Competitive and Recreational Sports in Children with Limb Deficiencies
CHARLES H. EPPS, JR., M.D. AND D'ORSAY D. BRYANT, III, M.D.
Competitive and recreational sports participation can have a positive effect on the growth and development of children with both congenital and acquired limb deficiencies. The amputee can compete successfully if the activity is safe, yet provides a reasonable degree of challenge. The tremendous progress in prosthetic technology allows limb deficient children to increase their involvement in athletics. Energy-saving prosthetic feet (Carbon Copy II and Seattle Foot) permit the athlete to have better toe-off in ambulation and a more natural gait pattern. Children can compete more vigorously in sports events with prostheses made with lighter-weight materials, such as carbon graphite, various plastics, and titanium. For optimal athletic performance, the prosthesis should be tailored to the amputee's specific needs.
Competitive and Recreational Sports in Children with Limb Deficiencies
"Sport puts the fight back into a fighter"
Sir Ludwig Guttmann (27)
Athletic participation provides a healthy self-image to children with limb deficiencies. Important differences exist between an amputation in adulthood, secondary to infection, trauma, or diabetes, and a congenital limb deficiency. Unlike an adult amputation, the congenital amputee's extremity malformation occurs in utero26. Therefore, the congenital amputee does not undergo a period of significant psychological and physical readjustment to the missing body part. The limb deficient child readily accepts the deformity and can lead a fairly normal life-style with proper guidance26.
The principle considerations in the amputee's sports participation are; the level of challenge to the child; the safety of the activity; the degree of success the child will have; and the ability of the amputee clinic to provide special assistive devices to improve the child's performance.24 The sport must be carefully selected. An important difference exists between a competitive versus a recreational activity. For example, a quadrimembral amputee should be guided to an appropriate recreational activity. These patients enjoy no competition or competes only against their previous performance. Otherwise, if allowed to participate in a competitive activity against children without a limb deficiency, the patient's self-image could be affected negatively.
Recent advances in prosthetic research and design should improve the ability of the amputee to participate in athletics. However, the love, support, and acceptance from family and friends are the most important factors in the amputee's sports participation.
Amputee Sports Participation
"It is not what you have lost, but what you have left that counts."27
Several individuals with limb deficiencies have achieved prominence in professional sports. Some excellent examples can be cited in professional football and baseball. Tom Dempsey was a leading field goal kicker with the New Orleans Saints in the National Football League. Dempsey had absence of one hand and congenital absence of the forefoot. He made field goals of 55 and 54 yards in one season and holds the record for the longest field goal in NFL history; a 63 yard field goal on November 8, 1970 which won the game. In baseball, Monte Stratton played for the Chicago White Sox with a below-knee amputation sustained in a hunting accident. His courageous return to pitching, using a below-knee prosthesis, was the theme for a motion picture. Jim Abbott, a starting pitcher with the California Angels in the American League, is presently the greatest inspiration to children with limb deficiencies. He has congenital below-elbow amputation, yet pitches the baseball without using a prosthesis. In 1988, he was the recipient of the Sullivan Award as the nation's outstanding amateur collegiate athlete, prior to his participation in professional baseball.
