Bangladesh biggest limitations for amputee patient. Mobility is one


is a developing country located in South Asia and is home of approximately 160
million people. It is a country of widespread poverty, with 44.3 % of the
population living below the poverty line, inadequate health, education, and
social security services, low employment and at high risk from natural
disasters, particularly flooding (CDD, 2011). According to World Bank Group the
prevalence of the person with disability of Bangladesh about 10%. Other survey
shows that between 9%-16% people are disable in Bangladesh (Disibility ,2012). This
report also shows that 3.4 million children suffer from some kind of disability
in Bangladesh.

indicate that 10% of the population means 16 million people are living with a
disability. Government and NGO deliver development programs to minimize the
disability and promote their life style include their rights, vocational
training to increase job opportunity, arranging awareness program, provide
assistive device and other  but only
reach a small proportion of the population benefited by the program still need

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is one of the biggest limitations for amputee patient. Mobility is one of the
basic needs for all activities like education, social events and livelihood
activities. One’s a person misses lower limbs loss major mobility function and
also removing bottle tops, lacing shoes and using scissors and others most of
them are loss their job or change job. A person with amputee faces difficulties
in activity in daily life self care, productivity and also leisure.



USA about 50,000 new amputations every year in USA based on information from
National Center for Health Statistics. The World Health Organization (WHO) has
estimated that in low-income countries like Bangladesh, about 0.5% of the
population is in need of Prosthetic and Orthotic (P) mobility  and assistive device (CRP,2012-13). According
to the United Nations more than 13 million people in Bangladesh are believed to
have disabilities, with more than 22.5% of these reported to be individuals
affected by physical disabilities. Another source reported that about 0.7 percent
of total population in any low income countries needs orthosis and prosthesis
services per year. That means in Bangladesh more than 1 million people need
prosthesis and Orthosis services per year (Revive Bangladesh, 2016). The
Amputee Coalition of America estimates that there are 185,000 new lower
extremity amputations each year just within the United States and also reported
that there are nearly 2 million people living with limb loss in the United
States (LLC,2012). In 2009, hospital costs associated with amputation totaled
more than $8.3 billion. In united state among person those living with limb
loss, the main causes are vascular disease (54%) – including diabetes and
peripheral arterial disease – trauma (45%) and cancer (less than 2%) (Ziegler, 2008).
African?Americans are up
to four times more likely to have an amputation than white Americans.  Lives of the amputee are more miserable than
other. Persons with disabilities tend to experience higher unemployment and
have lower earnings than people without disabilities (CDD,2011). In South Asia
developing country the number of person with disabilities is 10%. The
combination of India & Bangladesh population almost 1.4 billion and more
than 9 million persons with mobility related disabilities who need for
prosthetics and orthotics services (Cochrane, 2015). In India the prevalence
rate of amputees are 0.62 per 1000 population (Mohan, 1986). Because of amputee
person face many limitation and difficulties. The ratio of upper limb to lower
limb amputation is 1:4. Around 30% of USA amputee patient have lower limb loss
and 10% upper limb loss patient (ISHN, 2014). Maximum of the amputee patient
are unsatisfied for their income. One study estimated that only 7.3% of amputee
patient received rehabilitation services. (Jang et al, 2011). Persons with
amputee who use prosthesis device for functional or cosmetic purpose were more
satisfied in psychologically than physically.


Literature review:


is a devastating and traumatic experience. Amputation could be described as the
removal of a body extremity by surgery or trauma. It may be done to treat
injury, disease, or infection. It can be easily define as amputation is loss of
all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or
finger (WebMD,2017). Amputee means one who has had an amputation especially of
the arm(s) or leg(s) (taber’s medical dictionary, ed-18. P 86). Amputation can
involve either the upper or lower limb and occurs at a variety of levels. Loss
of limbs always creates of limitation to perform daily living activities makes
the person dependent. Artificial limbs may make the person independent especially
mobile and bring the person back to work (Revive Bangladesh, 2016). Amputation
constantly remains a cause of burden or concern for individuals, their
families, and society. Incidence of lower limb amputation has increased over
the years by road traffic accident, Diabetes or vascular diseases (Pirouz,
2014). A Nepalian study said that patient with amputee
face difficult to finding employment and vocational training that’s why they
become depended upon others. This limited ability create negative self image (Jarnhammer
et al. 2017). A study on Malaysian people with amputee about their
Quality of life reported that patient who use prosthesis device are more
satisfied in psychologically than orderly social, environmental and last
physically (Razak et al, 2015).


