Questionnaire Survey Concerning Age at Initial Fitting
Barbara L. Sypniewski
Extracted from The Child with Terminal Transverse Partial Hemimelia: A Review of the Literature on Prosthetic Management. The full text of Miss Sypniewski's report will be printed in the Spring 1972 issue of ARTIFICIAL LIMBS.
This questionnaire survey sought to document a trend toward earlier initial fitting of upper-extremity prostheses in the congenital amputee. As the most frequently occurring limb deficiency, unilateral terminal transverse partial hemimelia was selected as the focus of consideration. An extensive review of the literature had seemed to indicate a trend toward earlier fitting. While children were formerly fitted just prior to school age or even during the middle or late teens the achievement of independent sitting balance is now a widely accepted criterion for prosthetic prescription. According to Gesell and Ama-truda's studies of motor development1, the norm for the achievement of this maturational level is nine months (36 weeks).
It was the belief of the author that 1) even earlier fittings are being performed in significant numbers; 2) a passive hook is most frequently prescribed; and 3) the development of the Münster-type socket has played a role in the trend toward earlier fitting.
Questionnaires were mailed to the 28 clinics participating in the Child Pros thetics Research Program (A cooperative endeavor conducted under the auspices of the Subcommittee on Child Prosthetics Problems of the Committee on Prosthetics Research and Development.). The information requested was of three types: age at time of initial fitting, type of socket and terminal device most frequently prescribed, and basic developmental levels considered essential for fitting the prosthesis.
The sample consisted of 40 new patients with upper-extremity terminal transverse partial hemimelia initially fitted between March 1, 1969, and approximately March 1, 1971. The frequency of fittings is indicated in the chart on the following page.
One clinic whose data were too non-specific to be included in the chart reported fitting more than 200 cases. A relatively small number (between 15 and 20) was fitted between the ages of six and nine months, and a much larger group (50 or 60) was fitted after the age of 12 months. Two other clinics indicated that the information needed to complete the questionnaire was not readily available. One of these stated that all of their children were fitted after the age of 12 months.
In requesting the data, no upper limit was set on the last interval (later than 12 months). For this reason no statistical analysis of the central tendency (mean or median) was possible. The return on this survey was 43 per cent, the low response level being partly attributable to the fact that no date was designated for the return of the questionnaire.
The frequency distribution indicated that 65 per cent of the children were fitted under one year of age. Using nine months as the age for reaching the developmental level of independent sitting, the data indicate that 37.5 per cent were fitted before this age. It is also interesting to note that 20 per cent of the sample was fitted before six months and 7.5 per cent before three months. This information indicates a trend toward fitting earlier than the widely accepted criterion of independent sitting balance. The very important concept of parental attitudes and other intangible factors were not considered, nor was the age when the child was first seen at the clinic taken into account in this study. If it were, perhaps an even stronger trend toward earlier fitting would be noticed.
Regarding the type of terminal device, seven clinics prescribed a Dorrance 10P or 12P passive hook most frequently. One fitted a non-functioning hand (mitten) initially and changed to a hook at about two years of age. The ninth clinic listed both the passive hook and the passive hand in their response. Five of the clinics prescribed a conventional double-walled plastic laminate socket most frequently and four clinics most often prescribed a Münster or modified Münster socket.
An interesting outcome of this survey was the compilation of developmental criteria for fitting employed by the various clinics. In the chart which follows the list of criteria is paired with developmental norms described by Gesell and Amatruda.
One clinic indicated that they did not adhere to any developmental criteria but felt that as soon as the child was three or four months old a prosthesis could be fabricated with adequate socket fit. It was their belief that the earlier the socket was fitted the better.
It is hoped that persons responsible for prescribing prostheses might consider the criteria proposed by other clinics for fitting of prostheses for congenital upper-limb amputees. The advantages that prompted the change from preschool age fitting to fitting at the developmental level of independent sitting continue to exert an influence toward still earlier fitting. The greatest advantage claimed is that of acceptance of the prosthesis. Logically, if the artificial limb is provided before a one-handed activity pattern is developed, chances for acceptance are increased. It would further seem logical that when the capacity for two-handed grasp in the midline develops (at approximately four months) a prosthetic limb should be there to oppose the normal limb. The proximal stability necessary for control is developed previously in the on-elbows position.
Many factors interact to affect the age of initial fitting. The age at which the limb-deficient child is referred to the clinic is certainly a significant one. Parental attitudes are closely associated with this consideration. The development of prosthetic parts specifically designed for children is important, as is the increase in knowledge in the entire field of prosthetic management of the juvenile amputee. Disseminination of this knowledge to the related health fields, especially to those individuals in contact with the mother of the newborn child with limb deficiencies, may promote earlier referral to the appropriate prosthetic team.
It is believed that the trend toward earlier fitting is advantageous. A difference in the practice of various clinics has been noted. A polarity exists with a tendency for some clinics to fit predominantly at a very early age range and others only later. Three of the clinics indicated fitting only after 12 months. It would be useful for all clinics participating in the management of congenital amputees to carefully evaluate their criteria for prosthetic fitting and training.
School of Physical Therapy Russell Sage College-Albany Medical College Troy, New York
Gesell, Arnold, and Catherine S. Amatruda, Developmental diagnosis, normal and abnormal child development, 2nd ed Hoeber Medical Division, Harper & Row, New York, 1947.