Although several amputees have been successful in professional sports, few studies have reviewed the general sports participation of children with congenital limb deficiencies. However, the establishment of single sport programs for juvenile amputees, such as snow-skiing, archery, and horseback riding, has been reported. In 1968, the Three-Track Ski Club was formed by the Children's Hospital of Denver, Colorado, for patients with amputations."20 In three-track skiing, two specially designed outriggers and a single ski are used by individuals with either an above-knee amputation, or hip disarticulation, to ski down the slopes.20,21 In 1971, Kuhlthau13 described the use of a special assistive device called a rein bar, that allows children with above-elbow and below-elbow amputation to participate in horseback riding. Pettit25 reported the establishment of an archery program for physically handicapped children, conducted by the Cypress Orthopedic School in Ontario, California. The program was successful because: the sport was challenging, constant positive verbal reinforcement was given to the child to build confidence, and each child was able to achieve success." In Germany, Marquardt15 noted that horseback riding and skiing were possible for children with limb deficiencies caused by Thalidomide exposure. In Marquardt's clinic, pediatric amputees were able to participate in activities such as swimming, archery, jumping, dancing, ballplaying, and trampoline jumping.15
Kegel et. al,10,11 and Smith28 surveyed the athletic and recreational activities of adults with amputation. These studies reported that fishing, swimming, bowling, and golf were popular recreational activities. However, the respondents were not completely satisfied with their ability to participate in athletics. The reports concluded that physical therapists were not providing adequate preparation for amputees to pursue recreational activities, more innovation in prosthetic design was needed, and the physical therapist, the prosthetist, and the patient need more education about special adaptive equipment and recreational prostheses.
The Team Approach
The juvenile amputee clinic should employ a team approach to achieve a high level of sports participation. This type of approach for the management of amputees has often been recommended.2,5,9,14,15,24 The team is usually composed of an orthopaedic surgeon, pediatrician, prosthetist, physical therapist, occupational therapist, nurse, and social worker. If necessary, psychological and genetic counseling can be made available.
The team gives parents a realistic appraisal of the child's abilities and limitations, and the possibilities of achievement during development. By actively involving the family, in the care of the limb deficient child, the clinic is able to include them as the most important members of the team. Forty-one patients in our clinic, between 5 and 21 years of age, participate in a total of 152 competitive and recreational sports activities (Table 1 ).
Recent advances in prosthetic research and design have improved the ability of amputees to participate in sports activities. These new innovations include energy-storing and releasing prosthetic feet,2,9,18,22,29,32 computer-aided socket designs,2,6,12,18,22,29,32 and lightweight prosthetic materials.2,9 In general, patients are unable to run using the traditional single-axis prosthetic foot, for the individual lacks the ability to push off after foot flat. To address this problem, the energy-storing, spring action prosthetic foot has been designed to simulate normal gait. The foot stores energy in early stance. It then releases the energy at toe-off to spring the patient forward. The patient has a more normal gait and can participate better in athletic activities that require running. Numerous brands of energy-storing feet are available. These include, the FlexFoot, Springlite Foot, STEN Foot, Carbon Copy II and III, and the Seattle Foot. Presently, most energy-storing and releasing prosthetic feet cost three to four times as much as the traditional solid ankle cushion heel (SACH) foot.9
Innovations in prosthetic design are now available that can increase the sports participation of children with above-knee amputation. In general, amputation at the below-knee level is preferable to above-knee. Those with higher loss have more difficult prosthetic training and increased metabolic demands.8,16,31 The quadrilateral socket has been the universally accepted above-knee socket for over three decades.17 However, patients have difficulty using the quadrilateral socket for running sports. The use of the quadrilateral socket results in pronounced lateral trunk bending due to persistent abduction of the femur. The ischial containment socket provides a better configuration, better suction suspension and prevents socket toggle.8 It includes the ischium and stabilizes the femur in adduction, which allows for a more normal, physiologic gait.4
The Icelandic-Swedish-New York (ISNY) flexible above-knee socket was introduced in the United States in 1984.7 The socket is constructed from lightweight thermoplastic materials and provides greater sensory feedback.1 Fishman et. al7 investigated the performance of ISNY prosthesis in ten pediatric above-knee amputees. The amputees cited several advantages: better function; improved appearance; and increased comfort. The children noted that it was easier to walk, dance, run and jump using the ISNY prosthesis.
