A postal questionnaire survey was conducted with 968 amputees, who had received an upper extremity prosthetic device from the Center of Prosthetics and Orthotics in the Department of Rehabilitation Medicine at Seoul Veterans Hospital during the period January, 2000, to June, 2008. Questionnaires were returned by 344 amputees, but 37 were incomplete and excluded from the analysis. Additional exclusion criteria were cases with disabilities affecting the functioning of their lower extremityies, and those with nervous system lesions and diseases, which could affect activities of daily living or their occupation. There was no case in 307 amputees.

The content of the questionnaire (see Appendix) included items about the general characteristics of the respondents, questions about their prosthetic limbs, and issues related to activities of daily living, rehabilitation training, occupation and driving. More specifically, the information requested about general characteristic included gender, current age, age at the time of amputation, educational background, side of the dominant hand prior to amputation, and side and level of amputation. Questions about their prostheses included the type of prosthetic limb used most frequently, levels of satisfaction with their prosthetic limbs and the average duration of daily usage of the prosthetic limbs. Information was obtained about whether amputation was unilateral (right or left) or bilateral and about the levels of the amputation on the left and/or the right side. Pictures along with explanations were included in the questionnaire in order to assist the the respondents' understanding of the questions relating to levels of am putation and type of prosthetic limb used. If the responses to these questionnaire items were missing or inadequate, the relevant information was obtained from the medical records kept at the hospital as well as the records available at the Center of Prosthetics and Orthotics.

The respondents were asked whether they had received rehabilitation training after wearing their prosthetic limb and the perceived importance of the rehabilitation training. Questions were also asked about levels of satisfaction and the extent to which the amputees could perform daily living activities after receiving their prosthetic limb. A total of 17 examples of the daily living activities were included: washing face, combing hair, putting on and taking off underwear, buttoning shirts, closing zipper of pants, wearing socks, tying of shoes laces, eating with spoon, opening and drinking canned beverages, writing name with a pencil, using scissors, opening doors by turning door knobs, opening and drinking a bottled beverage using a bottle opener, making telephone calls by pressing buttons on a mobile phone, opening envelopes, putting on and taking off prosthesis without the help of another person and mixing of blackbean-sauce noodles. The questions asked whether it had been possible to perform the above tasks and, if so, the extent of the difficulties in carrying out such tasks. In reality, almost all the subjects, who said the task was possible, failed to indicate the extent of difficulty in carrying out the task. For the purpose of analysis, the subjects were therefore coded into two groups: capable and or incapable of conducting the task. For the 17 detailed items, reference was made to the list of activities associated with upper extremities used by Davidson,6 but these were modified to make them more representative of daily living in Korea. For the extent of return to their previous occupation after amputation, the amputees were asked about occupational changes and the issues, which were problematic in terms of returning to their initial occupation. For the question about whether the amputee currently has an occupation, subjects were given the opportunity to indicate whether they had ceased employment due to their age. The items related to driving inquired whether the amputee drove vehicles before and after amputation, whether the vehicle had been remodeled if amputee continued to drive, and the reasons for not driving if the amputee had ceased to drive after amputation. Finally, items were included, which related to the presence, extent and types of pain/discomfort at stump sites.

All analyses were performed with PASW Statistics 18, and statistical significance was set at p<0.05. General characteristics and issues related to prosthetic limbs were summarised with descriptive statistics and frequency counts. Pearson's chi-square test was used to analyse variables related to the usage of prosthetic limbs, rehabilitation training and driving. ANOVA and independent t-tests were conducted to examine differences in the variables related to activities of daily living and occupation.

The results are summarized in Table 1. All of the 307 subjects were male and ranged in age from 27 to 88 years with a mean of 66.85 years. There were 95 subjects in their 70's (30.9%), 79 in their 60's (25.7%) and 59 in their 50's (19.2%). The mean age at the time of amputation was 25.70 years, and the mean time elapsing since the amputation was 40.15 years. In terms of educational background, 107 (34.9%) of the amputees were high school graduates. This was the largest group, followed by 84 (27.3%) with only elementary school education, 58 (18.9%) middle school graduates, and 58 (18.9%) with university or graduate school education. Among the total sample of amputees, 273 had anamputation only on one side of the body, while 34 had bilateral amputations. In the case of unilateral amputation, 150 (54.9%) subjects had damage on the dominant hand side.

