers 

with upper limb amputations who return to work, and 

the modifications they use, remains unknown. It is also 

unclear how these drivers are assessed for safety and 

how their need for modifications is determined.33

Participation in society is an important outcome of 

rehabilitation according to the World Health Organization’s International Classification of Functioning, Disability, and Health.

34 The US Centers for Disease Control 

and Prevention and Bureau of Labor Statistics measure 

participation by counting days missed from work as a 

result of a work-related amputation. Methods developed by the World Health Organization, Centers for 

Disease Control and Prevention, and Bureau of Labor 

Statistics to measure participation could be applied to 

study the degree to which upper limb amputees are 

able to participate in society. 

Evidence for effectiveness of training in the use of 

upper limb prosthetics is necessary for third-party 

reimbursement of rehabilitation, but cannot currently 

be found in the literature. Models of prosthetic training should also be investigated (eg, peer training, 

inpatient, outpatient, and telerehabilitation).35

UPPER LIMB RESEARCH: MEASURES

From a health-services perspective, outcome measures monitor the extent to which invested resources 

contribute to desired results.36 From a clinical perspective, outcome measures predict the relationship between doses of therapy and patient responses.37 From 

a rehabilitation perspective, outcomes to be measured 

are functional health status and patient satisfaction.38

Thus, outcomes can be measured at the system and 

patient levels. A challenge to measuring upper limb 

amputee and prosthetic outcomes is the interaction 

between the technology and the patient—a relationship that complicates AT research. Finally, once desired 

outcomes and appropriate measures have been identified, robust analyses must also be conducted.

Informal measures typically include using checklists 

developed by clinicians for assessment, developing 

an intervention plan, and monitoring progress. There 

are several informal checklists available. Occupational 

therapist Diane Atkins developed informal measures 

for upper limb amputees using body-powered prostheses. Occupational therapists at Otto Bock have 

developed the Occupational Therapist Upper Extremity Functional Evaluation and the Upper Extremity 

Prosthetic Functional Activity Checklist, both available 

on the Otto Bock Web site.

Formal measures have resulted in published psychometric properties; that is, reliability and validity 

have been tested. Reliability measures the consistency 

or repeatability of the measurement with the intent of 

separating true score from error. Validity is the strength 

of the inference or the extent to which the construct was 

measured, minus the threats and biases that can undermine results and generalizations. One problem with 

upper limb amputation and prosthetic research is the 

inconsistency in operational definitions of prosthetic 

“use” and “satisfaction,” resulting in the vast range 

(7%–88%) discussed earlier in this chapter.39–43 Without a valid, reliable, and preferably standard measure 

of use, the relationship between use and functional 

status cannot be established. Without a valid, reliable 

and preferably standard measure of satisfaction, the 

quality of care provided to amputees cannot be established. In this context, a standard measure is one that 

may be considered the goal and used in a variety of 

environments so study results can be compared. For 

example, there are many measures of quality of life. 

For many, the Short Form-36 Health Survey remains 

the subjective standard that is conducive to comparison of health status across populations.44,45 The Short 

Form-36 Health Survey has been used in at least one 

study of lower limb amputees.44

Three valid and reliable formal measures used 

in upper limb amputee and prosthetic research are 

the Disabilities of the Arm Shoulder Hand (DASH) 
602

Care of the Combat Amputee

questionnaire, the Orthotics and Prosthetics User 

Survey-Upper Extremity (OPUS-UE) scale, and the 

Trinity Amputation and Prosthetic Experience Scales 

(TAPES).36,46–49 The DASH is a 30-item questionnaire 

developed by the Canadian Institute for Work & Health 

and the American Academy of Orthopaedic Surgeons. 

It measures the physical and social impact of upper 

limb disorders. Scoring is done on a 5-point Likert 

scale, with a lower score indicating less disability. 

Davidson used the DASH to determine disability of 

patients with upper limb amputations and to compare 

those to other upper limb injuries.41 According to her 

findings, patients with brachial plexus injuries, Complex Regional Pain Syndrome, and bilateral upper 

limb amputations demonstrated significantly higher 

levels of disability compared to patients with unilateral 

upper limb amputations. Additionally, partial hand 

amputees reported a higher level of disability than 

major unilateral upper limb amputees.41

The OPUS-UE is a Rasch scale that measures activity limitations (23 items), quality of life (23 items), 

and patient satisfaction with services and devices (20 

items). A lower score indicates higher function. The 

OPUS-UE is commonly used in lower limb amputation 

research; no studies were found that used the upper 

limb version. 

The 54-item TAPES is designed to examine the psychosocial processes involved in adjusting to a prosthesis. 