For below-knee amputees, the computer-aided design (CAD)/computer-aided manufacturing (CAM) of sockets has several advantages over the traditional plaster casting and modification techniques. CAD/CAM socket fabrication allows the user to store experience from previous designs, avoids duplication of work, and improves product reproducibility.19 A second computer-aided socket manufacturing process was reported by Faulkner et al.6 They use a computerized ultrasound sensing mechanism to improve socket design.6
For children with upper extremity limb deficiency, the myoelectric prosthesis is suitable for recreational activities. In a study which compared myoelectric hands with a conventional prosthesis (cable-controlled hook), Stein and Walley30 reported that adult patients wearing myoelectric prostheses had a better range of motion and an improved cosmetic appearance. The myoelectric prosthesis provides biofeedback and frees the amputee from control cables and suspension systems of the conventional below-elbow prosthesis.3 However, the myoelectric prosthesis has several disadvantages which preclude its use in high level sports activity such as, slower performance time, increased weight, and a cost four to five times that of the conventional prosthesis.3
The fabrication of prostheses, using new lightweight polymers and alloys will increase the sports participation of limb deficient children. Stronger, yet lighter weight prostheses, can now be constructed from carbon graphite, aromatic polyamide fibers, higher density plastics, and titanium.2,9 The aforementioned ISNY socket is a lightweight, flexible prosthesis that allows the aboveknee amputee to run and jump with greater ease. A lightweight prosthetic limb increases the ability of the amputee to pursue more vigorous sports activities.
"How do you value human needs in a marketplace in which the trend is toward price reduction?"2
The recent advances in prosthetic research and design can improve the ability of the amputee to participate in competitive and recreational activity. A lightweight, yet stronger prosthesis, with better function, will decrease the energy demands of the amputee. The limb deficient child will then have the ability to undertake new sports activities and improve his athletic performance.
Our juvenile amputee clinic has been successful in encouraging limb deficient children to participate in athletic activities (Fig. 1 , Fig. 2-a , Fig. 3 , Figs. 4-a and 4-b , Figs 5-a and 5-b ). However, none of them has been able to benefit from the new advances in prosthetics due to the high cost. At the present time, the new prosthetic technology is too expensive for routine usage by juvenile amputees. However, with further research, and a commitment of the government and other third party payers to cover the costs, more limb deficient children will be able to have access to new prosthetic innovations. Successful sports participation builds self-confidence and can positively affect the personal growth and development of children with limb deficiencies.
- Coombes AGA, Greenwood CD: Memory Plastics for Prosthetic and Orthotic Applications. Pros Orth Intl, 12:143151, 1988.
- Cooney DFM, Binnecour KE: An Advanced Approach Toward Improved Prosthetic Fittings. Clin Pros Ortho, 9(3):4-8, 1985.
- Dalsey Robert, Gomez William, Seitz WH, Dick HM, Hutnick Glen, Akdeniz Robin: Myoelectric Prosthetic Replacement in the Upper-Extremity Amputee. Ortho Rev 18(6):697-702, June 1989.
- Epps CH Jr: Amputation of the Lower Limb. In Evarts CM, ed. Surgery of the Musculoskeletal System. Churchill Livingstone: New York, 1990.
- Epps CH Jr: The Role of the Orthopaedic Surgeon in the Clinic Team. Clin Proc Child Hosp. Dist Col 24(7):260-266, July-Aug. 1968.
- Faulkner Virgil, Walsh NE, Gall NG: A Computerized Ultrasound Shape Sensing Mechanism. Ortho Pros, 41:5765, 1988.
- Fishman Sidney, Edelstein JE, Krebs DE: Icelandic-Swedish-New York Above Knee Prosthetic Sockets: Pediatric Experience. J Ped Orthop, 7:557-562, 1987.
- Flandry Fred, Beskin James, Chambers RB, Perry Jacquelin, Waters RL, Chavez R: The Effect of the CAT-CAM Above-Knee Prosthesis on Functional Rehabilitation. Clin Orthop, 239:249-262, Feb. 1989.
- Gottschalk FA, McClellan Bruce: Functional Mobilization of the Lower Limb Amputee. J Musc Med 55-67, March 1990.
