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Musical Instruments for Upper-Limb Amputees

During the 17 years since the inception of the Child Amputee Prosthetics Project at UCLA, staff therapists have often been questioned about types of musical instruments appropriate for children with upper-limb deficiencies. Since few therapists possess extensive knowledge of this area, answers have had to be based on limited information. A thorough search of the literature has revealed that several articles have been written on related subjects such as recreation for physically handicapped persons, how to make rhythm-band instruments for cerebral-palsied children, and how to use musical instruments as therapy in physical rehabilitation centers. However, the only information found which was specifically related to active musical participation by the amputee appeared in a recent issue of the Inter-Clinic Information Bulletin.

To locate material for the present article, several persons with professional knowledge of instrumental music were interviewed, including music teachers and the owners of music stores. The subject was also discussed with other therapists and with amputees who played a variety of musical instruments. It is hoped that the information presented will be helpful to therapists and other interested persons working with amputees throughout the country.

A Means of Self-Expression

Not every amputee will have an interest in playing an instrument. However, those who do should be encouraged and given as much information as possible. Therapists have the responsibility of stimulating interest in this area, and often a question from the therapist will arouse the child's interest and encourage him to begin thinking about participation in a new activity. Music has the potential to be a major source of enjoyment and leisure enrichment comparable to other hobbies that increase knowledge and encourage creativity and performance. With talent and the persistence necessary to acquire a technique, music could even become a means of livelihood. However, even if the amputee does not choose to become a professional musician, playing an instrument will provide a means of constructive and disciplined self-expression, help develop self-confidence, and promote coordination.

Most public schools offer a musical-instrument program which usually begins at the fourth or fifth grade. In many schools, however, an even earlier opportunity for musical participation is provided by simplified devices such as the Orff instruments, tone bells, and a variety of rhythm-band instruments. These items are more than toys, and can stimulate a child's interest in rhythm and melody at a very early age.

Selecting an Instrument

When the child is ready to begin a program of instruction, some guidance in the selection of an instrument is necessary to assure the best chance for success. The most important single factor is certainly an active interest in some particular instrument; otherwise the child is not likely to develop the self-discipline needed to practice and become proficient. There are also physical considerations involved: the child's general strength and health, and the limitations on the choice of instrument which may be imposed by his physical disability. Individual personality traits should also be considered; for example, a shy, introspective child may not do well on the trumpet, bass drum, or cymbals.

In this paper, several types of instruments are discussed and recommendations are made concerning those appropriate for specific levels and types of amputations. Because of space limitations the variety of individual deficiencies (e.g., phocomelic limbs) will not be discussed in detail. It is intended merely that the information provided might serve as a guide in the selection of an instrument. A qualified music instructor working closely with trained personnel in a music store can provide this guidance, and it is recommended that the child be taken to such a center where he can test the instrument in which he is interested in order to determine whether he might have the ability to learn to play it.

The Cornet and Trumpet

Of the brass instruments, the cornet (or trumpet) and trombone are in greatest demand in school bands or youth bands, and offer the child the prospect of early participation. However, these groups also may badly need other brass instruments such as French horns, baritone horns, alto horns or mellophones, tubas or Sousaphones.

There are distinct differences between the cornet and trumpet; however, the use of the hands is similar for both instruments, and so the terms are used interchangeably in this article. Either instrument is an excellent choice for a unilateral amputee with a prosthesis regardless of level of amputation, or for the partial-hand, below-elbow or long-above-elbow amputee who does not wear a prosthesis. The child with a higher level of amputation who does not wear a prosthesis would probably need some type of custom-made device to enable him to support the instrument. Because of the position of the three valves, either the right or left hand can be used to operate the valves while the deficient limb supports the instrument. The hand used to operate the valves should have at least three functional digits for effective fingering. Both the cornet and trumpet are equipped with a ring for supporting the instrument which can easily be held with a hook-type terminal device. If necessary, this ring can be repositioned at any music store which repairs brass instruments. If the child does not wear a prosthesis and intends to use his stump to support the instrument, he should experiment to make sure he can do this effectively before making his choice.

