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Body Image: The Lower-Limb Amputee

James W. Breakey, PhD, CP

ABSTRACT

A 110-item survey was sent to lower-limb amputees to examine their self-perception and psychosocial well-being. The subjects (N = 90) were male unilateral, traumatic, lower-limb amputees.

The author used an amputee body-image scale (ABIS) to measure each amputee's perception of his body image. Data obtained from the ABIS were used to determine correlations with the other assessment scales.

Findings indicated significant positive correlations between body image and self-esteem, anxiety and depression. This suggested an amputee's evaluation of his or her body image can influence these variables in either a positive or negative manner. A significant correlation also was found between body image and life satisfaction, indicating the more negative an amputee feels about his or her body image, the less satisfied he or she is with his or her life.

Results of this study support the hypothesis that a relationship exists in lower-limb amputees between their perception of their body image and their psychosocial well-being. In fact, the significant correlations tend to support other studies in which physical disability was found to increase a person's tendency toward anxiety, depression, low self-esteem and less satisfaction with life.

Introduction

The thought of losing an anatomical part, such as a lower limb, is devastating to most people. When it happens, amputation causes a threefold loss in terms of function, sensation and body image.

Compounding the problem is the general public's misconception about prostheses and their function. For example, media hype of amputees running in the Boston Marathon or climbing mountains colors viewers' perceptions, preventing them from fully realizing the emotional impact this loss can have on the individual.

Few studies have been reported in the literature in the area of research on body image and the amputee. This study examines the perception amputees have of their bodies and attempts to determine if a relationship exists between this perception and amputees' psychosocial well-being.

Cash (1) states, Psychologists use the term body image to refer to the attitudes we have about our own body and its appearance. In other words, body image refers to our perceptions, thoughts, feelings and reactions to our looks." Each person holds an idealized image of the body, which he uses to measure the percepts and concepts of his or her own body (2). According to Kolb (3), an alteration in an individual's body image sets up a series of emotional, perceptual and psychological reactions. He suggests the loss of a limb by amputation could lead to a long-term disorder in the individual's body experience.

According to Newell (4), less conventionally attractive people will likely receive less reinforcement from others, resulting in a decrease in self-esteem and a decrease in positive self-image. Therefore, amputation of a limb not only results in a loss of function and sensation but also requires a revision of body image (5). Fishman (6) states a person "must learn to live with his perceptions of his disability" rather than "with his disability." He goes on to say the amputee tends to focus his or her anxieties on the altered anatomy and to give the disability more importance in his or her future than is realistic. Successful adjustment for the amputee appears to be in the incorporation of the prosthesis into his or her body image and his or her focus on the future and not on the part lost (7,8).

Goldberg (9) suggests even when amputation does not interfere with one's ability to perform a job or to take part in social or recreational activities, it can have a great impact on self-esteem. As a result, a person may focus his or her attention on the loss of normal physical appearance and attempt to conceal the disfigurement. Goldberg further suggests an assessment scale to measure body image of amputees would be useful in assessing the psychological aspects of adjustment to amputation (9).

Should an individual have a limb amputated, the person will tend to compare the appearance of his or her body and functional capabilities to others'. Based on these comparisons, one could speculate it might be difficult for the amputee to have a positive attitude toward his or her body. The author hypothesizes if an amputee has a poor perception of his or her disability from a body-image perspective, one might expect a higher degree of anxiety and depression, lower self-esteem and less satisfaction with life.

Review of the Literature

Fishman (10) studied 96 transfemoral amputees, all war veterans, to determine whether a relationship existed between self-concept and adjustment to a prosthesis. His findings indicate a significant relationship: When attitudes toward the self are healthy and the loss of limb is accepted, behavioral adjustment is positive and sound. Fishman (10) states, "There is little doubt that an individual's self-concept sheds considerable light on the meaning of the disability to the individual and in that sense is of great importance in understanding the individual's behavior."

Later, Fishman (6) determined the amputee's perception of his or her physical disability has a greater influence on successful rehabilitation than the extent of the disability. He states, "A number of very specific psychological, social and physiological human needs are thwarted when one becomes physically handicapped as a result of amputation.... The method of adjusting psychologically to an amputation is primarily a function of the preamputation personality and psychosocial background of the person." Fishman also has observed that, in time, the amputation and the prosthesis are not the main focus for the amputee who becomes successfully rehabilitated.