There are four sections: (1) psychosocial (general adjustment, social adjustment, and adjustment to limitation 

subscales), (2) activity restriction (functional, social, 

and athletic restriction subscales), (3) satisfaction with 

the prosthesis (functional, aesthetic, and weight characteristics), and (4) exploration of phantom limb pain, 

residual limb pain, and other medical conditions not 

related to the amputation. The only known study using 

the TAPES with upper limb amputees was a study of 

the psychometric properties of the TAPES.50

ANALYSIS OF OUTCOMES

The majority of studies cited previously in this chapter used a survey design with descriptive statistical 

analyses that yield measures of central tendency. More 

recent studies use more robust study designs, such as 

logistic regression, that adjust for confounding factors 

such as marital status, employment status, educational 

level, and location of amputation.43,50 These studies 

control for factors that vary from one amputee or one 

prosthetic device to another. In addition, these studies 

can identify interactions between the amputee and the 

device, amputee factors that are present only when 

certain device factors are present, and vice versa. From 

these studies, the conditions under which a device will 

benefit an amputee can be predicted. 

Deathe et al studied formal versus informal outcome 

measures used in Canada.51 Doffing and donning a 

prosthesis was informally assessed by 90% of respondents, dressing by 78%, bath transfers by 81%, and car 

transfers by 56%. Informal home visit assessments were 

performed by 29% of respondents. Formal assessments 

were categorized according to whether they were used 

in the academic or clinic environments. The Functional 

Independence Measure (the most widely accepted functional measure in the research community; an 18-item, 

7-level ordinal scale intended to be sensitive to change 

in an individual over the course of a comprehensive 

inpatient medical rehabilitation program), the Prosthetic 

Profile of the Amputee (a clinical follow-up questionnaire that measures both actual prosthetic use and factors potentially related to prosthetic use by individuals 

with lower limb amputation), and the walking speed, 

walking distance, repetitive chair rise, and timed upand-go tests were performed in both environments.52,53

The Barthel Index, a 10-item measure commonly used in 

rehabilitation medicine, measures functional outcome, 

including factors like mobility and self-care, and was 

only used in the clinic.54 The Minimal Data Set (which 

evaluates the functional capabilities of residents in 

Medicare- and Medicaid-certified residential facilities), 

the Short Form-36 Health Survey (which produces a 

physical and mental component summary score), and 

goal attainment scaling (in which clinician and patient 

set individualized goals on a five-point scale) were only 

used in research.45,55–58

SUMMARY

Epidemiology and evidence-based research studies 

in upper limb amputation are few and outdated. There 

are potential upper limb amputation and prosthesis 

outcome measures that have yet to be used in research. 

Studies that pilot these measures, from surgery to community reintegration, are needed.
603

Upper Limb Amputation and Prosthetics Epidemiology, Evidence, and Outcomes

REFERENCES

1. Baumgartner R. Upper extremity amputation and prosthetics. J Rehabil Res Dev. 2001;38(4):vii–x.

2. Bethel A, Sloan FA, Belsky D, Feinglos MN. Longitudinal incidence and prevalence of adverse outcomes of diabetes 

mellitus in elderly patients. Arch Intern Med. 2007;167(9):921–927.

3. Collins TC, Beyth RJ, Nelson DB, et al. Process of care and outcomes in patients with peripheral arterial disease. J Gen 

Intern Med. 2007;22(7):942–948.

4. Ephraim PL, Dillingham T, Sector M, Pezzin L, MacKenzie EJ. Epidemiology of limb loss and congenital limb deficiency: a review of the literature. Arch Phys Med Rehabil. 2003;84(5):747–761.

5. Kurichi JE, Stineman MG, Kwong PL, Bates BE, Reker DE. Assessing and using comorbidity measures in elderly 

veterans with lower extremity amputations. Gerontology. 2007;53(5):255–259.

6. Zucchino D. Amputee Marine returns to combat duty. Los Angeles Times. August 6, 2008. Available at: http://www.

latimes.com/news/nationworld/world/la-fg-amputee6-2008aug06,0,1297101.story?page=1. Accessed October 8, 

2008.

7. van Houtum WH, Lavery LA. Methodological issues affect variability in reported incidence of lower extremity amputations due to diabetes. Diabetes Res Clin Pr. 1997;38(3):177–183.

8. Centers for Disease Control and Prevention. National Health Interview Survey on Disability (NHIS-D). Washington, DC: 

CDC; 1997.