The student shown in Fig. 1 is thirteen years of age and has played the trumpet for the past two years. She takes private lessons and plays in the school band. She has also played in parades with a marching band. Her long-below-elbow deficiency has not hindered her study of the instrument. She did find that her terminal device scratched the surface of the trumpet, and to prevent this she has covered the appropriate portion of the instrument with masking tape.

The Trombone

The trombone produces variations in tone by means of a telescopic slide instead of valves. This slide can be operated easily with one hand and therefore the trombone is an excellent instrument for the unilateral amputee with a prosthesis, regardless of amputation level. The sound extremity is used to operate the slide while the deficient limb supports the instrument. Either the right or left hand can be used to operate the slide. The unilateral amputee who does not wear a prosthesis and has no ability to grasp with the deficient extremity should experiment with the instrument to make sure he can support it effectively before he chooses it. Since it has no valves, the trombone has potential for an amputee with bilateral partial hands or bilateral below-elbow deficiencies. As long as the patient has some ability to grasp with each limb, he should be able to handle the trombone either with or without prostheses. However, in order to operate the slide, complete elbow extension is necessary on one side, and thus it would not be a practical choice for a bilateral with above-elbow or higher level of involvement. When considering the trombone for a bilateral amputee, two points should be kept in mind:

  1. The ability to develop a smooth, accurate slide technique is essential; therefore the child should have good control over his limbs and/or prostheses.
  2. In the more advanced stages of learning, after the student has developed a full, resonant and free "straight" tone, a technique known as "slide vibrato" is employed. This requires wrist motion or some substitute motion in the extremity used to operate the slide.

The trombone has a post for use in supporting the instrument, and this can be repositioned easily. Also, counterbalances can be added to shift the weight balance from the front to the back. Counterbalances are frequently added for young students to make it easier for them to support the weight of the instrument.

Valve Trombone

A similar instrument, the valve trombone, should be considered for the unilateral amputee. Use of the hands is similar to that described for the trumpet or cornet. The valve trombone resembles a standard trombone in appearance but uses three valves instead of a slide. It is not in as great demand and has never been a real rival to the slide trombone because its tone is somewhat unreliable and of indifferent quality. On the other hand, the valve trombone is comparatively easier to play and is sometimes utilized in marching bands because it eliminates the problem of keeping the slide out of the way.

The French Horn

Although the French horn becomes a two-handed instrument in the more advanced stages of performance, it is still a possibility for the patient with a unilateral deficiency. However, it is a difficult instrument to master, and certainly not one to provide quick satisfaction. As one reference states, the person learning to play the instrument must have a keen ear and cool nerves. The French horn is frequently in demand in school bands but is used in smaller numbers than the cornet or trumpet. Because of the placement of the valves on the left side of the instrument, the left hand is used to manipulate these while the right hand supports the horn and is also employed for special effects and hand muting.

If the right hand were used to operate the valves, balancing the instrument and manipulating the valves would be more difficult; therefore the French horn would be most suitable for a right unilateral amputee at any level of amputation with a prosthesis. Without a prosthesis it would be more feasible for a right partial-hand or below-elbow amputee. If the child progresses beyond the elementary stages and is highly motivated to continue study of the instrument, it may be possible to pad the stump or a hook-type terminal device in such a way that it can be used in the bell of the horn for hand muting. However, this may not be feasible because proper placement of the right hand is crucial: increasing the muting effect can lower the pitch by at least a semitone, while decreasing the amount of hand-cupping will raise the pitch. An alternative would be use of a transposing mute which is available commercially and approximates the hand-muted effect. The right-limb amputee would need to remove and replace the mute with his prosthesis as required by the music.

The Mellophone

The mellophone, which is similar to the French horn in appearance, is easier to learn to play. Unlike the French horn, the valves of the mellophone are usually manipulated with the right hand while the left is used for support. It is a one-handed instrument and therefore a good possibility for a left unilateral amputee with a prosthesis regardless of level of amputation. Without prosthesis, it would be more feasible for a left partial-hand or below-elbow amputee; the right hand, which must have at least three functional digits, would be used to finger the valves while the left limb-deficient extremity supports the instrument.

