The Importance Of Early Evaluation Of The Whole Child

Marcus Stewart, M.D. is the Campbell Clinic Co-Chief Les Passees Rehabilitation Center, Memphis, Tennessee


Since World War II giant forward strides have been made in the classification of amputees, in the manufacture and fitting of prostheses, and in education and training, especially of the juvenile amputee. This progress continues to keep pace with advances in medicine and surgery; and in human values, is as significant as the progress being made in modern electronics, atomic energy and space exploration. Research in the development of aids such as artificial muscle substitutes activated by electric energy, compressed gases and similar devices continually raises our treatment horizons not only for amputees, but for all those who are physically handicapped.

However, as in the totality of man's so-called "modern progressive civilization", I wonder if we too, in this field of amputee treatment, especially of those with the more severe congenital handicaps, are not falling far behind in our sociological, moral and spiritual obligations. In other words, do we really consider the child's problem as a whole; and if so, do we assume the associated obligations and responsibilities early enough in the infant's life? The provision of paternal love and devotion is not necessarily the direct responsibility of our Amputee Clinics. Nevertheless it is our responsibility, insofar as is possible, to see that these elements vital to the child's development are provided, giving intelligent direction and guidance to those making this contribution. We must constantly remind ourselves that the first three or four years of life are the most important in developing emotional stability and character.

In addition to meeting the spiritual and psychological needs of the child, we must continue our utmost efforts toward the development of mechanical aids that best suit the individual case and not have to fit the case to the expediency of the device.

As Milton Wilder has so aptly stated, "In the treatment of the child amputee, there is ample scope for intelligent experimentation and trial ventures. New ideas and concepts should be welcomed, discussed, and developed, since it is only in an atmosphere of this type that a child's Amputee Clinic can satisfy the varying needs of its patients." (1)

In short, we must see the forest as well as the trees and we cannot do so by slavish adherence to rigid concepts of treatment.

Thus our treatment of the child amputee must begin early, combine imagination with the best of current prosthetic knowledge, and be enriched by parental love and support. The case histories which follow illustrate the effectiveness of these ingredients.

Early Fitting of Bilateral Shoulder Disarticulation Amputee

In the bilateral shoulder disarticulation amputee, with or without phocomelia, or the patient with bilateral short, above-elbow stumps, achieving balance for sitting and walking is one of the primary problems. Fig. 1 illustrates this problem of lack of balance - at 18 months this child could not walk or even stand alone. Fig. 2 depicts a similar case, presenting the same problem. However, as soon as these children were fitted with simple shoulder cuffs, they were able to stand and to walk shortly thereafter. As they grew and developed, the prostheses were extended first to the elbow, later to the wrist, and then completed with terminal devices, and training began. Fig. 3A and Fig. 3B show the child (K.S.) depicted in Fig. 1 . He has no pectoral girdle excursion or power and uses a harness attached to upper thigh cuffs to activate his prostheses. The child feeds himself surprisingly well and writes a very legible hand.

How much training should be provided with the upper extremity prostheses, and how much the child should be allowed to use his feet, has always been a debatable question. We believe it should not be resolved on generalities but upon evaluation of each individual case. The age at which the prostheses are initially fitted is, of course, a prime consideration.

Quadruple Amputees

Fortunately, quadruple amputees, especially congenital quadruple amputees, are exceedingly rare. However, when encountered, each patient of this group presents distinct individual problems in addition to the routine physical disabilities and poor control of body temperature.

Case 1

T.C. (Fig. 4A ) first came under our care at the age of five months. Fig. 4B shows the complete skeletal deficiency of his lower extremities. This child's story had been told very effectively in a number of lay publications including the syndicated column "Strolling", (2) (3) and the International Harvester magazine. (4) (5) Perhaps the most unusual feature of the saga is that T.C. was an adopted child, and the needed love and warmth was provided by his foster family.

Shoulder cuffs were applied early and they gave the child balance. He promptly learned to sit alone on his ischial tuberosities. He was then provided with a plastic bucket which could be attached to chairs, roller platforms and his "wonder horse". Fig. 4C shows the type of bucket used, although the picture was taken at a later stage of development.

At the age of six months, his upper arm units were fitted down to the elbow. At eight months, cable type arms with spatular type terminal devices were fitted (Fig. 4D ). He immediately learned to use these for balance, for protection in falling, and for turning pages in books and magazines.

Following the completion of these temporary upper extremity prostheses it was surprising how well he could ride his "wonder horse", (Fig. 4E ). He could maneuver his roller platform across the floor nearly as fast as one could walk.

At one year and two months, he was given passively operated split hooks. It was an amazing sight to see him cross the floor, using his arms to pull roller toys behind him.

T.C. manipulated his triangular roller platform so vigorously that on several occasions he tipped over. To prevent this tipping, forward and aft extensions were built on to the platform.

At eighteen months of age, active controls were provided for both upper extremity prostheses, including terminal devices, in order to let the child determine his dominant hand. During this period he was under the expert training of Miss Elizabeth Speltz, R.P.T. of the Crippled Children's Hospital.

