Prosthetic Training of a Three-Year-Old Acquired Quadrimembral Amputee
ROBERTA KUCHLER-O'SHEA, PT ANDMARCIA SCHWARZ, OTR*Chicago, Illinois
Joe is a 3-year-old boy with amputations of all four extremities (Fig. 1 ) caused by severe vasculitis associated with meningococcal meningitis. The gangrene and necrosis lead to auto-amputation of the distal extremities within hours. The final revisions occurred at the age of 2 years resulting in left short below-elbow, right long below-elbow and bilateral short above-knee amputation limbs. Severe burn-like scarring is apparent over all limbs, especially the lowers, and the trunk. Joe received six months of rehabilitation when he was fitted with bilateral upper-limb prostheses having Plastisol-covered hooks and a pair of lower-limb stubbies.
When first evaluated at La Rabida Children's Hospital, the child was able to operate both terminal devices simultaneously to manipulate medium-sized objects and was able to feed himself using a large-handled spoon. He could drink from a glass on a table using a straw and was able to lift a glass independently without prostheses. Occupational therapy concentrated on fine motor development with the upper-limb prostheses, as well as feeding and dressing. Joe was able to lift medium and small objects isolating the opening of one terminal device only if the opposite prosthesis were physically held at his side.
After six sessions Joe began to approach an object with his right upper limb exclusively, with some overflow opening of the left terminal device. Holding onto one crutch while ambulating seemed to help him to learn to use one terminal device independently. He could doff his upper-limb prosthesis, assist in doffing the lower-limb prostheses eat using a regular fork in his right terminal device and a regular spoon as a "pusher" in his left terminal device (Fig. 2 ), and drink from a cup.
New prostheses were fabricated with a flexion wrist unit on the right side. Bilateral Adept terminal devices have been ordered. Joe practiced with a unilateral Adept terminal device. After one week he was able to grasp medium-sized objects without difficulty
Following session eleven Joe could open his right terminal device independent of the left one. We are currently working on bilateral coordination, transferring objects from left to right, stringing beads, and opening and closing drawstring bags. Joe is learning to don his prostheses and a shirt using the overhead method. Currently he succeeds with verbal cuing and moderate assistance.
When initially seen in physical therapy, Joe had one month's wear of bilateral above-knee prostheses with a pelvic band, unlocked hips, constant friction knees with external locks, and bilateral SACH feet. He did not like to wear the prostheses and had temper tantrums when they were applied. When wearing the prostheses, Joe was able to cruise sideways and ambulated with maximal assistance at the pelvis and with both terminal devices held. Our first session concentrated on donning and doffing the prostheses, tolerating prosthetic wear, and shifting weight while standing. During the second and third treatments, Joe was acquainted with a reversed Kaye Postural Control Walker* (Fig. 3 ). We put adaptive L-shaped brackets on the walker to allow Joe to grasp and control it. The walker is wider than the standard walker. By the third session, Joe could manipulate the walker on all surfaces. We then allowed him to take the walker home. His mother reported Joe used the walker regularly and was excited that he could be as active as her peers and siblings.
Week four of physical therapy concentrated on ambulation with one terminal device held, as well as independent standing. Joe could now use the walker at all speeds and appeared ready to progress. During the fifth and sixth sessions Joe was walking with bilateral Lofstrand crutches, using a standard four-point sequence (Fig. 4 ). We also attempted transferring from sitting on the floor to standing and vice-versa. At the end of the sixth week of therapy Joe ambulated forward without the therapist's assistance. The seventh session stressed bilateral Lofstrand crutch gait laterally and backwards, increased speed during forward gait, as well as proper weight shifting during ambulation. Joe improved rapidly and was again keeping up with his peers and siblings using crutches consistently. He seemed excited with his new faster mobility and freedom. It became apparent that Joe was ready to progress when he tried to walk while holding his crutches in the air. Treatment weeks eight, nine, and ten were spent teaching a single crutch gait pattern. Joe was quite hesitant and fearful of his new adventure. He also lacked his original motivation and excitement because walking with one crutch was slower. We began by using one crutch and one terminal device held, as well as maximal support at the pelvis (Fig. 5 ). Eventually he would carry a small toy instead of having his hand held. Finally, at session ten, Joe felt secure enough to ambulate with one Lofstrand crutch and minimal pelvic support. He preferred to keep his weight back on the heels of his feet. This was a problem because Joe had a tendency to fall backwards. The prosthetic feet were plantarflexed slightly. Joe continued to ask for his other crutch and complained about not using it.
At session eleven, Joe took fifteen steps with one crutch held in the left terminal device. He ambulated up and down a small ramp with one crutch and minimal support at the pelvis. When attempting go up and down five steps using a side-step technique, he required minimal to moderate assistance. He transferred from floor sitting to upright standing with minimal assistance during the last phase. Joe dons and doffs lower-limb prostheses requiring minimal assistance with the pelvic band and socks. Goals now are independent stair ascent and descent, ambulation with one Lofstrand crutch without therapist support, eventual independent ambulation, complete independence in donning/doffing all prostheses, and ability to lock and unlock the knee locks.
In six months Joe learned to ambulate with the assistance of one Lofstrand crutch, assist in donning/doffing clothing and prostheses, eat with a regular fork and spoon, and perform some fine motor skills. He has an uncanny desire and motivation to learn new things and keep up with his peers. Joe will enter the Chicago school system which will offer him new social and cognitive challenges. He continues to be seen weekly at La Rabida for out-patient physical and occupational therapy.
*Kaye Products, Inc., 1010 East Pettigrew Street, Durham, NC 27701-4299
*LaRabida Children's Hospital, East 65th Street at Lake Michigan, Chicago, IL 60649