Other Brass Instruments

The baritone and alto horns are two other brass instruments which may be considered for the unilateral amputee. Because of the design of both instruments, it is easier to manipulate the valves with the right hand while the left limb-deficient extremity supports the instrument. Except for the fact that these instruments are more suitable for a child who has lost his left limb, the considerations of amputation level and prosthesis versus no prosthesis would be the same as described for the trumpet.

Tubas and Sousaphones are also utilized in a school band. Since the average fourth- or fifth-grade student is too small to handle these instruments, he is often started on the baritone horn and at a later date changed to the Sousaphone or tuba. At first glance these instruments appear to be bulky and unwieldy and not good possibilities for an amputee; however, three points should be noted:

  1. Lightweight fibreglass or plastic instruments are available commercially. (At least one high school band has used these lightweight instruments when marching in the Rose Bowl Parade.)
  2. There is a "junior-size" tuba made for student use. It is shaped like a full-size tuba and rests in the student's lap.
  3. Sousaphone and tuba chair stands are commercially available. These chair stands support the instrument and allow the student to sit down inside the tubing. These are not often found at the elementary school level but are frequently used in junior and senior high school bands.

If a chair stand is utilized, the child with a unilateral left amputation of any level could play these instruments regardless of whether or not he wears a prosthesis. The valves are positioned in such a manner that they are easier to manipulate with the right hand. In a marching band, the Sousaphone is easier to carry than the tuba. Neither instrument would be suitable for a forequarter amputee in this situation, and it would be necessary for an amputee of any other level to try marching with a Sousaphone or tuba to determine whether he could carry it effectively.

The bugle might also be considered, although being a valveless instrument it has a limited tonal range. However, fife, drum, and bugle corps are found in cities throughout the country. The bugle would be a possibility for the unilateral right or left amputee with any level of amputation regardless of whether or not he wears a prosthesis. It is also worth consideration for the bilateral partial-hand or below-elbow amputee with or without prosthesis, or the bilateral above-elbow patient who wears prostheses. There is also a single-valve piston bugle, in which the valve is used to change the range of the instrument, although it is not utilized as frequently as the valves on a trumpet. This instrument would be suitable for a unilateral right or left amputee with the ability to support the instrument and finger the valve simultaneously. It might also be considered for a bilateral partial-hand, below-elbow, or possibly an above-elbow amputee, if the patient can support the bugle and finger the valve simultaneously.

Woodwind Instruments

Woodwind instruments such as the flute, piccolo, clarinet and saxophone require a great deal of fingering with each hand. A woodwind should be considered for the unilateral partial-hand amputee with at least two or three functional digits on the limb-deficient side; however, these instruments are not recommended for any other level of amputation. Although it is possible that a few limb-deficient children do play instruments of this group, there are many other instruments which are more practical and easier for them to learn.

String Instruments (bowed)

The violin, viola, cello, and string bass are a great challenge to anyone, even with normal extremities. It takes a long time to become skillful on any of these instruments, and the child who selects one should not have a need for immediate success and should be highly motivated to practice. Customarily, a sound left extremity is used to finger the strings. The right hand then needs to be able to grasp the bow or be fitted with a prosthesis capable of secure grasp. In order to handle the bow properly, pronation and supination of the forearm as well as active elbow flexion and extension are needed. Some ulnar deviation of the wrist is also helpful but not absolutely necessary. Therefore, this group of instruments would be ideal for a unilateral right partial-hand or long-below-elbow amputee with ability to pronate and supinate the forearm. A stringed instrument might also be considered for a left partial-hand or long-below-elbow amputee, but further adaptations would be required. For example, the young CAPP patient shown in Fig. 2 has a congenital left transcarpal deficiency. Although she wears a long-below-elbow-type prosthesis for other activities, a special opposition post with cutout is used to hold the bow when she plays the violin ( Fg. 3 ). The post permits her more pronation and supination, more sensory feedback, and better control over the bow than docs the hook terminal device of her prosthesis. The only other adaptation necessary was reversal of the strings so she could finger the chords with her right hand and handle the bow with her left. Once the strings were reversed she was able to use standard violin music without difficulty. She had difficulty only with advanced bowing techniques.