In addition, Fishman (6) identified seven human needs common to amputees:

  • Physical function with a prosthesis.
  • Visual and auditory considerations for the prosthesis.
  • Comfort of the prosthesis.
  • Energy expenditure in using the prosthesis.
  • Achievement in various activities with use of a prosthesis.
  • Economic security.
  • Status and respect of one's peers.

He affirms these needs cannot be completely satisfied, and the consequences of the frustration that arises can result in psychological conflict and varying behavior (6).

According to Goffman (11), some amputees experience psychic pain that translates into a stigma. As a consequence, they expect to be ostracized from the group as less acceptable human beings. Fearing rejection, new amputees may view themselves as revolting and project these feelings onto relatives and friends. They may withdraw from and reject their friends to avoid the pain and anxiety of the anticipated rejection (12,13).

According to Kohl (13), a person who has lost a limb must see him- or herself as just that (a person who has lost a limb) and not burden him- or herself with labels such as "amputee." Kohl suggests this attitude is the key to a positive adjustment to a new body image after an amputation. Shontz (14) suggests an individual who is missing a limb has three body images: the preamputation intact body, the body with limb loss and the body image when wearing a prosthesis.

Weiss et al. (15) assessed amputees using the Bender-Gestalt test in an attempt to identify those amputees who, because of personality difficulties, could not be prosthetically rehabilitated. They relate findings indicating 47 percent of the sample were likely to present rehabilitation problems. Although their findings are statistically significant, their results are not sufficiently reliable to allow use of the test on individual amputees to predict successful prosthetic rehabilitation.

A year later, the same investigators (16) studied 56 transfemoral amputees and 44 transtibial amputees using a comprehensive battery of tests and a 50-item Amputee Behavior Rating Scale. The rating scale assessed the actual behavior of the amputees as observed by the members of the amputee clinic team. This form was completed by the team members: the physician, therapist, prosthetist and rehabilitation counselor. On nearly all measures the transtibial amputees obtained better scores than the transfemoral amputees. The investigators (16) found "the level of amputation was significantly related to numerous aspects of psychophysiological and personality functioning while etiology was not." They concluded that since transtibial amputees are less disabled as a group, they generally function better than transfemoral amputees. In addition, they suggest the less-positive self-image of the transfemoral amputees also can be attributed to a less-appealing gait, often with a noticeable limp (16).

Parkes (17) reports having interviewed 46 amputees four to eight weeks and again 13 months following amputation, asking 18 questions to detect depression and 12 questions to detect autonomic reaction. One-third to one-half of the subjects showed moderate disturbance, which continued a year later. One-quarter of the group reported feelings of insecurity, self-consciousness, restlessness and depression as well as insomnia. These symptoms were consistent from the first to the second interview. Additionally, as a group, the amputees' levels of depression and autonomic reaction, as indicated by test scores 13 months postamputation, were twice as great as those of nonamputee U.S. men and women of the same age.

According to Kolb and Brodie (18), a healthy amputee is one who accepts his or her loss, uses a prosthesis to assist in returning to work, and resumes his or her position in the family. On rare occasions, serious personality disturbances arise, which interfere with the amputee's marital and vocational adaptation and cause him or her to resist using a prosthesis. This upsurge of anxiety and hostile feelings results from a distortion of the amputee's concept of his or her body and, therefore, of him- or herself (18). Reporting on discussions held with amputees at a support group, Racy (5) considered most of the members to have accepted their new body image with their prosthesis as part of themselves. However, all of the group members continued to experience self-consciousness in social situations. For example, members admitted to a tendency to walk more clumsily in public when they felt they were being observed.

Thompson and Haren (19) studied 134 unilateral lower-limb amputees, comparing recent amputees (N = 73) who had just received their first prosthesis with prosthetic wearers of one to two years (N = 61). Using clinical measures and interviews, they found both groups were nearly equal in regard to risk of psychiatric illness. At risk were 47 percent of the new patients as compared to 44 percent of the one-to-two-year group.