9. Koepsell TD, Weiss NS. Disease frequency: basics. In: Koepsell TD, Weiss NS, eds. Epidemiologic Methods: Studying the 

Occurrence of Illness (Medicine). New York, NY: Oxford University Press; 2003: 37–62.

10. Adams PF, Hendershot GE, Marano MA. Current estimates from the National Health Interview Survey, 1996. Vital 

Health Stat 10. 1999;200:1–203.

11. Esquenazi A, Meier R. Rehabilitation in limb deficiency. Arch Phys Med Rehabil. 1996;77(Suppl):S18–S28.

12. McCall BP, Horwitz IB. An assessment and quantification of the rates, costs, and risk factors of occupational amputations: analysis of Kentucky workers’ compensation claims, 1994–2003. Am J Ind Med. 2006;49(12):1031–1038.

13. People with amputation speak out. Amputation Coalition of America, Limb Loss Research and Statistics Program 

Web site. Available at: http://www.amputee-coalition.org/people-speak-out/index.html. Accessed August 3, 2008.

14. Dillingham TR, Pezzin LE, MacKenzie EJ. Limb amputation and limb deficiency: epidemiology and recent trends in 

the United States. South Med J. 2002;95(8):875–883.

15. Esquenazi A. Amputation rehabilitation and prosthetic restoration. From surgery to community reintegration. Disabil 

Rehabil. 2004;26:831–836.

16. Conn JM, Annest JL, Ryan GW, Budnitz DS. Non-work–related finger amputations in the United States, 2001–2002. 

Ann Emerg Med. 2005;45(6):630–635.

17. Centers for Disease Control and Prevention, National Institution for Occupational Safety and Health. Fatal and Nonfatal 

Injuries, and Selected Illnesses and Conditions. Atlanta, Ga: NIOSH; 2004.

18. Dudek NL, Marks MB, Marshall SC. Skin problems in an amputee clinic. Am J Phys Med Rehabil. 2006;85(5):424–429.

19. Dudek NL, Marks MB, Marshall SC, Chardon JP. Dermatologic conditions associated with use of a lower-extremity 

prosthesis. Arch Phys Med Rehabil. 2005;86(4):659–663.

20. Meulenbelt HE, Geertzen JH, Dijkstra PU, Jonkman MF. Skin problems in lower limb amputees: an overview by case 
604

Care of the Combat Amputee

reports. J Eur Acad Dermatol Venereol. 2007;21(2):147–155.

21. Dillingham TR, Pezzin LE, MacKenzie EJ. Incidence, acute care length of stay, and discharge to rehabilitation of traumatic amputee patients: an epidemiologic study. Arch Phys Med Rehabil. 1998;79(3):279–287.

22. 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):723–729.

23. Datta D, Selvarajah K, Davey N. Functional outcome of patients with proximal upper limb deficiency—acquired and 

congenital. Clin Rehabil. 2004;18(2):172–177.

24. Graham L, Parke RC, Paterson MC, Stevenson M. A study of the physical rehabilitation and psychological state 

of patients who sustained limb loss as a result of terrorist activity in Northern Ireland 1969–2003. Disabil Rehabil. 

2006;28(12):797–801.

25. Jones LE, Davidson JH. The long-term outcome of upper limb amputees treated at a rehabilitation centre in Sydney, 

Australia. Disabil Rehabil. 1995;17(8):437–442.

26. Davidson J. A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther. 2002;15(1):62–70.

27. Roeschlein RA, Domholdt E. Factors related to successful upper extremity prosthetic use. Prosthet Orthot Int. 

1989;13(1):14–18.

28. Edelstein JE, Berger N. Performance comparison among children fitted with myoelectric and body-powered hands. 

Arch Phys Med Rehabil. 1993;74(4):376–380.

29. Pinzur MS, Angelats J, Light TR, Izuierdo R, Pluth T. Functional outcome following traumatic upper limb amputation 

and prosthetic limb fitting. J Hand Surg [Am]. 1994;19(5):836–839.

30. Lotze M, Grodd W, Birbaumer N, Erb M, Huse E, Flor H. Does use of a myoelectric prosthesis prevent cortical reorganization and phantom limb pain? Nat Neurosci. 1999;2(6):501–502.

31. Melendez D, LeBlanc M. Survey of arm amputees not wearing prostheses: implications for research and service. J 

Assoc Child Prost Orthot Clin. 1988;23(3):62–69.

32. Hebert JS, Ashworth NL. Predictors of return to work following traumatic work-related lower extremity amputation. 

Disabil Rehabil. 2006;28(10):613–618.

33. Boulias C, Meikle B, Pauley T, Devlin M. Return to driving after lower-extremity amputation. Arch Phys Med Rehabil. 

2006;87(9):1183–1188.