History of uses of prosthesis device:

 A very long history had the use of prosthesis
device. The animation and cartoon Sinbad tell us the concept of the prosthesis
is from long long time ago in deep pirates. The historical records shows that
the use of prosthetic device was in the time of Greek and Roman. One Roman
general lost his right hand in second Punic War at about 218-210 B.C. He used a
prosthesis hand.  Other records has a
prosthesis foot that was 3000 years old that found in a Egyptian Mommy.  (Clements, 2017). This is the world first
prosthetic toe & it was functional. About 300 B. C. in Capua, Italy found
an artificial leg.  The time 476-1000 is
called the Dark ages because during this time prosthesis device are made only for
hide deformities or injury not functional. In 1400-1800 the Renaissance change
the process of made prosthesis this time prosthesis generally made of iron,
steel, coper and wood. In middle of 1500 and then the prosthesis become develop
and still developing day by day. (Norton, 2007).

Types of amputation:

There are two main categories of amputation

Traumatic amputation

Surgical amputation (serious)

amputation:  It refers to the way in which the amputation
has occurred. Ex: violent, road traffic accident, explosions or blast injuries,
Electric Shocks.

This traumatic amputation is an incredibly dangerous
and often life-threatening situation.

 Surgical amputation:  A vital practice in medicine for thousands of
years though the frequency of this type of amputee has been diminished as
medicine has advanced. Ex. Complications of blood vessels.

The medical team will aim to save as much of the
injured limb as possible from further damage.

Reason of amputation:

The most common causes
of disability are chronic diseases (Diabetes, cardiovascular disease and
cancer). Injuries (traffic accident, fall, violence, work place accident).
Mental health problem, birth defects.(CDD,2011). The accident rate of the
Bangladesh is increasing day by day. In recent year several numbers of
tragedies happen and huge number of people died (Rana plaza, Tazreen fashion’s)
& many people lose limbs  According to Bangladesh road transport
authority (BRTA) In year 2-13-14 there 4421 accident occur
and injured patient are 3493 and almost 2430 are death (reported accident
only). The World Health Organization reported that Bangladesh has chaotic
traffic & poor safety.

There also has reason/ causes of amputation that’s
are (webMD,2017):

Peripheral arterial disease (poor
circulation of blood). In USA 54% amputation happens for this. (Amputee

Severe injury (road traffic accident,
burn). 45% amputation happen in USA

Cancerous tumor in the bone or muscle of
the limb

Diabetes: About 26 million Americans
have diabetes, and an estimated 65,000 had a lower limb amputation in 2006,
(Narton, 2011). Below-knee amputations are the most common amputations,
representing 71% of vascular amputations. Nearly half of the individuals who
have an amputation due to vascular disease will die within 5 years (Robbins,

Serious infection that does not cure
with antibiotics or any other treatment.

Congenital defect: congenital limb
deficiency in 1996 was 25.64 per 100,000 live births in USA (ISHN, 2014)


Areas of amputation:

Amputation can happens any limb of both upper and
lower half of the body. The level of amputation is usually named by the joints to
the major bones through which the amputation has been made. As more specific
amputation areas are:

Level of upper extremity

Partial hand amputation

Metacarpal amputation

Wrist disarticulation

Below elbow amputation(transradial)

Elbow disarticulation

Above elbow amputation

Shoulder disarticulation

Upper limb prostheses are used for both cosmetic
purpose and functional activities.

Levels of lower extremity amputations:

Hemipelvectomy (transpelvic)

Hip disarticulation

Above knee amputation (transfemoral)

Through the knee amputations

Below knee amputations (transtibial)

Ankle disarticulation

Partial foot amputation

A study shows that in lower limb
amputee transtibial amputation is found most frequently.


Orthotics are the device that deals
with the support of weak or ineffective joints or muscles using supportive
braces and splints. The needed of orthosis to reduce pain or to provide support
to an extremity that has lost function due to damage to bones, ligaments,
nerves or muscle. (CRP, 2014). Ex: upper-limb orthoses, foream-wrist orthoses,
hand orthoses (hand splint). Foot orthoses (FO), ankle-foot orthosis (KFO) etc.
now a day’s use of orthoses device are increasing.  In 2015-16 year CRP team provided 1348
orthoses device. As a assistive device orthoses is very helpful for person who
face difficulties this device support them to become fully functional.