Kashani et al. (20) interviewed 65 amputees and found 23 (35 percent) met the DSM-III criteria for major depressive disorder. Thus, the study "documents a significantly greater frequency of depression among a sample of amputees than would be expected in the general population." Each subject also completed the Beck Depression Inventory. The depressed amputees scored a higher mean as compared to the nondepressed group. Therefore, amputation alone, they contend, cannot be the sole reason for this high frequency of depression. Instead, they hypothesize other factors are involved, including difficulty in securing a job, decreased social interaction, increased dependency and "lowered self-esteem due to distortion of body image."

Frank et al. (21) explain their use of the Beck Depression Inventory, the Symptom Checklist-90 and interviews to evaluate 65 amputees. They set a median age of 65 years to divide amputees into young (N = 31) and old (N = 35) and a median time since amputation of 18 months to define recent and long-term amputees. Their findings revealed that, in the older group, the longer the time since amputation the fewer psychological symptoms and less depression exhibited. In contrast, the younger amputees had increased psychological symptoms and increased depression. "The picture of the younger amputee [that] emerges from the present study is of an anxious, sensitized, vigilant person who has difficulty integrating his/her present life." The investigators theorize the older amputees, because of their adaptation to the aging process, may be more malleable in altering their body image after limb loss.

Frierson and Lippmann (22) describe the results of their evaluation of 86 amputees referred to them for consultation over a 10-year period. This represented only 6.2 percent of the amputations performed during the 10 years by the referral sources. In order of frequency, normal grief, followed by life circumstance problems, were the two most common psychiatric diagnoses determined. The most common symptoms among the 86 patients, also in descending order from most frequent, were despondency, anxiety, insomnia, suicidal thoughts, phantom-limb phenomena and flashbacks. Mention is made that a few amputees were referred because of alteration in body image, but no specifics are presented.

Rybarczyk et al. (23) sampled 89 lower-limb amputees. Using a 70-item self-report questionnaire, they obtained medical, demographic and psychosocial information. Included in the 70-item questionnaire was the Center for Epidemiologic Studies' Depression Scale (CES-D), which consists of 20 statements, plus the 40-item Interpersonal Support Evaluation List, a single question on perceived health, a six-item scale on prosthetic satisfaction (three-item measure of aesthetic aspects and three-item measure of functional aspects), and a social discomfort scale. The social discomfort scale is a three-item measure "written to address social discomfort associated with the subjects' amputations and prostheses" (23). On the CES-D scale, 23 percent of the subjects were found to have depressive symptomatology; a significant correlation between social discomfort and depression also was found. A nonsignificant relationship between social discomfort and satisfaction with the functional and aesthetic aspects of prostheses was reported.

Nicholas et al. designed a 123-item questionnaire to study 94 amputees (24). They report a negative correlation between the period of time following amputation and depression. The authors consider their findings to suggest that emotional well-being improves with time after amputation. They also point out that amputees who wore their prostheses for longer durations daily were less depressed.

Methodology

The purpose of the study was to determine whether a relationship exists between body image and psychosocial well-being. The author created an amputee body-image scale (ABIS) to measure the amputee's perception of his or her body image. The data obtained from the ABIS allowed correlations to be made in respect to other assessment scales.

To determine if a relationship exists between body image and anxiety, depression, self-esteem and satisfaction with life, the statistical technique Spearman rank-order correlation coefficient (rs) was used. Simply known as "Spearman correlation," this statistic is a measure of association between two nonparametric variables measured on an ordinal scale (25). The Spearman correlations were corrected for ties. The Mann-Whitney U test was used (25) to compare differences between groups.

Research Methods

The parameters for selecting the amputee subjects in this clinical study included 1) gender of subjects (male), 2) etiology of amputation (trauma), 3) level of amputation (unilateral transtibial and unilateral transfemoral amputees), and 4) all subjects at least one year postamputation.

From the files of the author's prosthetic practice, 162 lower-limb amputees were identified. Using a random number table, a sample of 110 subjects was selected.

The subjects were asked to fill out a 110-item self-report questionnaire consisting of six scales:

  • The amputee body-image scale (20 items)
  • A scale to measure self-esteem (25 items)
  • A scale to measure nonpsychotic depression (25 items)
  • A clinical anxiety scale (25 items)
  • A satisfaction-with-life scale (five items)
  • Demographic data (10 items)

The survey was mailed to the subjects. A cover letter was included with the assessment scales. Subjects were later followed up by letter.