The young man in Fig. 4 , a former CAPP patient who is now an adult, began violin lessons as a teen-ager. He has played in an orchestra, and for his own enjoyment, during the past twelve years. He has a traumatic right wrist disarticulation and wears a long-below-elbow-type prosthesis with a Dorrance Functional hand when playing the violin. The prosthetics laboratory staff at CAPP made him a special violin-bow holder which permits the bow to swivel but prevents it from sliding out of the functional hand ( Fig. 5 ). With this adaptation he handles the bow well and has difficulty only with very refined bowing techniques. Recently he has also started playing the cello, and feels that he has more control over the bow, is able to utilize broader strokes, and achieves a better tone quality. For this he uses the same bow holder as for the violin.

Lack of pronation and supination and the need to support the weight of the prosthesis and the bow with the humerus abducted and internally rotated would make handling the bow difficult for a short-below-elbow amputee. An alternative might be to play pizzicato (a technique in which the strings are plucked rather than bowed), but each amputee would need to try this method to determine whether it is easier or more difficult for him than handling the bow. The string bass is often played in this manner, particularly in stage or dance-band work.

String Instruments (plucked)

Therapists at CAPP are frequently questioned about the guitar, a member of this group. It is an ideal instrument for a right partial-hand or below-elbow amputee because no changes in the instrument are needed. The chords can be formed by the sound left hand while the strings are stroked with the right limb-deficient extremity. If a prosthesis is worn, the pick can easily be held in the terminal device. Depending on the rubber-band loading, it may or may not be necessary to use an extra rubber band to hold the pick. If a prosthesis is not worn and no grasp ability is available, a simple adaptation could be made to hold the pick in position for strumming.

The guitar is somewhat more difficult for an above-elbow amputee because of the need to substitute shoulder motion for elbow flexion and extension, pronation and supination; however, it should not be ruled out. It is possible to play with an above-elbow prosthesis, although one student with an elbow disarticulation reported that her prosthesis scratched the guitar. She prefers to play without prosthesis and has adapted an old cuff from her below-knee PTB-type prosthesis to hold a pick ( Fig. 6 and Fig. 7 ).

For a left partial-hand, below-elbow, or above-elbow amputee the guitar can be easily adapted: all that is necessary is to reverse the strings on the instrument. Depending on the type of guitar, reversal of the bridge may also be necessary. Once the strings are reversed and the guitar is turned around so the chords can be formed with the right hand, a standard right-hand instruction book can easily be utilized. It is possible to purchase a left-handed guitar; however, this should definitely be considered a luxury rather than a necessity. There is no difference between a left- and right-handed nylon string guitar except that the strings are reversed. On a left-handed steel-string guitar, the strings are reversed and the pick guard is placed on the opposite side of the instrument. On an electric guitar, all six tuning pegs are placed on one side, and on the left-handed model the tuning pegs are simply moved to the opposite side and the string reversed.

The guitar is not a recommended instrument for a shoulder-disarticulation or short-above-elbow amputee with limited shoulder motion.

The electric bass, another instrument in this group, is held like a guitar but is simpler in design and easier to play. It generally has four strings instead of the usual six, and usually only one string is plucked at a time. Also, single notes rather than chords are played.

Other instruments in this group are the mandolin, banjo and ukelele. These are also possibilities for the types of amputees mentioned above. In each case, the strings can be easily reversed for left-limb deficiencies.

The dulcimer, an old instrument usually used for accompanying singing groups, is played by holding down the strings with a dowel or one finger while strumming with the other hand. It is a possibility for either the unilateral or bilateral patient.

Percussion Instruments

As demonstrated by the bilateral amputee shown in Fig. 8 , the drums offer possibilities for any level of unilateral or bilateral amputations.

The young CAPP patient shown here began studying the drums at the age of thirteen and has played regularly during the past eight years. He has a congenital left upper-extremity amelia and a right very-short-above-elbow deficiency, and is fitted with bilateral shoulder-disarticulation-type prostheses. He uses trunk and scapular motion entirely when performing. He has one set of prostheses which he uses only for drumming. These have rigid shoulder joints, elbow joints locked at 90 deg., and rotation turntables locked into position. The harness must be very snug for drumming, even though it would hinder function if worn full time. Using 88-X terminal devices, this boy plays with two hardwood sticks which are notched to fit his hook tines and uses wide rubber tubing to hold the sticks in place. Although his principal instrument is the snare drum, he has a full set of drums and also plays timpani. He played the snare drum in one parade, but stated that it required much experimentation to strap the snare drum in place so that he could march and play at the same time. His principal interest is in playing with small instrumental groups, and he plans to make this his career.

