The Directional Senses of the Child Amputee
Ronald W. French, Ed.D. Susan D. Clarke, O.T.R.
This work was supported by a grant from the Maternal and Child Health Services MCT-204-21-0.
Supplemental data gathered in a previous investigation10 suggested that children with severe limb deficiencies perform poorly on directionality tasks. That is, based on the results of a standardized test14, these amputees were inferior to "normal" children of the same sex and chronological age with regard to internal awareness and external understanding of directional orientations (i.e., left-right, up-down, over-under).
The directional-sense level of amputees may be related to academic achievement, although this relationship is not universally accepted4,7. Difficulties in right-left discrimination may hinder children's ability to learn arithmetic, reading, writing, and music1,2,3,5,13,17. Numbers, letters, and other symbols must be directionally constant to retain their correct designation and meaning13. For instance:
Letters may not be rotated (Z to N).
Letters may not be near-far mirror-rotated (f to t).
Letters may not be right mirror-rotated (b to d).
At present there is a paucity of information in the literature regarding the skill level of amputees on specific variables, such as directional awareness, which may be involved in academic achievement. The purpose of the investigation reported here was to determine whether relationships exist between the basic etiology of amputation and directional sense, and between the severity of amputation and directional sense. The development of a sense of directionality is often linked with experience obtained in the manipulation of objects and movements within the environment8,11,15. Hence a scale to categorize the severity of involvement was devised, based on the limitations imposed by the limb deficiency to manipulation or movement (Table 1 ). If a relationship does exist between any of these variables, this may indicate that the absence of a limb or limbs does alter the normal development of directionality sense, not compensated for by alternative developmental processes.
Specifically, this study was devised to test the following hypotheses:
There will be no significant difference between directionality test scores of amputees as a group, and those of a comparable normal population.
There will be no significant difference between directionality test scores of congenital and traumatic amputees.
The severity of deficiencies of the lower limb as related to ambulation, and the manipulation of objects with respect to the upper limbs, will not significantly influence directionality test scores.
The sample consisted of 83 amputees (51 males and 32 females) who were outpatients of the Child Amputee Prosthetics Project at the University of California at Los Angeles. With the exceptions of the children with multiple limb deficiencies, all patients were selected according to their availability to the tester during regular visits to the Child Amputee Project. All available children with multiple limb deficiencies were tested to provide an adequate number for statistical analysis. The chronological age of the sample ranged from 5 years and 10 months to 17 years and 4 months, with a mean of 11 years, 4 months, and a standard deviation of 4 years, 1 month. Sixty subjects had congenital limb deficiencies, while the remaining 23 had acquired amputations. The severity of limb deficiencies within the total sample ranged from unilateral partial-hand amputations to quadrimembral deficiencies (Table 2 ). To determine the effects of the type and extent of limb deficiency on directional sense, the subjects were grouped by general type of amputation, i.e., upper or lower limb; congenital or acquired; and by severity of amputations, as related to ability to ambulate with the lower limbs or to manipulate objects with the upper limbs.
A Standardized Road-Map Test of Directional Sense14 was administered individually to all subjects according to instructions in the test manual for the determination of directional awareness. This test was chosen because it requires only verbal responses of right and left on the part of the subjects. The final directionality-sense score is adjusted for chronological age and sex, and is expressed in percentile rank according to standardized norms.
Definitions of the major statistical terms utilized in this investigation are presented in Table 5 .
The data were organized to test the essential hypotheses posed in this study. The first hypothesis was that limb deficiency would not significantly influence directionality test scores. This hypothesis was substantiated. The mean percentile scores for the total amputee sample, as well as for the children with congenital and acquired losses as separate groups, were all approximately at the median or fiftieth percentile (Table 3 ).
The second hypothesis stated that no significant differences in directionality mean percentile test scores would be found between the congenital and the acquired limb-loss group. This hypothesis was substantiated. The mean percentile score was 50.87 and the standard deviation 30.49 for the congenital amputees; and 49.17 and 29.82, respectively, for the acquired amputees (Table 3 ).
The third hypothesis proposed that the severity of limb deficiency would not influence directionality test scores. This hypothesis was accepted (Table 4 ). No significant differences were obtained between the directionality mean percentile test scores of amputees with mild, moderate, or severe limb deficiencies (F = 1.62, df .82, p > .05). While no significant differences were obtained, it should be noted that the mean percentile score of the severely involved was 27 percentile points below that of the mildly involved and 30 points below the moderately involved (Table 3 ).
The present study investigated the influence of the etiology and severity of limb deficiency upon directionality. A major limitation of the study was the small test sample in groups II and III (children with moderate and severe limb deficiencies). The large standard deviations in the scores of these groups, combined with the small numbers, made description of the group through statistical analysis unsuccessful. A statistically significant difference was not shown between etiology and severity of limb deficiency and directional awareness. However, the individual scores in groups II and III showed that eight of the eleven children in the severe group (III) scored below the twentieth percentile, and in the moderate group (II) three out of eight fell below the thirty-fifth percentile. The severe group shows a definite trend toward a deficit in directional awareness, and the moderate group appears to have some tendencies in the same direction. The high scores in the same groups, which ranged up to the ninety-ninth percentile, would indicate that etiology and severity of limb deficiency alone are not responsible for the development or lack of development of directional awareness. However, the preponderance of low scores for the severe group would indicate that a problem may exist in this area for the child with severe limb deficiencies. A search of the literature on directional awareness revealed that such awareness may be closely related to motor development and the establishment of a body schema through exploration of the environment. Delacato, Kephart, and others10,11 advance the theory that a child must go through particular motor stages during development if he is to possess certain qualities of adult thought. If a stage is omitted or a child is unable to perform certain movements, his ability to generalize at a higher intellectual level will be adversely affected. The child in the group with severe limb deficiencies is limited in his ability to fulfill a number of experiences considered important for normal motor development. He has limited mobility and/or manipulative abilities, and his opportunity for tactile and proprioceptive feedback is reduced because of his missing limbs. From past clinical experience it is known that the limb-deficient child, when encouraged, will use any method of manipulation or mobilization available to him, such as substituting foot use for hand use or scooting for crawling. These substitute methods for tactile input and manipulation as well as for mobility are basic to maximal growth and development for the child with severe limb deficiencies. If the theory of Kephart and his co-workers is accepted, the preponderance of directional awareness deficits in this group may be an indication that, for some of the severely involved amputees, current methods of meeting these needs may be inadequate.
Ronald French is Assistant Professor, Department of Physical Education, New York State University College at Brockport.
Susan Clarke is Occupational Therapist, Child Amputee Prosthetics Project, University of California at Los Angeles.
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