Justification for the Amputee Body-Image Scale (ABIS)

Evidence suggests amputees experience dissatisfaction with their body image (5,12,22,26-29). This negative self-image remains despite receiving a prosthesis (6,16,13,30,31). Furthermore, many amputees have been found to have concurrent symptoms of social anxiety, social isolation and depression (20-24,27,29).

Currently, criteria used for physical appearance disturbance is categorized under Body Dysmorphic Disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (32) and constitutes features of at least four other disorders. These disorders include anorexia nervosa, bulimia nervosa, sexual disorder not otherwise specified and delusional disorder somatic type. There is no category in DSM-IV for a body-image disorder as a result of amputation.

When the study was implemented, a scale to assess if an amputee has a body-image disturbance specifically related to the amputation and its effects on body experience was not available. Therefore, the ABIS was designed by the author.

Development of the Amputee Body-Image Scale (ABIS)

The manual Standards for Educational and Psychological Testing (33) maintains test instruments should be designed based on logical evidence, and the domain used in item selection should be described.

According to Thompson's extensive review of the literature (34), "overconcern" with physical appearance is the "core feature of body-image disorder."

Research studies have identified other components of body-image disturbance, including affective, cognitive and behavioral components. The affective component of measuring a person's anxiety regarding his or her body has been reported in studies (35,36) indicating individuals with body-image disorders presented biases, distortions and cognitive errors in rating their bodies (35,37,38). Moreover, the behavioral component of body-image disturbance has been reported by Rosen et al. (39) and Thompson et al. (40).

Thompson (34) proposes criteria for body-image disorder. Using a DSM (diagnostic and statistical manual of mental disorders) model, he proposes, "If the symptoms are distressing to the individual to the point of functional interference in daily activities," a body-image disorder may be present. Thompson's criteria for a body-image disorder, based on the DSM model, is summarized as follows:

  1. A continual dissatisfaction with an aspect of one's physical appearance that impairs involvement in social activities or vocational functioning.
  2. Presence of two of the four following symptoms:
  1. Affective anxiety on a daily basis, which becomes aggravated by social situations.
  2. Cognitive distortions of dissatisfaction with a body area.
  3. Behavioral avoidance of circumstances when one's physical appearance can be evaluated by self or by others.
  4. Perceiving body size to be at least 25 percent larger than actual.

According to Shontz (14), to understand how a physical condition, such as an amputation, affects an individual's body image, a description of the scope and dimension of its effects at each of the "levels" and on each of the "functions" of body experience must be considered. Shontz (41) relates the four levels to the seven functions of body experience. To summarize, "body schemeta" is related to the body function as a sensory register and as an integrator of incoming information. Body self-level is related to the body function serving as a source of needs and drives, which serve as a stimulus to self and as an instrument for action. The body acting as an expressive instrument and a stimulus to others is related to the body fantasy level. Finally, body concept is related to the body's experience as a private world.

In referring to the normal functions of body experience as described by Shontz (14,42), amputation can be viewed in this way: Loss of a limb alters direct body sensation and can affect body schemata in the expression of a phantom limb. Amputation also changes the body as an instrument for action, as a stimulus to the self and as a stimulus to others.

The ABIS (see Table A) is comprised of 20 items that assess how an amputee perceives and feels about his or her body experience. Based on the above evidence and information, the questions, which were described in more detail in Reference 43, were formulated.

Scoring of ABIS

The subjects were asked to indicate their responses to the questions using a scale of 1 (none of the time) to 5 (all of the time). This scale produces scores that range from 0 to 100, where low scores indicate the relative absence of a body-image concern, and higher scores indicate the presence of a more severe problem. Three of the questions (numbers 3, 12 and 16) are reverse-scored.

Validity

Corcoran and Fischer (44) and Anatasia (45) affirm logical content validity in test development can be demonstrated by the developers following a procedure evaluating the selection of content items and encompassing the content domain. The author attempted to logically select items and formulate questions to tap the domain of body image and the lower-limb amputee.

Test Reliability

Evaluating the internal consistency of a test instrument is a method of determining reliability (44,45). Internal consistency of a test is influenced by content sampling and the heterogeneity of the particular construct domain being sampled (45). To determine if the 20 items of the ABIS are tapping into a similar domain, Cronbach's coefficient alpha research procedure (46) was used and found to be .88. Nunnally (47) affirms the internal consistency for measurements in a preliminary state of development and validation should be at least .70. Since alpha coefficients exceeding .80 suggest a test instrument is internally consistent (44), the ABIS may be considered reliable.