Among the 273 unilateral upper limb amputees, transradial amputation was the most frequent (n=132, 48.4%), followed by transhumeral amputation (n=53, 19.4%), partial hand and fingers amputation (n=49, 17.9%), shoulder disarticulation (n=18, 6.6%), wrist disarticulation (n=18, 6.6%) and elbow disarticulation (n=3, 1.1%) (Table 2). Among the unilateral upper limb amputees, the types of prosthetic limb currently used included cosmetic hands (n=219, 80.2%), functional hands (n=41, 15.0%), and hook hands (n=13, 4.8%). Only one amputee in the entire group surveyed (including the bilateral upper limb amputees) used a myoelectric prosthetic limb. Those with an amputation of the dominant hand were found to use functional and hook hands more frequently than those with an amputation of the non-dominant hand (p<0.05). In response to the question about the level of satisfaction with the prosthetic limb currently being used, largest number of subjects (n=113, 41.4%) reported it to be 'moderate'. The number of respondents, who reported being 'very satisfied' or 'somewhat satisfied' (n=82, 30.0%), was similar to the number, who were 'dissatisfied' (n=78, 28.6%). Differences in the degrees of satisfaction with prosthetic limbs according to the level of the amputation and type of prosthetic limb (Table 3) were not statistically significant. When the amputees were asked about the hours of daily use of their prostheses (Table 4), 122 (44.7%) subjects reported an average daily use of 8-16 hours, 64 (23.4%) answered 4-8 hours, and 37 (13.6%) used their prostheses for less than 4 hours. A group of 50 (18.3%) subjects indicated almost no use. There were no significant differences in the reported average duration of daily use of prosthetic limbs by level of amputation or by type of prosthetic limb.

While only 20 (7.3%) of the unilateral amputees reported receiving rehabilitation training after being given a prosthetic limb, 59 (21.6%) responded that they felt rehabilitation training is essential. Although the group who received rehabilitation training was more aware of the importance of rehabilitation training (p<0.001), there were no significant clinical differences between the groups who and had not felt the need for rehabilitation training. On the question of the extent of usage of a prosthetic limb for the upper extremity in activities of daily living (Table 5), 9 (3.3%) subjects responded that they were able to perform complicated tasks, including repairs in the house, 12 (4.4%) reported that they could hold and lift objects, 8 (2.9%) responded they could hold onto their surroundings to prevent falling, 119 (43.6%) indicated that used their prosthetic limbs all the time for cosmetic purposes, 91 (33.3%) responded that they wore their prosthetic limbs occasionally for cosmetic purposes when going out, and 34 (12.5%) stated that their prosthetic limbs did not provide any functional assistance. A total of 210 (76.9%) subjects responded that they used their prosthetic limbs all the time or occasionally for cosmetic purposes. The amputees using prostheses for cosmetic purposes were not statistically different from those using them for functional purposes in terms of the type of prosthesis, average duration of daily usage of prosthetic limb, or level of amputation, but they did report a lower level of satisfaction with their prosthetic limbs (p<0.05). On the question of level of satisfaction with activities of daily living which they performed without the help of others, 7 (2.6%) subjects were highly satisfied, 57 (20.9%) were somewhat satisfied, 121 (44.3%) moderate, 36 (13.2%) were somewhat dissatisfied, and 52 (19.0%) were highly dissatisfied. There were no significant differences in the levels of satisfaction about the execution of activities of daily living according to the level of amputation or the type of prosthetic limb. Turning to difficulties encountered in performing the 17 detailed daily life activities, the most difficult tasks for the unilateral upper limb amputees were tying shoe laces (63.7%), opening and drinking a bottled beverage with a bottle opener (46.5%), using scissors (42.9%), and buttoning shirts (42.1%) (Table 6). The cosmetic and functional hand groups found tying shoe laces to be most difficult, while the hook hand group found that opening and drinking a bottled beverage with a bottle opener was the hardest task. In terms of level of amputation, the most difficult task for those with shoulder disarticulation, transhumeral or transradial amputation was tying shoe laces, for those with wrist disarticulation it was using scissors, and for those with partial hand and fingers amputation it was buttoning shirts.