Quality of life; Bangladesh.


Prosthesis (also called
a prosthetic limb, artificial limb, or limb “replacement” though natural
limbs are irreplaceable is an artificially made substitute for a limb lost
through a congenital defect (present at birth), accident, illness, or wartime
injury. The replacement of missing body parts after amputation in broader terms
called ‘prosthesis’. Prosthesis is made artificially that use d to restore body
factions. And prosthetics the name of a field concerned with the development
and fitting of artificial body parts. (Bery, 2005). Annual report of CRP 15-16 reported
that they successfully delivered 211 lower limb prostheses and 14 upper limb
prostheses device. People with
disabilities in low-income countries have the right to personal mobility and
available and affordable assistive technology, such as prosthetic and orthotic
services, according to the Convention of Rights of Persons with Disabilities

Types of prosthesis device:

Prosthetics can be classified into three major
categories for the patients: cosmetic prosthesis, body-powered prosthesis, and
myoelectric externally powered prosthesis. (LeTourneau, 2009)

Cosmetic prosthesis:

This type of prosthesis
is designed to be purely cosmetic and has little or no function. Ex. Artificial
hands often fall into this category. Study
reported that most of the prosthesis are use for the cosmetic purposes. This
type of prosthetic is designed for people who want to use their other limbs for
most major functions. And patient with
this prosthesis face a lot of difficulties in daily living activity.
(Rehabil, 2011)  



Body-powered devices are operated using cable and harness
systems that require the patient to use body 
movements (moving the shoulders or the arm, for example) to pull the
cable and make the terminal device (a hand, hook or prehensor) open or close
much in the way a bicycle handbrake system works. Patient use the body powered
device because it take lower Initial Cost. It is Lighter, Easier to repair,
Offer better tension feedback to the body. But some patient reported that it is
difficult to use.

Myoelectric Prosthesis:

which is a myoelectric
externally powered prosthesis, picks up the electrical action potential in the
residual muscles in the amputated limb. This type of prosthesis get power by
rechargeable battery and give the electric signals to activated the motor to
response the action. However this device is heavier and more expensive than the
other two types. But this is the most advanced and effective prosthesis
available for upper limb.

Type of
prosthesis limb (according to site):


Type of prosthesis
are generally named according to type of amputee level or the part of the body
that they are used to replace. But their four common type of prosthetic limb,
(Woodford, 2016).

Partial foot prosthesis

Below the knee (BK, transtibial)

Above the knee (AK, transfemoral)

Partial hand prosthesis

Below the elbow (BE, transradial)

Above the elbow (AE. transhumeral)


Purpose of use prosthesis device:

Advanced technologies
and environmental, social, and economic factors have led to considerable
improvements in prostheses. The prime objective for any prosthesis is to
provide function in a comfortable manner, but comfort is mainly subjective and
difficult to standardize. Comfort primarily involves the pressures between the
socket and residual limb. But people with lower limb amputation remain
dissatisfied with prostheses. prosthesis
device helps the person with amputee to return the ability to move, do something
independently, make the person functional. prosthesis device also decrease the
negative self image that results for the apmutee. But prosthesis device need
maintanence to keep them porper functional. A study in Sierra Leone and Malawi reported that 86% of
assistive device that are their use but half needed repair, 1/3 of the
participant reported pain when they use assistive device.


Quality of

The WHO defines
QOL as “an individual’s perception of
their position in life in the context of the culture and value systems in which
they live, and in relation to their goals, expectations, standards and
concerns” (WHO, 2014).


Individual and
societies general wellbeing is known as QOL. It has some context like
international development, healthcare, politics and employment. It is consists
of some component like wealth and employment, healthy environment, physical and
mental health, education, recreation, leisure time and social relationships
(Gregory et al.2009).



“Physical health
as a state of physical well-being in which an individual is mechanically fit to
perform their daily activities and duties without any problem” (WHO, 2014).

Psychological health:

“Mental health
is defined as a state of well-being in which every individual realizes his or
her own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to her or his
community” (WHO, 2014).


health comprises those aspects of human health, including QOL, that are
determined by physical, chemical, biological, social and psychosocial factors
in the environment. It also refers to the theory and practice of assessing,
correcting, controlling and preventing those factors in the environment that
can potentially affect adversely the health of present and future generations
(WHO, 2014).