Other Assessment Instruments

Four rapid assessment instruments (RAIs) were chosen to be used in conjunction with the ABIS. These RAIs were chosen for the following advantages: 1) ease of administration and scoring; 2) access to attitudes, feelings and behavior of subjects that may be difficult to observe overtly; and 3) retrieval of sensitive information from subjects that may be difficult to verbalize (44,48,49).

The following four scales that measure self-esteem, depression, anxiety and satisfaction with life tap into what Cash et al. (50) call "psychosocial well-being."

Index of Self-Esteem (ISE)

Self-esteem as measured with respect to the ISE is considered "the evaluative component of self-concept" (48). This 25-item scale has consistently achieved an alpha coefficient of .90 or larger (48). With respect to content, construct, factorial and known groups, this scale achieves validity coefficients of .60 or greater (48,51,52). This scale correlates highly with scores on the General Contentment Scale (GCS). The ISE scale has excellent stability with a two-hour test-retest correlation of .92 and a low standard error of measurement (S.E.M.) of 3.70 (48).

Generalized Contentment Scale (GCS)

The GCS focuses largely on the affective aspects of clinical depression (48). This 25-item scale has consistently achieved an alpha coefficient of .90 or greater (48). With respect to content, construct, factorial and known groups, the GCS achieves validity coefficients of .60 or greater (48,52). This scale has a low S.E.M. of 4.56 and a two-hour test-retest correlation of .94 (48).

The GCS has demonstrated good concurrent validity, correlating in two studies .85 and .76 with the Beck Depression Inventory and .92 and .81 for two samples using the Zung Depression Inventory (48).

Clinical Anxiety Scale (CAS)

The CAS is a 25-item scale designed to measure the amount and the degree of clinical anxiety. This scale has consistently achieved an alpha coefficient of .90 or greater (53). With respect to content, construct, factorial and known groups, the CAS achieves validity coefficients of .60 or greater (52,53). The CAS has a low S.E.M. of 4.2 (53) and has demonstrated a test-retest reliability ranging from .67 to .74 (54).

Satisfaction with Life Scale (SWLS)

This five-item scale is designed to measure cognitive-judgmental aspects of general life satisfaction and is recommended as a compliment to scales that focus on emotional well-being. The SWLS has demonstrated a coefficient alpha of .87 (55) and .85 (56) and a two-month test-retest correlation of .82 (55). Blais et al. (57) report a strong negative correlation (r = -.72, p <.001) between the SWLS and the Beck Depression Inventory (58). The SWLS has been shown to be highly correlated with self-esteem (56). Arrindell et al. (59) found the SWLS to be significantly correlated with anxiety (r = -.54) and depression (r = -.55).

Scoring

The ISE, GCS and CAS give a potential range of scores from 0 to 100 with higher score values indicating more evidence of the presence of problems with self-esteem, increased depression and heightened anxiety, respectively. On the other hand, the SWLS gives a range of scores from 5 to 35, with higher scores reflecting more satisfaction with life.

Demographic Data

This 10-item questionnaire obtained information on the following: age, marital status, racial group, education completed, vocational status, level of amputation, cause of amputation, number of years an amputee and number of hours per day the prosthesis is worn.

Hypotheses and Statistics

The study began with four hypotheses related to the assessment instruments:

  1. There will be a significant positive relationship between the ABIS and the ISE.
  2. There will be a significant positive relationship between the ABIS and the GCS.
  3. There will be a significant positive relationship between the ABIS and the CAS.
  4. There will be a significant negative relationship between the ABIS and the SWLS.

Spearman correlation coefficients were calculated to support all hypotheses. Because higher scores indicate a negative situation in the ABIS, ISE, GCS and CAS, all correlations between ABIS and ISE, GCS and CAS were hypothesized to be positive. Because higher scores reflect a more positive circumstance in the SWLS, a negative correlation was hypothesized between ABIS and SWLS.

