Figure 1: An early example of using the finished appearance as a form of self-expression. This bilateral lower-limb amputee and military veteran has images of calendar girls painted on his prostheses. Photograph circa 1949. Image courtesy of the collections of the Otis Historical Archives, Armed Forces Institute of Pathology, Walter Reed Army Medical Center, Washington DC.
A growing number of individuals with upper-limb loss are electing to use their prostheses as a means of self-expression. An anatomically realistic prosthesis may still be ideal for many, but tattoos, custom artwork, bright colors, patterns, and even the raw display of the upper-limb prosthetic device's mechanical components is becoming more prominent and accepted. Patients may elect to incorporate artwork onto their prostheses for a variety of reasons, and the options for such customizations are increasing. For individuals with limb loss, customization of their prostheses can create a greater sense of control, personal connection to themselves and others, and, ultimately, acceptance. This article introduces the topic of self-expression and the positive clinical impact it can have for the prosthetic patient population.
Body Image and Self-Expression
Body image refers to our perceptions and feelings about our appearance and how others perceive us. It is shaped by the world around us, through our experiences, and through the reactions of others. Whether positive or negative, body image has a direct effect on our physical and mental health. The growing body of work in the field of psychoprosthetics, "the study of the psychological aspects of prosthetic use and of rehabilitative processes in those conditions that require the use of prosthetic devices," helps us to better understand the concepts of body image and coping for individuals with amputations.1
Figure 2: Transradial myoelectric prosthesis (frame shown) customized by Mike Cissell at Other Side Customs, Dallas, Texas.
Merriam Webster defines self-expression as "the expression of one's own personality: assertion of one's individual traits." All people express themselves, their feelings, and their body images purposefully, whether by choosing to get tattoos, or wear makeup, jewelry, or certain types of clothing (Figure 1). It is only natural that as individuals adjust to limb loss, they would choose to use their prosthesis for self-expression—as a way of incorporating the prosthesis into themselves, reflecting their body image, and expressing their personality to the world.
Control and Connection
Figure 3: Transradial myoelectric prosthesis with Fred’s Legs SleeveArt® American flag laminating sleeve finish and Euro International red Masterflex inner socket.
Stress is the body's natural reaction to a threat, real or perceived. The trauma associated with amputation and the daily stress associated with limb loss is real. Significant stress-inducing threats may cause mental and physical illness. A person's perception of control over his or her disability has a significant impact on psychosocial adjustment.2 When an individual has control over his or her body and situation, stress is reduced and an overall sense of well-being is realized. Not only does reducing stress increase a person's ability to heal emotionally—to recover, cope, and learn—it also allows the body to heal physically and fight disease.3
Helping patients to feel a sense of personal control is a simple way thoughtful practitioners can further assist their patients. Allowing patients to choose the type of prosthesis they use, specialized componentry options, and what their prosthesis looks like can have a positive psychological impact at a time when they may feel they have lost so much. This form of patient empowerment subscribes to one of the cornerstones of evidence-based practice—respecting and integrating patients' values.4
Leo, a patient of Lake Prosthetics and Research, Euless, Texas, is a longtime upper-limb amputee secondary to motor vehicle trauma. He recalls the strange looks and reservations he felt he received in public because of his prosthesis, and how he consistently wore long-sleeve shirts to hide it. A motorcycle enthusiast, Leo recently chose to work with a local chopper shop to design and paint custom artwork on his prosthesis that coordinates with an existing tattoo he has on his upper arm, just proximal to his prosthesis (Figure 2). His decision to add a tattoo to his prosthetic limb has helped him to make an important connection. He now feels his prosthesis is a part of him, and he enjoys the attention he receives because of it. Positive distractions such as this bring patients a sense of control and allow them to make a personal connection to their new limb.
Figure 4:Transtibial prostheses customized by Dan Horkey with Global Tattoo Orthotic Prosthetic Innovations (GTOPI), Port Orchard, Washington.(Photograph courtesy of Kitsap Sun newspaper, Bremerton, Washington.)
Available Options for Prosthesis Customization
There are a number of options for patients who would like to personalize their prostheses with custom artwork: water transfer printing, spray-on chrome, and airbrush painting, to name a few. A common method of prosthesis customization is to use graphic fabric, T-shirts, or laminating sleeves during the final socket lamination. Charlie, another Lake Prosthetics and Research patient, and a former member of the U.S. armed forces, chose to have an American flag pattern laminated onto his prosthesis (Figure 3). Not only does his SleeveArt® artwork, provided by Fred's Legs, Dania Beach, Florida, reflect his sense of pride and dedication to his country, it serves to break the ice in social situations, and he enjoys discussing it with friends, neighbors, and even strangers.
Another method for prosthesis customization has been developed by Dan Horkey, founder of Global Tattoo Orthotic Prosthetic Innovations (GTOPI), Port Orchard, Washington. A motorcycle accident survivor, Horkey covered his lower-limb prosthesis with shaped foam for 20 years. His eventual dissatisfaction with its appearance motivated him to start a business that would serve the cosmetic needs of amputees in a way that would empower and inspire them. GTOPI uses a patent-pending technique to provide patients with custom-painted finishes, as well as airbrushed and hand-painted artwork, similar to those used for custom paint jobs on hot rods and motorcycles (Figure 4).
Figure 5: By being present during the painting process, the patient is empowered and becomes a partner in the design process. This patient is shown during the painting of the passive silicone prosthesis at ARTech Laboratory, Midlothian, Texas.
Discussion
Given the positive feedback and potential benefit to our patient population, the topic of self-expression through prosthesis customization warrants more investigation. We may be able to enhance both the physical and psychological well-being of our patients by offering expanded options for prosthesis customization. To confirm this clinical observation, we should document our patients' feelings and body image perceptions before and after prosthesis customization.
Clinicians can play a critical role in empowering patients to have a more positive body image and attitude. This may come in the form of a realistic prosthesis that refocuses attention on the person's ability rather than on his or her disability (Figure 5), or it may come in the form of an eye-catching prosthetic design that reflects the patient's personality. Regardless of the result, placing patients at the center of care by respecting their values helps foster a sense of control for our patients.
Chris Lake, CPO, LPO, FAAOP, is the clinical director of Lake Prosthetics and Research, Euless, Texas, and the chair of the American Academy of Orthotists and Prosthetists (the Academy) Upper-Limb Prosthetics Society. Mary Lake is the business director of Lake Prosthetics and Research.
Society Spotlight is a presentation of clinical content by the Societies of the American Academy of Orthotists and Prosthetists in partnership with The O&P EDGE.
References
- Rybarczyk, B. and J. Behel, 2010. Limb Loss and Body Image. In: Psychoprosthetic, 23—31. London: Springer-Verlag London Limited.
- Desmond, D. M. 2007. Coping, affective distress, and psychosocial adjustment among people with traumatic upper limb amputations. Journal of Psychosomatic Research 62:15—21.
- Azar, B. 2001. A new take on psychoneuroimmunology. Monitor on Psychology 32(11):34—6.
- Sackett, D. L., S. E. Straus, W. S. Richardson, W. M. C. Rosenberg, and R. B. Haynes, 2000. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. New York: Churchill Livingstone.