34. World Health Organization. International Classification of Functioning, Disability and Health. Geneva, Switzerland: WHO; 

2001.

35. Lake C. Effects of prosthetic training on upper-extremity prosthesis use. J Prost Orthot. 1997;9(1):3–9.

36. Heinemann AW, Fisher W, Gershon R. Improving healthcare quality with outcomes management. J Prost Orthot. 

2006;18(1S):46–50.

37. Granger CV. Quality and outcome measures for rehabilitation programs. eMedicine from WebMD. Available at: http://

www.emedicine.com/pmr/TOPIC155.HTM. Accessed August 5, 2008.

38. Ware JE Jr, Phillips J, Yody BB, Adamczyk J. Assessment tools: functional health status and patient satisfaction. Am J 

Med Qual. 1996;11(1):S50–S53.

39. Datta D, Selvarajah K, Davey N. Functional outcome of patients with proximal upper limb deficiency—acquired and 

congenital. Clin Rehabil. 2004;18:172–177.
605

Upper Limb Amputation and Prosthetics Epidemiology, Evidence, and Outcomes

40. Davidson J. A survey of the satisfaction of upper limb amputees with their prostheses, their lifestyles, and their abilities. J Hand Ther. 2002;15(1):62–70.

41. Davidson J. A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the 

Arm, Shoulder and Hand (DASH). Disabil Rehabil. 2004;26(14-15):917–923.

42. Pezzin LE, Dillingham TR, MacKenzie EJ. Rehabilitation and the long-term outcomes of persons with trauma-related 

amputations. Arch Phys Med Rehabil. 2000;81(3):292–300.

43. Pezzin LE, Dillingham TR, MacKenzie EJ, Ephraim PL, Rossbach P. Use and satisfaction with prosthetic limb devices 

and related services. Arch Phys Med Rehabil. 2004;85:723–729.

44. Ware JE. Conceptualizing and measuring generic health outcomes. Cancer. 1991;67(3):774–779.

45. Ware J. SF-36 Health Survey Manual and Interpretation Guide. Boston, Mass: Nimrod Press; 1993.

46. Heinemann AW, Gershon R, Fisher W. Development and application of the orthotics and prosthetics user survey: 

applications and opportunities for healthcare quality improvement. J Prost Orthot. 2006;18(1S):80-85.

47. Heinemann AW, Bode RK, O’Reilly C. Development and measurement properties of the Orthotics and Prosthetics 

Users’ Survey (OPUS): a comprehensive set of clinical outcome instruments. Prosthet Orthot Int. 2003;27:191–206.

48. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of 

the arm, shoulder and hand). The Upper Extremity Collaborative Group (UEGC). Am J Ind Med. 1996;29(6):602–628.

49. Beaton DE, Katz JN, Fossel AH, Wright JG, Tarasuk V, Bombardier C. Measuring the whole or parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions 

of the upper extremity. J Hand Ther. 2001;14(2):128–146.

50. Desmond DM, MacLachlan M. Factor structure of the Trinity Amputation and Prosthesis Experiences Scales (TAPES) 

with individuals with acquired upper limb amputations. Am J Phys Med Rehabil. 2005;84(7):506–513.

51. Deathe AB, Miller WC, Speechley M. The status of outcome measurement in amputee rehabilitation in Canada. Arch 

Phys Med Rehabil. 2002;83(7):912–918.

52. Gauthier-Gagnon C, Grisé MC. Prosthetic profile of the amputee questionnaire: validity and reliability. Arch Phys Med 

Rehabil. 1994;75(9):1309–1314.

53. Hershkovitz A, Brill S. Get up and go—home. Aging Clin Exp Res. 2006;18(4):301–306.

54. McGinnis GE, Seward ML, DeJong G, Osberg JS. Program evaluation of physical medicine and rehabilitation departments using self-report Barthel. Arch Phys Med Rehabil. 1986;67(2):123–125.

55. Hurn J, Kneebone I, Cropley M. Goal setting as an outcome measure: a systematic review. Clin Rehabil. 2006;20(9):756–

772.

56. Uniform Data System for Medical Rehabilitation. The FIM System Web site. Available at: http://www.udsmr.org/

WebModules/FIM/Fim_About.aspx. Accessed August 5, 2008.

57. Ware J. SF-36 health survey update. Spine. 2000;25(24):3130–3139.

58. Forbes DA. Goal attainment scaling. A responsive measure of client outcomes. J Gerontol Nurs. 1998;24(12):34–40.
606

Care of the Combat Amputee