amputation is a complex procedure with physical , social , and psychological components . in 
 developing countries , amputation rates have increased because of accidents , trauma , and 
 various systemic diseases . a study in 2008 estimates nearly 2 million people are living with 
 limb loss in the united states and it is projected that the number will more than double by 
 20501 . a recent study that demonstrated 
 the impact of limb loss in the us , showed that more than 57,000 ( 40% ) of all amputation 
 procedures were related to diagnose of diabetes2 . unfortunately there is insufficient data about causes , procedures , 
 and team - work for limb loss , and trauma - related amputation is more frequent in turkey3 , 4 . both traumatic and non - traumatic limb loss is often associated with multiple systemic 
 conditions or complications like diabetes , obesity , cardiovascular disease , musculoskeletal 
 problems , depression , and emotional stress2 , 5 . studies also estimate that 50% to 74% of 
 people with limb loss have 5-year mortality rate higher than many cancers , especially due to 
 vascular disease , diabetes , and some chronic conditions based on obesity2 , 3 , 6,7,8 . therefore , the amputee requires 
 multi - perspective expertise in coping with these systemic problems9,10,11 . as a critical part of the rehabilitation program , physiotherapy has an important role in 
 ensuring ideal functional outcome . in 1979 , malone et al.12 suggested that significant financial and therapeutic benefits 
 accrue from the application of an accelerated rehabilitation approach . additionally , recent 
 studies indicated that amputees who were accepted into multi - disciplinary rehabilitation 
 programs reached their highest functional level , and achieved or improved independent 
 mobility and self - care with a significant reduction in time9,10,11 , 13,14,15 . therefore , in accordance with this literature , the aim of our study is to demonstrate the 
 frequency of prosthetic applications and to appraise the importance of amputee 
 rehabilitation in turkey . questionnaires were administered to owners or employees of 36 institutions and the obtained 
 data were evaluated . the questionnaire consisted of 3 subsections including information 
 about the corporation , prosthesis , and rehabilitation . descriptive information about 
 corporation , number and profession of employees and frequency of professional training and 
 scientific research were questioned in the first subscale . amputation levels , types of 
 applied prosthesis and the frequency of patient control were questioned in the prosthesis 
 section . the study protocol was approved by the non - interventional clinical researches ethics board 
 of hacettepe university faculty of medicine . four hundred prosthetics application centers were contacted by e - mails or interviews . 
 questionnaires that we created were administered to owners or employees of 36 
 institutions . while 75% of institutions had no physiotherapist , 22.2% had 1 physiotherapist , 2.8% had 2 
 physiotherapists . there were 4 or fewer technician in 86.1% of the institutions and the 
 majority of employees were out of profession in almost all institutions ( table 1table 1.frequencies of physiotherapists and technicians employed by institutionsn=360123 or morephysiotherapist27 ( 75)8 ( 22.2)1 ( 2.8)0 ( 0)technician0 ( 0)17 ( 47.2)10 ( 27.8)9 ( 25)values in parentheses are percentages . ) ; 55.6% , 75% , 16.7% , and 25% of the institutions frequently encountered 
 above - knee , below - knee , above elbow , and below elbow amputees respectively ( table 2table 2.frequencies of different levels of amputees admitted to these institutions and 
 different types of prosthetics manufactured in these institutionsn=36frequentlyoccasionallyrarelyneverbelow knee27 ( 75)5 ( 13.9)3 ( 8.3)1 ( 2.8)above knee20 ( 55.6)10 ( 27.8)5 ( 13.9)1 ( 2.8)below elbow9 ( 25)13 ( 36.1)12 ( 33.3)2 ( 5.6)above elbow6 ( 16.7)10 ( 27.8)17 ( 47.2)3 ( 8.3)classical3 ( 8.3)7 ( 19.4)20 ( 55.6)6 ( 16.7)technological23 ( 63.9)12 ( 33.3)1 ( 2.8)0 ( 0)advanced technological11 ( 30.6)13 ( 36.1)9 ( 25)3 ( 8.3)values in parentheses are percentages . ) . the frequency of manufacturing and application of classical prosthetics was 8.3% , that of 
 technological prosthetics was 63.9% , and that of advanced technological prosthetics was 
 30.6% ( table 2 ) . falls and complications were reported in 83.3% and 75% of the institutions , respectively , 
 and 58.3% of them reported occasionally encountering cases with need of repair ; 55.6% of 
 institutions performed preprosthetic evaluations , 63.9% used gait analysis , and 50% 
 performed prosthetic rehabilitation frequently ( table 
 3table 3.frequencies of preprosthetic evaluation and prosthetic rehabilitation made by 
 these institutionsn=36frequentlyoccasionallyrarelyneverpreprosthetic evaluation20 ( 55.6)0 ( 0)0 ( 0)16 ( 44.4)prosthetic rehabilitation18 ( 50)10 ( 27.8)7 ( 19.4)1 ( 2.8)values in parentheses are percentages . ) . the reported evaluation methods were non - standardized , usually comprising measurement of 
 stump and information about patient and amputation . subjective methods , like observational 
 gait analysis , were often used as a method of gait analysis . rehabilitation process 
 consisted of basic activities like wearing and removing prosthesis , transfers , stair 
 climbing , and walking on uneven ground . the results of this study revealed that many of the institutions in turkey do not employ 
 physiotherapists specializing in prosthetics and orthotics , observational and subjective 
 evaluation methods are used by the institutions , and rehabilitation program consists of only 
 teaching basic activities of daily living with prosthesis . amputation is not only an aesthetic loss but also a permanent disability that affects 