In social
science, a social relation or social interaction is any relationship between
two or more individuals. Social relations derived from individual agency form
the basis of social structure and the basic object for analysis by social
scientists (Social relation, 2012).


with amputee:


In case of job satisfaction
amputee patient are less happy than normal employee.

Upper limb amputees experienced a worse general health compared to lower
limb. Vocational rehabilitation for returning job is so important for the
amputee patient. A
study from Egypt reported that about 42.27% males and 38.1% female who are
acquire disability by amputation are illiterate and they had job that require
physical efforts (Mohammed et al, 2014).  Around
30% of patient who return their job has adjustment in their workplace. But
above 60% of patient has no adjustment in their workplace (sluis et al, 2016). Only 7.3 % amputees receive their rehabilitation training. Who use
prosthesis the wear the device more than 8 hour one a day. Most of them reported pain some of them felt phantom pain.


Orthosis and prosthesis service
in Bangladesh:


All Bangladesh  prosthesis and orthosis service are provided
exported who get training through other countries. A small number of workshops
graduates of various international programmes are believed to be working in
Bangladesh. Local experts indicated that most services are delivered through
non-governmental organizations ist also a factor that prosthetics &
orthotics services There also do not appear to be any regulatory bodies
governing either education or service delivery for prosthetics and orthotics. Through
Bangladesh has no known lists of service providers exist.  There did not appear to be prosthetic and orthotic
services available in government run hospitals and no national referral centres
were providing prosthetic and orthotic services at the time of the study (Helen et al, 2015).
According to the Centre for the Rehabilitation of the Paralyzed (CRP), only 25
people in the country have international certification to produce artificial
limbs, braces, and splints (Mahmud, 2016)


and orthotic services are limited in low-income countries.
A Study found that only three departments offering prosthetic and orthotic
service in Bangladesh (Cochrane et al. 2015) that’s are:

for the Rehabilitation of the Paralysed 
(CRP), Savar Dhaka

for Disability in Development(CDD), Dhaka

(formerly Bangladesh Rural Advancement Committee), Dhaka


CRP introduction: “CRP’s
journey began in 1979 in order to meet the desperate needs of People with
Disabilities. CRP provides medical treatment, rehabilitation and
support services focusing on physical, emotional, social, psychological and
economic aspects. It promotes the development of skilled personnel in health
care and rehabilitation in the country. CRP has developed centres in different
parts of the country to expand the services for disabled people in
collaboration with other organizations.  It promotes empowerment of
disabled people through community based services, advocacy and networking on
disability issues and empowerment of disabled girls and women. CRP also raises
awareness on disability issues nationally, regionally and internationally. The
P&O department of CRP  is providing
service since 2003. in 2013-16 crp total provide nearly 700 prosthesis device.


Center for Disability in Development(CDD): CDD works in partnership with a
network of over 350 organizations both nationally and internationally. The
Centre for Disability in Development (CDD) is a not for profit organization
established in 1996 to develop a more inclusive society for persons with a
disability. CDD produces and supplies thousands of different assistive devices
to help persons with disabilities to become more mobile and independent, such
as wheelchairs, artificial limbs, hand splints and visual and hearing aids.


BRAC (formerly Bangladesh Rural
Advancement Committee): BRAC creating opportunities for people living in
poverty to realize their potential. They pilot, perfect and scale innovation to
impact the lives of millions. The approach is comprehensive, from operating the
largest secular private education system in the world to the largest NGO-led
legal aid programme in the world. The BRAC are almost completely self
sustainable in Bangladesh trough our own network to development programmes, At
the BRAC Limb and Brace Fitting Centre successfully provide 2,836 artificial
limbs since 2008. In Rana Rlaza Tragedy BRAC provide 12 prosthetic limb to the
survivors (BRAC annual report 2013) 



Institute of Traumatology and Orthopaedic Rehabilitation (NITOR): Pongu
Hospital In Sher-E-Bangla Nagar. 2013 Frokash Bhandari leading the camp 500
articical limbs. (The independent, 2016)

Others some organization they provide prosthesis
device but small amount:

Easy Life (Dhaka)

Revive Bangladesh(Dhaka)

Impact foundation Bangladesh(Dhaka)