Abstract: Infant and Child Upper Extremity Amputees: Their Prostheses and Training
The following is an abstract of an article entitled Infant and Child Upper Extremity Amputees: Their Prostheses and Training, which appeared in the March-April 1962 (Vol. 28, No. 2) issue of The Journal of Rehabilitation. The article was written by Jeannine F. Dennis, OTR, who has been associated with the Child Amputee Prosthetics Project, University of California at Los Angeles, since its inception in 1955.)
When the infant missing a portion of his arm is able to maintain good independent sitting balance, he is ready for his initial fitting. As in the upper extremity prosthesis for the older child or adult, the infant's appliance incorporates the missing limb segments and functions but differs in that all the functional parts are passively or manually operated. As the child matures and exhibits greater prosthetic skill, active functioning is ntroduced with the therapist playing a major role in evaluating this "readiness".
Immediately after the completion and delivery of the first prosthesis, the therapist instructs the parents in the care and operation of the unit. The importance of full time wear and of maintaining good fit and function of the prosthesis is stressed. After the initial training program, which usually requires about three sessions, the infant is seen by the therapist once or twice a month.
The very young child begins his prosthetic experience with a small plastic-covered hook as a terminal device. The control cable is not applied at this stage because the child is unable to control grasp and release. The infant is provided with a hook so that he may observe and experience the function of grasp. The parents are encouraged to open the hook and to place attention-getting objects into its grasp.
The cable system is added, joining the harness and the hook and enabling active operation of the hook, when the child is able to follow simple training directions, has reasonable attention span, is interested in activities that require two-handed grasp, and has achieved sufficient neuro-muscular development to perform the body motions necessary for active opening and closing of a hook. This usually occurs at about the age of two years. By this time the child is aware of the concept of grasp and the transition from passive to active control of the hook is accomplished with a minimum of change and confusion for the child.
Daily training sessions begin immediately after the addition of the hook control cable in order that the child will avoid the development of poor habits, will begin to learn skillful hook control and will also start to learn the use of the prosthesis for purposeful activities. The follow-up training program gives the child an opportunity to become more skillful and add new skills as his interests and maturity increase. After approximately ten daily sessions, a continuing program of training once or twice a week is recommended, depending on the needs of the individual child.
Unfortunately, the fitting of the upper extremity amputee in infancy is not always possible because of the difficulty in providing the closely supervised long-term program that is necessary. Consequently, the congenital amputee whose initial fitting has been delayed must be considered as well as the child who has sustained his amputation after infancy. Because these children have not grown up with a prosthesis, the degree of prosthesis acceptance by child and parents, the changing of old habits, and the reactions of schoolmates, have a direct bearing on the training program. Close interdisciplinary efforts are essential when a prosthetic program is recommended for these challenging cases.
Parents and child are instructed in the care and operation of the prosthesis and the cable assembly system. The prosthesis is to serve as an assist to the sound extremity; its chief use is to provide a stabilizing and holding function. The hook is used mainly for grasp but there are many occasions when it is appropriate to hold down or stabilize objects without using the prehensile function of the hook.
Role of Local Therapist
The parents gain a good understanding of the mechanics and appropriate use of the prosthesis during the early training session and are thus able to guide and assist the child. Following the initial training given at the project, local occupational and physical therapists continue the training after the child returns to his home. Prosthetic problems are noted and corrected or referred to the prosthetist for attention.
The local therapist also orients the child's school teacher. The latter prepares the other children for the arrival of a child with a prosthesis and helps to guide the child in various matters that arise in school.
Constant communication is maintained between the project and the local therapist. Project therapists provide details for the training program and the local therapist sends a progress report to the project prior to the child's regular clinic visit.
The article concludes by stating that experience has shown a prosthesis to be most advantageous when the parents and child accept the amputation and believe in the prosthetic program; when the prosthesis is kept in good fit and function at all times; and when the child learns to use this function for purposeful activities that are important in the achievement of independence and security. In this way he is prepared for productive adulthood.