If prostheses are not worn, the child must have the ability to grasp the drumsticks; otherwise he would have to use some adaptive equipment to hold the drumstick, use one stick only in the sound hand, or-in the case of a bilateral- be limited to clasping a single stick between his stumps.

The potential drummer must have, in addition to strong motivation, the physical ability to accomplish drum rolls-an essential part of a drummer's technique. Good coordination of upper extremities and/or prostheses is essential since the drummer is often required to perform very complex rhythmic patterns.

The bass drum, played with one soft-headed drumstick, poses no problem whatsoever for a unilateral amputee, and also has potential for a bilateral.

The vibraphone, marimba, xylophone, glockenspiel, bell lyre and triangle are other members of the percussion group. All of these would be comparatively easy for a unilateral amputee to master, and also have potential for a bilateral. The bilateral amputee would need to experiment with these instruments to determine whether he could hold the sticks or mallets effectively without dulling the sound of the instrument. The glockenspiel and bell lyre have special stands, and the triangle can be suspended by a cord from a music stand or any other suitable bracket. However, when any of these latter three instruments is chosen for use in a marching band, the bilateral amputee should first determine whether he can support the chosen instrument effectively.

The Piano and Organ

The excellent article by Mrs. Erickson, published in the March 1972 issue of the Inter-Clinic Information Bulletin , contains much valuable information, so the piano will be mentioned only briefly here.

At CAPP we have several unilateral patients who have learned to play the piano quite successfully. At the elementary stage of learning it is sometimes helpful to utilize music written for the melodica or chord organ, which is basically one-handed piano music. Another alternative is to discuss the amputee's abilities with a qualified piano teacher who will be able to select appropriate music. One right long-below-elbow amputee who plays without a prosthesis taught himself to play and transposes his own piano music. He often plays two notes of the treble clef with his right stump and the thumb of his left hand while he sometimes omits the lowest note of the bass clef.

In addition to other adaptive equipment, we have provided some CAPP patients with a piano hook made in our prosthetics laboratory ( Fig. 9 ). In making this device, the stud of an 88-X terminal device was used. The fingers were removed 1/2 in.-3/4 in. distal to the rubber-band guard; in their place, aluminum tubing with an outside diameter of 3/8 in. was welded on. Each finger measures 7 in. from the rubber-band guard to hook tip and is curved in such a way that an octave can be reached when the hook is fully opened. Full opening is 6 3/4 in., and the hook weighs 4 ounces. In order to keep the hook tips on the piano keys without applying excessive pressure, lead was melted into the distal tips of the aluminum tubing to add weight. To prevent chipping of the piano keys, either rubber tubing or a plastisol covering can be applied to the tips.

The girl in Fig. 9 has studied the piano for the past six years. She began by using a standard terminal device closed with a rubber band, then switched to the piano hook described above when it became available. She does not find it difficult to adjust the size of the hook opening to strike the two keys she wishes to play. She uses pronation and supination only when playing one key at a time. One of her teachers was quite skillful in adapting her piano music so that she is able to use her left thumb and the piano hook to play three notes in the treble clef simultaneously.

Although the organ is quite different from the piano in appearance, tone, and performance technique, the functional use of the hands is similar, and the instrument has potential for both the unilateral and bilateral amputee.

A portable chord organ is relatively inexpensive and can provide considerable enjoyment to any child with the basic musical ability. The chord buttons are usually placed on the left side, while the right hand plays the keyboard. A right-limb amputee could either play the keyboard with his stump or prosthesis, or would have the option of crossing hands and playing the chords with the right hand while the left hand played the keyboard.

Miscellaneous Instruments

There are a few other instruments which do not seem to fit into the categories already mentioned. One is the auto harp, which has excellent potential for unilateral as well as bilateral amputees with good shoulder range in the extremity used to strum or pluck the strings. One CAPP patient, a right long-below-elbow amputee ( Fig. 10 ) finds it easiest to hold the auto harp on her lap. She operates the chord buttons with her sound left hand and crosses over to strum with her prosthesis.