To test Thompson's findings that "overconcern" with physical appearance is the "core feature of body image disorder" (34), the group was divided. Using the median score of the ABIS, the group was divided into those amputees who were "less concerned" about their body image and those who were "more concerned." The two groups would be compared on the ISE, GCS, CAS and SWLS.

Results

Of the 110 unilateral male amputee subjects who were randomly selected for the study, 90 completed the six questionnaires. The sample included 60 transtibial amputees and 30 transfemoral amputees.

Demographic Characteristics of the Sample

The mean subject age was 45 (SD = 12.7) (range 22-74), and the distribution was more skewed toward the younger population. Fifty-three subjects were married (59 percent), 17 were separated or divorced (19 percent), 18 were never married (20 percent), and two were widowed (2 percent). Included in the group were 79 white, five black, and six Hispanic subjects.

Education level was relatively high, with a median level of some college or greater. Two subjects had some high school (2 percent), 17 subjects had graduated from high school (19 percent), 30 subjects had attended some college (33 percent), 24 were college graduates (26 percent), and 17 subjects had graduate degrees (20 percent). The vocational status of the subjects included six students, three unemployed, five employed part-time, seven retired, 14 on disability retirement and 55 employed full-time.

Of the 90 subjects, 60 were missing one limb below the knee while 30 were missing one lower limb above the knee. Causes of the traumatic amputations varied: 29 from motorcycle accidents, 18 from auto accidents, 21 from industrial accidents, eight from war injuries and 14 classified as "other." The "other" category was comprised of losses from four hunting accidents, three farming accidents, two boating accidents, two train accidents, two severe burns and one frostbite.

Number of years the subjects had been amputees presented a mean time period of 17 years (SD = 13.51) (range 1-70) and was skewed toward fewer years. Most subjects wore their prosthesis for most of their waking hours a mean time period of 14.5 hours (SD = 2.36) (range 8-18), with skewing toward more hours worn.

Amputee Body-Image Scale

The median score for the 90 subjects on the ABIS was 33.5 (IQR = 22) (range 4-76), with the scores skewed toward a lower value. When the subjects were divided into transtibial and transfemoral groups, the transtibial group (N = 60) had a median of 31 (IQR = 17) whereas the transfemoral group (N = 30) had a median of 35.5 (IQR = 32).

Using the Mann-Whitney U test, no statistically significant difference was found between these groups.

An analysis was conducted to determine if either the amputee's age or the number of years since amputation was related to the score values on the ABIS. A Spearman correlation addressed the relationship in regard to age and was found to be not significant (rs = -.10), indicating age did not influence how the subjects felt about their body images. Also, an association between the time since amputation and ABIS scores was found to be nonsignificant (rs = -.17), suggesting the amputee's perception of his or her body image does not improve with time.

Index of Self-Esteem

The median ISE score for the 90 subjects was 20.5 (IQR = 16) (range 1-54), with the distribution more skewed toward lower scores. The transtibial group (N = 60) presented a median of 20.5 (IQR = 14) whereas the transfemoral group (N = 30) had a median of 19.5 (IQR = 21).

An analysis was conducted to determine if self-esteen was related to the subject's ABIS scores. A Spearman correlation addressed the relationship for the group as a whole and showed it to be significant, rs (88) = .56, p < .0001, indicating a positive relationship between the amputee's body-image and his self-esteem.

When separated into transtibial and transfemoral amputee subject groups, the transtibial amputees presented a correlation coefficient of rs (58) = .50, p<.0001 while the transfemoral amputee subjects showed a coefficient of rs (28) = .64, p<.0005. Using the Mann- Whitney U test, the differences for subjects with transtibial and transfemoral amputations were found to be nonsignificant.

Generalized Contentment Scale

The group (N = 90) had a median score of 17 (IQR = 14) (range 0-55) and was skewed toward lower scores. The transtibial subjects (N = 60) scored a median of 17 (IQR = 13), and the transfemoral subjects (N = 30) had a median of 16.5 (IQR = 20).

A Spearman correlation addressed the relationship between ABIS and GCS and was found to be statistically significant, rs (88) = .64, p<.0001, indicating these two variables are positively related. The transtibial subject group presented a correlation coefficient of rs (58) = .50, p<.0001; the transfemoral subjects showed a correlation of rs (28) = .80, p<.0001. Both these correlations are statistically significant. When the Mann-Whitney U test was applied, the differences for the transtibial and transfemoral subjects were found to be nonsignificant.