In June, 1964, at age two and a half years, T.C.'s lower limbs were constructed by Mr. Floyd Simmons of Tri-State Limb and Brace Company. His immediate post-fitting balance was excellent. It was quite gratifying to see how quickly he was able to walk across the floor with the new legs (Fig. 4F and Fig. 4G ). This ambulation of course, was accomplished by a "to and fro" rotary motion of his body. A consultant pediatrician was amazed at the muscular development and coordination displayed by a child of Tommy's age.

Case 2

L.L.W. was first seen by one of my associates, Dr. A.J.I, in February, 1954, before we had established our own Amputee Clinic. The prenatal history on this child was normal with no difficulty reported except that the mother experienced some bleeding in the seventh month of pregnancy. The mother was 20 years old; the father was 21. One other sibling is normal. There appeared to be no familial history of abnormalities of a similar nature or even of single extremity absent in the family tree of either parent.

When first seen here at the age of two years the child had not learned to talk or to feed himself. The mother stated that his development had been slow, but that he was able to balance and sit up at sixteen months of age.

In April of 1954, Dr. Charles H. Frantz of Grand Rapids was contacted and agreed to evaluate this child on referral from the Tennessee Crippled Children's program. Dr. Frantz and associates did a tremendous job in fitting and training this child with both upper and lower extremity prostheses.

Our clinic began operations shortly after our first team, Miss Aline Bletcher, R.P.T., Mr. Ronnie Snell, CP., and Dr. M.J.S. had completed the prosthetic courses at U.C.L.A. L.L.W. was then returned to us through the Tennessee CCS program, and we began working with him early in the Spring of 1957 (Fig. 5A ). He had outgrown both his upper and lower extremity prostheses, and new ones were prepared. In April, 1957, one of my associates, Dr. T.L. W., who had joined the team after completing the lower extremity course at N.Y.U. saw this patient and made the following notes: "The new lower limbs fit quite well; however, his gait is extremely poor. The stumps are good. He has excellent muscle power. He is essentially normal as far as hip motion is concerned. Because of his poor gait and ambulation, he should be admitted for training." (Fig. 5B and Fig. 5C )

"This training was accomplished by Miss Aline Bletcher, R.P.T., and Miss Jackie King, R.F.T. (who also had completed the course at U.C.L.A.), and after three weeks the child was allowed to return to his home.

"On June 21, 1957, the child was walking most satisfactorily with his lower extremity prostheses, using Canadian crutches controlled by his upper extremity prostheses. His parents stated that he was able to feed himself an entire meal without assistance (this at age five years). The father stated he could throw a baseball 30 yards."

The child continued to improve for a year until April, 1958, when unfortunately a fire in his home destroyed all his prostheses. New ones were prepared. The delay of two months from the time of the fire until the four new prostheses were fitted retarded him to some degree, but not too much. In December, 1958, he was walking unassisted without crutches, feeding himself, drinking Coca-Cola, et cetera, and manipulating all his prostheses.

In November, 1959, because of a spurt of rapid growth, considerable adjustment had to be made on all his prostheses (and he was very pleased when his legs were lengthened to make him taller than his little brother). By this time, the child was not only feeding himself satisfactorily but completely dressing himself and going regularly to public school. He participated fully in school activities including playing with normal children. At age seven, by necessity, he learned how to get up from the ground unassisted. He was playing with the other children and fell. They were too busy to pick him up. He became angry, screamed and hollered, and beat the ground with his prosthesis, then rolled over to a prone position and, unassisted, pushed himself backwards with his arms, rocked a bit until he reached a position of balance in the standing position, and walked away. He has been accomplishing this feat ever since.

The child was last seen September 11, 1964 (Fig. 5D and Fig. 5E ). He had returned to school for the fall term and was in the sixth grade. He has been making satisfactory school grades, carrying a B average in essentially all subjects. He has a surprisingly legible handwriting (Fig. 5F ). He handles a motorboat and is an excellent spinning rod fisherman. Lonnie is a well-adjusted and well motivated boy.

Conclusion

The youngsters discussed in this paper have a future which can be full and successful because their problems could be evaluated in their totality by the clinic team, and treatment undertaken with complete paternal and maternal cooperation and love. Fortunately for the hundreds with similar disabilities, many competent teams are now available to provide the necessary guidance. Let us assume our full responsibility for these infants early, so that we may guide and direct the parents as well as the child. We must also remember that our obligation to these individuals continues for many years - until they are socially adjusted and economically solvent.

Marcus Stewart, M.D. is the Campbell Clinic Co-Chief Les Passees Rehabilitation Center, Memphis, Tennessee

References:
1. Wilder, Milton J., "The Use of Brace-Type Devices in the Treatment of Children with Congenital Malformations", Inter-Clinic Information Bulletin, New York University, December 1963. 
2. Roark, Eldon, "Strolling", Memphis Press Scimitar, Memphis, Tennessee, July 4, 1963. 
3. Ibid., circa, October 8-9, 1964. 
4. International Harvester Today, "No Tears for Tommy", Volume 14, Number 3, 1963. 
5. International Harvester Today, "Remember Tommy Cook?", Volume 15, Number 3, 1964