Initial Prosthetic Fitting of the Congenital Below-Elbow Amputee: Are We Fitting Them Early Enough? ANNE G. FISHER, O.T.R.
ANNE G. FISHER, O.T.R.
Early prosthetic fitting could probably be defined as fitting between 3 months and 1 year of age. The literature concerning the development of visually guided reaching suggests that fitting should be accomplished by 2 months of age. Possible complications of fitting this early are discussed.
The Area Child Amputee Center in Michigan was the first of the Cooperating Juvenile Amputee Clinics to advocate early prosthetic fitting of the juvenile amputee 6 . Frantz 6 felt that amputees passed through the same developmental stages as normal children, and early fitting permitted the development of normal gross bilateral prehension patterns away from the body. Yet, in spite of the current practice of fitting most congenital below-elbow amputees between 6 and 8 months of age, a certain percentage of these children ultimately reject their prostheses.
Prosthetic acceptance is closely related to and dependent upon the incorporation of the prosthesis into the body scheme. In turn, the child develops the prosthetic skill and awareness necessary for spontaneous and skillful use of the prosthesis. Since vision is used to guide the prosthesis in purposeful activity, the question is raised: Would congenital below-elbow amputees be more likely to accept the wearing of a prosthesis if they were initially fitted before they developed visually guided reaching?
Early prosthetic fitting has become a widely accepted practice 1,2,5,8,16 , but clinics have differed in their definition and/or practice of early fitting. In her questionnaire survey of the Cooperating Juvenile Amputee Clinics, Sypniewski 16 found that approximately 65 per cent of the children were fitted before the age of 1 year but that the clinics differed in their developmental criteria for fitting. While most of the children were fitted between 6 and 12 months of age, some of them were fitted as early as 3 months of age.
The Area Child Amputee Center's current practice of fitting most children when they develop sitting balance is probably typical of most clinics. But at least one child received his first prosthesis at 6 weeks of age: and several children, because they were not referred to the Center until they were older, could not be fitted as early as desirable.
The literature indicates that the trend toward early fitting has resulted in increased prosthetic acceptance among those children who were fitted before age 1 or 2 1,2,8 . As discussed above, some clinics have successfully fitted children under 4 months of age, thus indicating that this practice might be feasible on a more widespread basis. Of concern, however, is the effect of this practice on the normal development of the amputee.
The fitting of a below-elbow-type prosthesis provides the child with arms of equal length to enable him to function more normally in gross and fine bilateral activity. But, the prosthetic limb lacks the sensory feedback of a normal limb. As a result, the amputee has to rely primarily on visual feedback for accurate placement of the prosthesis during activity. If prosthetic fitting is to be initiated with the very young infant, these factors must be given further consideration.
The normal infant develops visually guided reaching by the time he is 4 to 6 months of age 4,7,13 . In their study of normal institutionalized infants, White, Castle, and Held18 found that visually guided reaching develops in eight stages of two weeks each. In the first three stages (1 to 2 and 1/2 months) the tonic neck reflex predominates. As a result, the infant tends to fixate on the hand toward the favored side. Toward the end of the third stage, the infant begins to swipe at objects; and during the next stage, his head is more frequently in the midline position with his hands symmetrically placed. Subsequently, the infant develops "visual monitoring" of his hands as they engage in bilateral activity over the midline. This is
followed by unilateral reach toward an object; and by 4 and 1/2 to 5 months, the infant has achieved "top-leveI reaching" characterized by rapid lifting of the opening hand toward an object. White and Held 19 described these first 5 months as a period of ". . . discovery of the hands and gradual development of manual control by the visual system culminating in true visually directed reaching."
According to Held and Bauer 11 , "Recent research indicates that an infant primate should be unable to reach for and grasp visible objects with a limb that it has never previously viewed." This belief that the development of visually guided reaching is dependent upon the opportunity to view the actively moving limb is supported by Hein, Gower, and Diamond 9 , Hein and Held 10 , and Held and Hein 12 .
One might question whether or not infants with below-elbow limb deficiencies have normal opportunities to view their foreshortened limbs. If they do not, would very early fitting (i.e.. by 2 months of age) promote their development of visually guided reaching, or would the potential advantages be negated by the very early loss of sensory feedback as a result of covering the residual limb with a potentially cumbersome prosthesis?
Nissen, Chow, and Semmes 14 found that when a chimpanzee's limbs are covered with cardboard tubes, thereby restricting the opportunity for sensory and manipulative experiences, it fails to develop the climbing and feeding behavior of unrestricted chimpanzees. Only after the tubes are removed for some length of time do these behaviors develop, and then only gradually. Conversely, the tubes apparently have little effect on the gross motor development of the chimpanzee, and the chimpanzee develops form and space perception as a result of exploring the contours of objects with the tubes. This suggests that even after prosthetic fitting, an amputee might receive at least gross sensory feedback from a prosthesis if the prosthesis is not so heavy as to make it impossible for the infant to move his limb. Held and Hein 12 suggested that self-produced movements as well as visual feedback were necessary for the development of visually guided reaching.
Furthermore, Taub and Berman 17 studied the effects of deafferentation of the forelimbs of monkeys. They found that when only one limb was deafferented, the monkeys are capable of making gross purposive movements, but they cannot use the deafferented limb in unrestricted situations. Although the socket and harness of the prosthesis are potential sources of sensory feedback to the amputee 15,16 , patients who rejected their prostheses at the Area Child Amputee Center have often been those patients who tended to keep their prostheses passively at their sides. While most patients who reject their prostheses do so because of failure to incorporate the prostheses into their body scheme and/or because they did not find them useful, it may be that they did not attempt to use them because of lack of feedback.
The review of the literature suggests that fitting the congenital below-elbow amputee before the development of visually guided reaching might enhance his ability to substitute vision for accurate placement of the prosthesis during activity. Bruner 3 has pointed out that studies investigating the effects of shutting off a sense modality have shown that when the apparatus cutting off the modality is removed, one observes not only the effects of the removal, but also, ". . . a whole train of development which has been built around this deficit." This can just as well be applied to the child amputee: the later a prosthesis is fitted, the greater the compensatory functional patterns developed by the amputee.
If, however, the prosthesis is to be fitted by 2 months of age, research and development must provide I) lightweight prostheses which do not impair the infant's movement of his limb, 2) prostheses which provide improved sensory feedback, and 3) prosthetic fabrication techniques that facilitate the rapid fitting of a prosthesis. With improved technology, and with controlled research studies documenting the long-term effects of fitting before 2 months of age, very early fitting might become a commonplace reality. Finally, very early fitting requires the facilitation of earlier referral to fitting centers.
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