The accordion would not seem a good possibility for the amputee; however, we have received a report of one adult with a unilateral left below-elbow amputation who plays successfully. He operates the keyboard with his sound right hand, and manipulates the chord buttons on the left side of the instrument with his hook-type terminal device. The buttons are too close together to use his stump, but with his prosthesis he can depress one button at a time without difficulty.

The melodica also should be considered for the unilateral or bilateral amputee. This instrument is related to the accordion as well as to the woodwinds. The sound is produced by blowing into it while the keyboard is played with one hand. A convenient strap on the back of the instrument allows it to be held easily, particularly with a hook-type terminal device. The melodica can also be purchased with an attachment so that it can be placed on a table and played by blowing through a tube. This would allow even a bilateral amputee with no active shoulder motion, but wearing at least one prosthesis, to play the instrument.

Although the harmonica is not generally considered a musical instrument, an amputee can achieve considerable enjoyment with it. It can be purchased with a holder which fits around the neck so that a child with any level of bilateral amputation could play it easily.

Resources for Musical Training

Public-school music programs offer excellent opportunities for active participation by the child who is interested in playing an instrument. Most schools throughout the country offer such programs, and the public-school music instructor has been trained in the fundamentals of all the major instruments. He will also be aware of opportunities for participation in community groups such as youth bands sponsored by civic organizations. The amputee needs to participate in recreational activities with nonhandicapped groups within the society in which he will live, rather than being isolated in a clinical setting.

Professional personnel interviewed agreed that it is important for the beginner to receive individual instruction from a trained music teacher. They consider that it is preferable to train the child properly from the beginning rather than try to break previously formed bad habits. At CAPP, we also agree that music teachers are better qualified to teach the amputee than a therapist who may have only a limited knowledge of instrumental techniques, although we do feel that therapists should be able to act as consultants to music teachers when questions arise about the child's prosthesis and/or his ability for function. If the music teacher desires a medical release from the child's physician, written permission could be requested before instruction is actually begun, as is done for participation in activities such as Little League sports or attendance at a summer camp.

Summary

Information has been presented concerning the values of music, resources for finding music instructors, appropriate ages to begin study, and selection of a proper instrument. The major instruments have been discussed and recommendations given in terms of levels and types of amputation along with examples of children who have played instruments successfully. For the unilateral amputee, several brass and percussion instruments, the piano, plus the stringed and plucked-string groups offer opportunities for musical enrichment. For the bilateral amputee, the percussion group and specific instruments within other groups (e.g., the trombone, piano, and dulcimer) as well as several miscellaneous instruments are suggested.

It is hoped that this material will serve as a guide for therapists and other interested persons who must answer questions about suitable musical instruments for amputees.

Acknowledgements

The University Music Center, 1 1833 Wilshire Blvd., Los Angeles, California. Wagnon, Richard, Music Supervisor, Santa Monica Unified School District, Santa Monica, California.

Wallicki, Fred, Westwood Musical Instruments, 1611 Westwood Blvd., Los Angeles, California.

West Los Angeles Music Co., 11345 Santa Monica Blvd., Los Angeles, California. Zachman, Robert, music teacher, Aurora School District, Aurora, Colorado.

References:
Erickson, Lorraine B , Piano playing as a hobby for children with problem hands.
Inter-Clin. Information Bull., 11:6:6 17, March 1972. Getchell, Robert, Teachers' Guide to the Brass Instruments. H & A Selmer, Inc.,
Elkhart, Ind., 1959.
Goldman, Richard Franko, Your Child and Music. H. & A Selmer, Inc., Elkhart, Ind., 1964.
Johnstone, Arthur Edward, Instruments of the Modern Symphony Orchestra and Band. Revised and Augmented Edition by Dr Edwin J. Stringham, Teacher's College, Columbia University. Carl Fischer, Inc , New York, 1930.
Pomeroy, Janet, Recreation for the Physically Handicapped. The Macmillan Company, New York, 1964.
Walter, Arnold, Carl Orff's "Music for Children." The Instrumentalist, January 1959 p. 38.