Clinical Anxiety Scale

The subjects as a group (N = 90) scored a median on the CAS of 8 (IQR = 8) (range 0-56), and the scores were markedly skewed toward lower values. The 60 transtibial subjects had a median of 7 (IQR = 7); the 30 transfemoral subjects had a median of 9 (IQR = 11).

A Spearman correlation exhibited a significant positive relationship between ABIS scores and CAS scores, rs (88) = .57, p<.0001. The correlation coefficients for the transtibial and transfemoral subjects were found to be rs (58) = .38, p<.004 and rs (28) = .78, p<.0001, respectively. The Mann-Whitney U test presented a nonsignificant difference between the two subject groups.

Satisfaction with Life Scale

The 90 subjects scored a median of 24 (IQR = 14) on the SWLS. The range of the scores was from 6 to 34. The transtibial subjects (N = 60) had a median of 24 (IQR = 13.5). The transfemoral subjects (N = 30) had practically the same median, 23 (IQR = 15).

To determine whether a relationship exists between being satisfied with one's life and how one scores on the ABIS, a Spearman correlation was used for analysis. A significant negative correlation was found: rs (88) = -.58, p<.0001. The SWLS, which is scored to indicate more satisfaction with life the higher the score value, results in a negative correlation. As ABIS scores went up (less satisfied with body image), the SWLS scores went down (less satisfied with life). The correlation coefficient of the transtibial group was rs (58) = -.44, p<.0008 whereas the transfemoral group was rs (28) = -.76 p<.0001. Using the Mann-Whitney U test, the differences for the subjects with transtibial and transfemoral amputations were found to be nonsignificant.

Table B presents ISE, GCS, CAS and SWLS scores for the "more concerned" group and the "less concerned" group, which were each compared by the Mann-Whitney U test. All comparisons had statistically significant differences at the .0001 level. In every comparison there were complete data (N for "more" = 45, N for "less" = 45). For the ISE, GCS and CAS the "more" group had higher scores, indicating the presence of more of a problem than the "less" group, whose scores were lower. On the SWLS test the "less" group had higher scores, indicating more satisfaction with their circumstances.

Discussion

Results of this study support the hypothesis that a relationship exists in lower-limb amputees between their perception of body image and their psychosocial well-being, namely, the degree to which they experience anxiety, depression, self-esteem and life satisfaction.

Significant correlations found in this study support the findings of Cash et al. (50) that, in men with physical disability or disfigurement, a relationship exists between a negative body image and poorer psychosocial well-being.

In all categories of psychosocial well-being, the subjects who were more concerned about their body image had significantly higher scores than the less-concerned subjects. Pruzinsky and Cash (60) state, because "body image is a highly personalized or subjective experience . . . there is no necessary correlation between subjective experience and objective reality." These findings support the premise of Thompson (34), Shontz (42), and Cash et al. (50) that body image is a subjective experience.

A nonsignificant correlation was found between body image and the age of the amputee subjects. Cash et al. (50) found as people age they do not report a poorer body image. Cash speculated that as people age they make adjustments to their standards of physical appearance. Earlier, Frank et al. (21) theorized that as amputees age, they may be more adaptable in altering their body image after limb loss. The findings of this study agree with Cash and Frank and further support the idea that the perception the amputee has of his or her body image is not influenced by chronology.

Conclusion

The findings of this study have implications for practical application in the fields of prosthetics and physical medicine and rehabilitation. Present rehabilitation efforts tend to address the physical limitations and potential capabilities of the amputee. Little attention is focused on the psychological state of the individual unless he or she presents with noticeable psychological problems. This study has demonstrated a significant relationship between how an amputee perceives his body and psychosocial well-being, specifically in the areas of anxiety, depression, self-esteem and life satisfaction. Since body image is related to these areas, focusing on increasing positive attitudes toward the body following amputation, during the rehabilitation process and throughout the life span of the amputee would be beneficial.

The findings of this study reinforce the understanding of the psychological consequences that amputation can have on an individual. More attention to enhancing the body image of the amputee is recommended. Assessment of body image also is recommended as an integral part of the rehabilitation program. Finally, body-image workshops, peer support with positive amputee role models and individual psychotherapy when necessary are recommended.


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