- Kegel Bernice, Carpenter ML, Burgess EM: Functional Capabilities of Lower Extremity Amputees. Arch Phys Med Rehabil, 59:109-120, March 1978.
- Kegel Bernice, Webster JC, Burgess EM: Recreational Activities of Lower Extremity Amputees: A Survey. Arch Phys Med Rehab, 91:258-264, June 1980.
- Klasson B: Computer Aided Design, Computer Aided Manufacture and Other Computer Aids in Prosthetics and Orthotics. Pros Orth Intl, 9:3-11, 1985.
- Kuhlthau Linda: Equitation for Amputees. Inter-Clin Info Bull, 10(5):9-12, Feb. 1971.
- Marks Linda: Lower Limb Amputees: Advantages of the Team Approach. The Practitioner, 231:1321-1324, Oct. 1987.
- Marquardt EG: A Holistic Approach to Rehabilitation for the Limb-Deficient Child. Arch Phys Med Rehab, 91:237242, June 1980.
- Medhat MA, McAnelly RD: What's New in Lower Extremity Amputation and Prosthetics: Part 1. Surg Rounds Orthop: 15-18, April 1990.
- Medhat MA, McAnelly RD: What's New in Lower Extremity Amputation and Prosthetics: Part 2. Surg Rounds Orthop: 36-47, May 1990.
- Medhat MA, McAnelly RD: What's New in Lower Extremity Amputation and Prosthetics: Part 3. Surg Rounds Orthop: 30-39, June 1990.
- Medhat MA, McAnelly RD: What's New in Lower Extremity Amputation and Prosthetics: Part 4. Surg Rounds Orthop: 37-39, July 1990.
- Messner DG: A Modified Outrigger for "Three-Track" Skiing. Inter-Clin Info Bull, 9(12):9-11, Sept. 1970.
- Messner DG, Williams Willie: The Three Track Ski Club and The National Amputee Ski Championships. Inter-Clin Info Bull, 13(1):1-4, Oct. 1973.
- Michael John: Energy Storing Feet: A Clinical Comparison. Cli Pros Orth, 11(3): 154-168, 1987.
- Oberg KET: Swedish Attempts in Using CAD/CAM Principles for Prosthetics and Orthotics. Clin Pros Orth, 9(2):19-23, 1985.
- Peoples Alan: The Juvenile Amputee: Physical Therapy and Sports Participation. In Kalamchi Ali, ed. Congenital Lower Limb Deficiencies. Springer-Verlag: New York, 1989.
- Pettit MH: On Target. Inter-Clin Info Bull, 9(10):14-16, July 1970.
- Pizzutillo PD: Sports Medicine in the Congenital Lower-Limb Amputee. In Kalamchi Ali, ed. Congenital Lower Limb Deficiencies. Springer-Verlag: New York, 1989.
- Roberts K: Sports for the Disabled. Physiotherapy, 60(9):271-274, Sept. 1974.
- Smith JP: In What Sports Can Patients with Amputations and other Handicaps Successfully and Actively Participate? Phys Ther, 50:121-126, Jan 1970.
- Staats TB: Advanced Prosthetic Techniques for Below Knee Amputations. Orthopedics, 8(2):249-258, Feb. 1985.
- Stein RB, Walley M: Functional Comparison of Upper Extremity Amputees Using Myoelectric and Conventional Prostheses. Arch Phys Med Rehabil., 64:243-248, June 1983.
- Volpicelli LJ, Chambers RB, Wagner FW: Ambulation Levels of Bilateral Lower Extremity Amputees. J Bone and Joint Surg 65A:599-604, June 1983.
- Wing DC, Hittenberger DA: Energy-Storing Prosthetic Feet. Arch Phys Med Reha bil 70:330-335, April 1989.
- D'Orsay D. Bryant III, MD, 5802 Williamsburg Road, Cincinnati, Ohio 45215