On the question of occupation before and after the upper extremity amputation for all the amputees (Table 7), before their amputations 70 (22.8%) subjects had been doing skilled manual work, 68 (21.5%) were in farming, 57 (18.6%) were in the military, and 42 (13.7%) had been office or clerical workers. After their amputations, 122 (39.7%) subjects could not work any longer, while 90 (29.3%) subjects worked at another workplace, 33 (10.7%) performed different tasks at the same workplace, and 27 (8.8%) performed the same tasks at the same work place. Although there were no statistically significant differences in the extent of return to their previous occupations in terms of the different types of prosthetic limb and different levels of amputation, there was tendency for a better extent of return to the original occupation in those with an amputation at a distal site than in those with an amputation was at a proximal site. Although there seemed to be no difference in the extent of return to the previous occupation according to whether or not the amputation was in dominant hand, the extent of return was found to be better for those working in offices than for military personnel, skilled manual workers or common laborers (p<0.05). In addition, those, who had been employed in farming, skilled manual work and common laboring prior to amputation, felt a greater need for rehabilitation training than those in the other occupational groups (p<0.05). On the question of reasons for not being able to return to their occupation following amputation, 143 (51.6%) subjects responded that they could not perform as well as before. The other reasons given (in order of descending frequency) were insufficient function of prosthetic limb (n=45, 16.2%), lack of social awareness about disabled persons (n=32, 11.6%), and continuous pain (n=15, 5.4%). In response to the questions about driving, 62 (20.2%) of all the subjects (unilateral and bilateral amputees) reported they drove prior to amputation. After amputation, 126 subjects (41.0%) stated that they drove, and 34 (26.9%) of this group said that their automobile had been remodeled. On the question of the reasons for not driving after amputation, the largest number of respondents (n=85, 47.0%) answered that they did not drive even before amputation. The next most frequent reason given was that driving with a prosthetic limb is uncomfortable (n=52, 28.7%). Although there were no differences according to side of amputation or type of prosthetic limb between the group which was driving after amputation and the group that was not , those with a more distal site of amputation were more likely to be driving (p=0.001) (for data, see Table 8).

Amongst all the subjects, 83 (27.0%) respondents reported experiencing pain or discomfort all the time, while 132 (43.0%) reported occasional pain. A group of 38 (12.4%) amputees indicated that the pain occurred when using their prosthetic limbs. On the issue of the types of symptoms related to pain and discomfort, 167 (54.4%) of the subjects complained of tingling at the amputation site, 112 (36.5%) reported pain at the stump, 93 (30.3%) complained of phantom pain, 65 subjects (21.2%) mentioned itching at the amputation site, and 43 (14.1%) reported paresthesia at the amputation site.

Transradial amputation on both sides was the most frequent (n=20, 58.5%) form of bilateral upper limb amputation, and the functional and hook hands were the most frequently used types of prosthetic limb, accounting for 20.6% and 41.2% of the bilateral upper limb amputees, respectively. Functional prosthetic limbs were statistically more frequent in the bilateral upper limb amputees than in the unilateral amputees (p<0.001). On the question of level of satisfaction with the currently used prosthetic limb, 13 (38.2%) subjects responded that they were 'moderate', while 12 (35.3%) were 'satisfied' and 9 (26.5%) were 'dissatisfied'. Most (n=23, 67.6%) used prosthetic limbs for an average of 8-16 hours a day, 4 (11.8%) for 4-8 hours, 3 (8.8%) for less than 4 hours, and 4 (11.8%) hardly ever used them. There were no significant differences between unilateral and bilateral amputees in levels of satisfaction or in average daily durations of use. However, on the question of the extent of usage of a prosthetic limb for daily life activities, 54.5% of the bilateral amputees responded that the prostheses were functionally helpful; this was significantly higher than the corresponding figure for unilateral amputees (p<0.001). In terms of the 17 detailed activities of daily living, the most difficult tasks for the bilateral amputees were (in the order of descending frequency) tying shoe laces (82.4%), buttoning shirts (79.4%), using scissors (76.5%), opening and drinking a bottled beverage with a bottle opener (67.6%), and washing one's face (58.8%) (Table 5). On the question of the extent of return to previous occupation after the amputations, 29 subjects (85.3%), could not return to work, while 5 (14.7%) worked on different tasks at a different workplace. Clearly, none of the bilateral amputees returned to the same workplace or performed the same tasks.