 functional independence16 , 17 . appropriate prosthetic design , rehabilitation programs , 
 and education are important to regain lost functions and improve the quality of life for 
 amputees17,18,19,20 . at present , new prosthetic designs , technologically advanced , and expensive prosthetic 
 components are available . some of the prosthesis component manufacturers argue that new 
 components create advantages to learn how to use these devices . however , technological 
 progress and new expensive components do not trivialize the rehabilitation , and make it even 
 more important21 . selection of the 
 appropriate prosthetic components and rehabilitation are important for patient s daily life , 
 occupational , and recreational activities22 . deficiencies related to physiotherapist employment , evaluation and 
 rehabilitation processes in prosthetic application centers that were interviewed in this 
 study can lead to errors in the choice of prosthesis , inability to sustain daily living and 
 occupational activities and additional problems ( wound on the stump , problems arising from 
 gait disturbance , falls , etc . ) . the patient s health may be impaired due to these factors 
 and patients may be affected socially and economically . consequently , quality of life can be 
 reduced . amputee rehabilitation is a long process and an experienced multidisciplinary 
 rehabilitation team is necessary in order to achieve successful outcomes for upper / lower 
 extremity amputees23 . experienced 
 physiotherapists , physicians and technicians should be involved in the amputee 
 rehabilitation process . twenty - seven of the institutions participating in this study do not 
 employ physiotherapists , 8 employ one physiotherapist and 1 employs 2 physiotherapists . these results indicate that the number of physiotherapists employed in prosthetic 
 application centers is very inadequate . this number should be increased for more success in 
 prosthetic application and amputee rehabilitation in turkey . as known , physiotherapists 
 contribute to improve balance and functional activities like walking , turning , walking 
 uphill and on uneven grounds independently with or without prosthesis after lower limb 
 amputation24,25,26 . they provide training to 
 perform activities of daily living and self - care after upper limb amputation26 . twenty institutions reported they often perform assessments before prosthetic application ; 
 23 reported they often perform gait analysis ; and 18 reported they often performed 
 prosthetic rehabilitation . the indicated assessment methods were non - standardized , usually 
 including knowledge of patient and amputation , stump measurements , and observational gait 
 analysis . the indicated rehabilitation process included basic activities like donning 
 prosthesis , transfers , climbing stairs , and walking on uneven ground . however , amputation is 
 a permanent disability ; therefore , amputee rehabilitation is essential not only in early 
 prosthetic stage but also lifelong23 . deathe et al.27 found that there was no 
 consensus regarding rehabilitation program or patient outcome measurement tools and the 
 common outcome measures and rehabilitation methods were nonstandardized , informal methods in 
 canada , with their same study . a limitation of this study was the small number of centers participating in the research . four hundred prosthetic application centers were contacted but only 36 participated in this 
 study . this indicates that awareness of these institutions about the rehabilitation process 
 is insufficient . to our knowledge , the majority of prosthetic application centers do not 
 employ physiotherapists and information about rehabilitation of the other staff in these 
 centers is limited . in addition , 
 some of the participants may not have answered all questions correctly with commercial 
 concerns . this study offers data about prosthetic applications , prosthetic application centers , and 
 the status of the rehabilitation process in these centers in turkey . the results of this 
 study reveal the requirement for more physiotherapists working in these centers , the 
 utilization of standardized - objective assessment methods , and the development of the 
 rehabilitation process for successful prosthetic applications and amputee rehabilitation in 
 turkey . this study can create awareness to develop appropriate recommendations in order to maintain 
 prosthetic applications and ensure healthier amputee rehabilitation . amputee rehabilitation 
 should be considered in a broader context and physiotherapist employment should be increased 
 for sufficient rehabilitation process in prosthetic application centers .
[ purpose ] the aim of this study was to determine the frequency of prosthetic applications 
 and to appraise the importance of amputee rehabilitation in turkey . [ subjects and methods ] 
 questionnaires were administered to owners or employees of 36 institutions and the 
 obtained data were evaluated . 
 [ results ] while 75% of institutions had no physiotherapist , 
 25% had 1 or 2 physiotherapists ; there were 4 or fewer technicians in 86.1% , and the 
 majority of employees were out of profession in almost all institutions . 
 a total of 83.3% 
 of institutions reported falls , 75% reported complications , 58.3% of them occasionally 
 noted the need of repair ; 55.6% of institutions made preprosthetic assessments , 63.9% used 
 gait analysis , and 50% performed prosthetic rehabilitation frequently . 
 [ conclusion ] the 
 results of this study reveal the need for more physiotherapists in these centers , the 
 utilization of standardized - objective assessment methods , and development of 
 rehabilitation processes for successful prosthetic applications and amputee rehabilitation 
 in turkey .