Toileting Device for High-Level Upper-Limb Amputees
Liesl Friedmann, O.T.R.
One of the most challenging problems of the upper-limb amputee is self-toileting. This task is especially difficult for the child under 11 years of age who usually cannot use his heel or the rim of the toilet bowl. A number of different devices have been developed by occupational therapists and/or engineers, but no standard solution is available for all types of patients.
In approaching this problem it is important, of course, that the child be trained to have bowel movements at home and nowhere else, either in the morning or in the evening. Fluid and food intake has to be controlled strictly and continuously as to type and amount.
There are devices developed in Heidelberg, Germany, which can be attached to a wall; however, not all landlords will permit the bathroom tiles to be broken through. German clinicians have also developed a number of portable units for after-toilet cleaning, but these are primarily for upper-limb phocomelics rather than amelics. Other good portable devices for phocomelics have also been reported from Roehampton and Toronto. A device developed at Kessler Institute for Rehabilitation (K.I.R.), New Jersey, seemed most promising for bilateral amelics, but is still not entirely satisfactory. The device described here is a modification of the one reported by K.I.R. in 1967.
After 11 years of age, children of normal size usually have buttocks which are wide enough so that they can scoot back and forth three or four times on the long side of the porcelain part of the toilet bowl to clean themselves on paper which has been placed there in four or five layers by their foot and/or teeth, draped the long way. There are also some youngsters and adults who have learned to use the other foot to place the toilet paper on the back of one heel and then rock back and forth to clean themselves on the paper. This procedure entails normal or almost normal use of the lower limbs.
The device reported here was developed on the principle that it is easier to rock in a diagonal rather than a straight-vertical, or straight-horizontal, plane. It is meant to be attached to a bathtub rim rather than a toilet seat and removed after use.
Kydex, two strips, 20 in. long x 1 1/4 in. wide, molded with a heat gun to fit the rim of the tub (Fig. 1 ).
Orthoplast, 3 1/4 in. x 3 1/4 in., which is attached at the distal midline of board # 1 with two screws.
One piece of wood (board #1), 6 in. long x 3 3/4 in. wide x 1/2 in. thick, cut to the shape (Fig. 2 ).
One piece of wood, 6 in. long x 2 1/2 in. deep x 1 5/8 in. high, cut at a 45-deg. angle (board #2) to which the proximal end of board #1 is attached.
Six thick screws 1 in. long.
All plastic and wood parts are prepared by sanding them down, then attaching the Orthoplast to the center of board #1, after putting it in boiling water and shaping it so that it looks like the Diagram below.
One side of this gutter-shaped piece should be slightly lower than the other so that the toe can get a start when inserting the paper. Some spring tension will be present; however, the amount should not be such that the toe cannot insert the paper.
After the above pieces have been prepared, board #1 is screwed to the diagonal side of board #2 with two thick screws, leaving the U-shaped wooden protrusion sticking down. To use this device, the patient first has to remove his pants and/or underpants (Fig. 3 ), then sit on the floor near the bathtub, tear off a long strip of toilet paper and fold the paper over about four times on the floor (Fig. 4 ). Then, scooting closer to the device, the patient uses one of his feet to grasp the paper and inserts it at its middle onto the gutter-shaped part of the device, using his big toe (Fig. 5 ). The patient stands up, turns his buttocks to the device, and leans against it (Figs. 6 and 7 ). He flexes and extends his hips and knees to rock back and forth ([popup8] ). This may have to be repeated up to four times. Thereafter, the patient removes the paper with one of his feet and drops it into the toilet, then flushes the toilet using his foot, heel, knee, shoulder, or chin.
It is the writer's hope that in the future she can come up with a further modification in which the two Kydex strips used to apply the device to the bathtub can be made removable, and a clamp substituted so that the remainder of the apparatus can be attached to a chair or other object.
Institute of Rehabilitation Medicine New York, New York