Training A Quadruple Amputee To Dress Herself
Karen A. Nelson, O.T.R. Liesl Friedmann, O.T.R.
A girl (K.C.), now ten and a half years old, who has congenital anomalies of all four limbs (Fig. 1A , Fig. 1 B/C ), has been followed in our limb-deficiency clinic since she was 13 months of age. The specific limb deficiencies have been classified as:
Upper Extremities: bilateral meromelia: T - (terminal transverse) humeral D (distal third).
Lower Extremities: bilateral meromelia: I - (intercalary transverse) femoral P, M; plus T/ (terminal longitudinal) Fibula; II, III, IV, V; or bilateral PFFDs with terminal longitudinal fibular hemimelias.
At 13 months of age, the child was provided with bilateral upper-extremity prostheses consisting of cuffs with passive mitts. When she was 27 months of age, these limbs were replaced with bilateral above-elbow prostheses which were activated three months later, except for the left elbow lock. At 16 months of age, she received temporary ambulation devices consisting of bilateral long-leg braces with a pelvic band, hip joints, wood feet, and knee joints, which were locked for ambulation. When the girl reached the age of 33 months, these devices were replaced by bilateral above-knee prostheses with funnel-shaped sockets to accommodate the shape of the stumps, single-axis knee joints, SACH feet, and bilateral Silesian suspension.
K.C.'s current equipment consists of:
Bilateral standard above-elbow prostheses with wrist flexion units.
The same type of bilateral lower-extremity prostheses as described above.
Modified Canadian crutches.
The patient was initially admitted as an inpatient for ambulation training when she was three years old and again when she was seven years old. She was recently admitted for a third inpatient period, primarily to receive training in activities of daily living. The purpose of this paper is to describe the special equipment which was found to be necessary for this patient with quadruple limb deficiencies, to outline the training program used, and to discuss the results achieved.
At the beginning of her most recent admission, K.C. was able to put on her undershirt and one of the upper-extremity prostheses. After her prostheses were donned, she was able to pull a blouse over her head. In undressing she was independent with the exception of garment fastenings and the removal of her lower-extremity prostheses. During her three-week inpatient admission, she was taught how to dress and undress herself, although she was still unable to manage garment fastenings located in the back.
Two items of equipment were especially devised for this patient to enable her to don her prostheses. A wooden frame with two platforms was built to hold the prosthetic forearms at the proper angle, and spring clips were used to hold the upper-extremity prostheses in position for donning (Fig. 2 ). For putting on the lower-extremity prostheses, a footboard with blocks was designed to position and hold the shoes when the appliances were laid on the bed (Fig. 3 ). The footboard also provided resistance against the prostheses and facilitated the placement of her stumps into the sockets.
Since it required approximately 29 minutes to don the four prostheses and clothes, we found it desirable to perform some preparatory parts of the task the prior evening after the prostheses were removed. Thus the time needed for dressing in the morning, when she had limited time before leaving for school, was reduced.
The procedure used in donning the prostheses follows:
In the evening, the underpants are drawn over the lower-extremity prostheses to a level above the knee joints (Fig. 4 ), and the prostheses are placed in the footboard. These activities require about nine minutes.
In the morning, K.C. positions the upper-extremity prostheses in the frame which is mounted on the wall near the middle of her bed. She then carefully adjusts the modified Silesian bands of the lower-extremity prostheses so that the two straps are in a position to be brought over the iliac crests (Fig. 3 ). She then puts on the undershirt which has all four stump socks attached to it (Fig. 5 ). These activities require about three minutes. For about three-fourths of its circumference, each upper-extremity stump sock is sewn around the corresponding sleeve of the undershirt, thus allowing her to get out of the stump socks when necessary without having to get undressed completely. The lower-extremity stump socks are attached only to the front of the undershirt, so that she can get the shirt over her head and later insert her lower-extremity stumps.
Donning the Upper-Extremity Prostheses
When the patient has her undershirt on, she uses her teeth to insert her upper-limb stumps into the socks and adjust them properly. She then backs into the frame so that the upper-extremity prostheses are behind her, and inserts the right stump into the socket first (Fig. 6 ), pulling the socket out of the spring clip. She then inserts the left stump into its socket, and pulls the left socket out of its spring clip. The final adjustment of the harness is made by maneuvering her body and pushing downward on the mattress with either prosthetic elbow. These activities require about four minutes.
Application of the Lower-Extremity Prostheses
Final preparations consist of positioning the pillow on the bed so that it will be under her head and enable her to see what she is doing when she is in her lower-extremity sockets. When this has been completed, K.C. lies down between the pillow and lower extremity prostheses and is in position to don the devices by maneuvering her stumps down into the sockets, with resistance provided by the footboard. The blocks on the footboard hold the prostheses in position, and the underpants hold the prostheses together with the elastic of the pants stretching when the lower extremities are pushed into the sockets.
The closures on the lower-extremity prostheses were originally buckles. However, bilateral Velcro closures with counterpull proved to be more effective. Large "D"-rings replace the buckles on the two long leather straps which are attached to the posterolateral aspects of the sockets. A five-inch shoe lace is attached to each "D"-ring. Small circular metal rings are sewn to the end of the Velcro straps which arise from the anterior aspect of each socket. Lateral trunk motion allows her to grasp the shoelace with the ipsilateral hook (Fig. 7 ). With the contralateral hook closed, she is able to insert the round ring through the "D"-ring (Fig. 7 ) by balancing the Velcro strap over the curved part of the fingers. Since it is difficult to open the hook near her body, she releases the shoelace and inserts the thumb of the ipsilateral hook into the round ring, then pulls the Velcro strap through the "D"-ring (Fig. 8 ). With the tips of the contralateral hook, she applies pressure to close the Velcro. Each side is done in the same manner. These activities require about six minutes.
K.C. then slides up in the bed, which frees the shoes from the footboard, and uses lateral trunk motion to move the lower-extremity prostheses off the bed. She sits on the edge of the bed by flexing her trunk and leaning on her prosthetic elbows and forearm. She then swings her right arm over to the left side, thus gaining additional momentum which enables her to sit up independently (Fig. 9 ).
Completion of Dressing
Finally, she proceeds to insert her closed hooks into the two loops in the front of her panties. She then stands up and pulls the panties higher as she assumes the standing position by unlocking the elbows, flexing the forearms further, and relocking the elbows (Fig. 10 ). These activities require about two minutes.
When the standing position has been achieved, the patient is able to walk to a chest-height dresser where she positions the dress properly. Dresses are pulled over her head, using shoulder abduction and teeth for final adjustment. She needs assistance with garment closures in the back; however, front-opening garments with Velcro, buttons or zipper closures can be managed independently. If buttons are used, a button hook is necessary. Donning a dress requires about five minutes.
She is then able to walk over to her wheelchair, sit in the wheelchair, and close the seat belt. She uses a long-handled comb and brush for grooming.
Toileting requires no special devices other than a raised toilet seat, a grab-bar in front of her, and loops on her panties which enable her to pull them up or down.
We appreciate that quadruple limb deformities are uncommon; however, we hope that our experiences with this patient will be of assistance to those managing similar cases.
Karen A. Nelson, O.T.R. and Liesl Friedmann, O.T.R. are associated with the Children's Occupational Therapy Institute of Rehabilitation Medicine New York University Medical Center New York, New York
1. Burtch, R. et al: "Nomenclature for Congenital Skeletal Limb Deficiencies, A Revision of the Frantz and O'Rahilly Classification," Artif. Limbs, 10:24-35, Spring 1966.